Influence of gender on early and one-year clinical outcomes after saphenous vein graft stenting

Compared with men, women may have a worse prognosis after native coronary revascularization. However, the influence of gender on clinical outcomes after saphenous vein graft (SVG) stenting is unknown. The purpose of this study was to compare early and 1-year clinical outcomes between men and women after stent implantation in SVG. A total of 1,199 consecutive patients with 1,858 SVG lesions were studied. Procedural success, in-hospital events, and late clinical outcomes were compared between men (n = 951) and women (n = 248). Overall procedural success was similar between men and women (97% vs 96%, p = NS). However, in-hospital (3.2% vs 1.6%, p = 0.07) and 30-day cumulative (4.4% vs 1.9%, p = 0.02) mortality rates were higher in women than in men. In addition, women had a higher incidence of vascular complications (12% vs 7.3%, p = 0.006) and postprocedural acute renal failure (8.1% vs 4%, p = 0.02). At 1-year follow-up, mortality was 13% in women and 11% in men (p = NS) and target lesion revascularization was 18% versus 23%, respectively (p = NS). By multivariate regression analysis, independent correlates of in-hospital mortality were female gender (odds ratio [OR] 3.6, confidence interval [CI] 1.0 to 12.5, p = 0.05) and left ventricular ejection fraction (OR 0.9, CI 0.9 to 1.0, p = 0.01). Female gender was found to predict 30-day mortality (OR 2.5, CI 1.1 to 5.5, p = 0.02). The sole predictor of 1-year mortality was diabetes mellitus (OR 1.6, CI 1.1 to 2.3, p = 0.01). This study shows that women compared with men treated with stent implantation in SVG lesions have (1) a trend toward higher in-hospital mortality, (2) higher risk of 30-day mortality, (3) increased incidence of vascular complications and postprocedure acute renal failure, and (4) similar 1-year clinical outcome.     

Procedural results and intermediate clinical outcomes after multiple saphenous vein graft stenting

OBJECTIVES: We evaluated the early and mid-term (18-month) clinical events in a consecutive series of patients undergoing a nonstaged multiple saphenous vein grafting (SVG) intervention with stents as compared with a single SVG stent procedure. BACKGROUND: Saphenous vein graft angioplasty has been limited by high rates of distal embolization, myocardial infarction, restenosis and late mortality. It is unknown whether stenting of multiple, different SVGs at the same setting is associated with higher risk. METHODS: We evaluated in-hospital and mid-term clinical outcomes (death, Q wave myocardial infarction [MI] and repeat revascularization rates up to 18 months) in 70 consecutive patients treated with coronary stents in 2 (93% of patients) or 3 SVGs, as compared with 649 patients undergoing stenting of a single SVG between January 1, 1994 and December 31, 1997. RESULTS: Overall procedural success was obtained in 97% of patients with 2 or 3 SVGs and 97% of patients with a single SVG (p = 0.94). Procedural complications were also similar (2.8% for multiple SVGs vs. 2.7% for a single SVG, p = 0.94). There was a higher prevalence of periprocedural non-Q wave MI (28% vs. 16%, p = 0.009) in the multiple SVG group. During follow-up (18 months), target lesion revascularization was 11% in multiple SVG and 15% in single SVG interventions (p = 0.19), and repeat revascularization (calculated per treated patient) was also similar for both groups (19% vs. 18%, p = 0.94). There was no difference in death (5.6% vs. 5.3%, p = 0.92) and Q wave MI rate (4.3% vs. 2.9%, p = 0.55) after the multiple SVG intervention. Overall cardiac event-free survival was similar for both groups (62% vs. 60%, p = 0.75). The study was powered to detect a clinically meaningful difference of 10% in mortality; smaller differences could not be evaluated on the basis of this sample size. CONCLUSIONS: Simultaneous stenting of multiple SVGs in carefully selected patients has similar in-hospital procedural success and major complications rates, as well as mid-term (18-month) clinical outcomes, as compared with single SVG stenting. Thus, multiple SVG interventions using stents may be a viable revascularization strategy for carefully selected patients and suitable lesions in multiple SVG disease.     

Comparison of debulking followed by stenting versus stenting alone for saphenous vein graft aortoostial lesions: immediate and one-year clinical outcomes

OBJECTIVES: We compared in-hospital and one-year clinical outcomes in patients undergoing debulking followed by stent implantation versus stenting alone for saphenous vein graft (SVG) aortoostial lesions. BACKGROUND: Stent implantation in SVG aortoostial lesions may improve procedural and late clinical outcomes. However, the impact of debulking before stenting in this complex lesion subset is unknown. METHODS: We studied 320 consecutive patients (340 SVG aortoostial lesions) treated with Palmaz-Schatz stents. Debulking with excimer laser or atherectomy was performed in 133 patients (139 lesions) before stenting (group I), while 187 patients (201 lesions) underwent stent implantation without debulking (group II). Procedural success and late clinical outcomes were compared between the groups. RESULTS: Overall procedural success (97.6%) was similar between the groups. Procedural complications were also similar (2.2% for group I and 2.6% for group II). At one-year follow-up, target lesion revascularization (TLR) was 19.4% for group I and 18.2% for group II (p = 0.47). There was no difference in cumulative death or Q wave myocardial infarction between the groups. Overall cardiac event-free survival was similar (69% for group I and 68% for group II). By Cox regression analysis, the independent predictors of late cardiac events were final lumen cross-sectional area (CSA) by intravascular ultrasound (IVUS) (p = 0.001) and restenotic lesions (p = 0.01). Similarly, final IVUS lumen CSA (p = 0.0001) and restenotic lesions (p = 0.006) were found to predict TLR at one year. CONCLUSIONS: These results suggest that, in most patients with SVG aortoostial lesions, debulking before stent implantation may not be necessary.     

Contemporary percutaneous treatment of saphenous vein graft stenosis: immediate and late outcomes

PURPOSE: The aim of this study was to evaluate the immediate and long-term outcomes following percutaneous treatment of an unselected series of saphenous vein graft (SVG) lesions. METHODS AND RESULTS: Consecutive interventions on 129 saphenous vein graft lesions in 101 patients were reviewed. Stents were implanted in 114 lesions (88%), which included the use of polytetrafluoroethylene-covered stents in 22 lesions (17%) and abciximab in 20 patients (20%). Angiographic success was achieved in 125 lesions (97%). In-hospital major adverse cardiac events (MACE) occurred in 11 patients (11%), with myocardial infarction being the most frequent event. Treatment of degenerated SVG lesions and SVG lesions with larger reference diameters correlated with the incidence of in-hospital MACE [odds ratio (OR) = 7.69 and 2.65, respectively; 95% confidence interval (CI) = 1.80Eth 32.8 and 0.99Eth 7.10, respectively)]. Clinical follow-up was achieved in all patients at 25 +/- 21 months. Successful revascularization to all three distributions of the major coronary arteries negatively correlated [relative risk (RR) = 0.43; 95% CI = 0.20Eth 0.92)], while treatment of a degenerated SVG positively correlated (RR = 1.92; 95% CI = 1.05Eth 3.51) with the occurrence of follow-up MACE. A final effective blood supply to the anterior wall and a higher left ventricular ejection fraction was found to negatively correlate with the occurrence of follow-up death (RR = 0. 20 and 0.61, respectively; 95% CI = 0.06Eth 0.60 and 0.41Eth 0.90, respectively). CONCLUSION: Treatment of SVG lesions continues to be associated with a high incidence of myocardial infarction, particularly in cases of degenerated SVG lesions. An effective blood supply to the anterior wall and a higher left ventricular ejection fraction were protective for the occurrence of death during the follow-up period.     

Distal filter protection during saphenous vein graft stenting: technical and clinical correlates of efficacy

OBJECTIVES: The aim of this study was to evaluate the clinical, angiographic, and technical factors related to successful stenting of diseased saphenous vein grafts (SVGs) using a novel filter-based distal protection device. BACKGROUND: Protection of the distal microvasculature with a balloon occlusion and aspiration system has been shown to reduce atherothrombotic embolization and peri-procedural myocardial infarction (MI) after percutaneous coronary intervention (PCI) in SVGs. The safety, efficacy, and technical factors relating to procedural success with filter-based distal protection devices are unknown. METHODS: Percutaneous coronary intervention was performed in 60 lesions in 48 patients undergoing SVG intervention with the FilterWire EX distal protection system in a phase I experience at six sites. A larger phase II study was then performed in 248 lesions in 230 SVGs at 65 U.S. centers. RESULTS: Cumulative adverse events to 30 days occurred in 21.3% of patients in phase I, including a 19.1% rate of MI. Numerous anatomic, device-specific, and operator-related contributors to these adverse events were identified, resulting in significant changes to the protocol and instructions for use. Subsequently, despite similar clinical and angiographic characteristics to the phase I patients, the 30-day adverse event rate in phase II was reduced to 11.3% (p = 0.09), due primarily to a lower incidence of peri-procedural Q-wave and non-Q-wave MI. CONCLUSIONS: Distal protection during SVG PCI with the FilterWire EX is associated with a low rate of peri-procedural adverse events compared to historical controls. A unique set of anatomic, technical, and operator-related issues exist with distal filters which, if ignored, may reduce their effectiveness.     

Effect of direct stenting on clinical outcome in patients treated with percutaneous coronary intervention on saphenous vein graft

Background

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with frequent postprocedural enzyme elevation and late cardiac events. New strategies are proposed to minimize distal embolization and to improve the outcome of patients treated with stenting for SVG lesions. The objectives of the current study were to examine direct stenting (DS) strategy of PCI in SVG lesions and its effects on creatine-kinase (CK) release, major adverse cardiac events (MACE), and late outcome when compared to conventional stenting (CS).

Methods

A consecutive series of 527 patients treated with stent implantation for SVG stenosis was analyzed. In this cohort, 170 patients with 229 lesions were treated with DS and 357 patients with 443 lesions were treated with CS. The inhospital and 12-month follow-up events were recorded and reported.

Results

Baseline clinical and postprocedural angiographic characteristics were similar between the 2 groups except for higher preprocedural prevalence of thrombus-containing lesions in the DS group. Patients in the DS group had less CK-MB release (P < .001), and less non-Q-wave myocardial infarction (P = .024). Multivariate analysis detected unstable angina (odds ratio [OR] = 1.8, P = .03) as a correlate for non-Q-wave MI; DS was inversely associated with non-Q-wave myocardial infarction (OR = 0.65, P = .04). At 1 year, the target lesion revascularization-MACE was significantly lower in the DS group (P = .021). Multivariate analysis showed that DS (OR = 0.47, P = .007) was associated with reduction of the target lesion revascularization-MACE.

Conclusions

When feasible, DS may be the best approach for treating SVG stenosis.     

Relation of early saphenous vein graft failure to outcomes following coronary artery bypass surgery

Up to 20% of saphenous vein grafts (SVGs) fail within 2 years of coronary artery bypass grafting (CABG). The long-term effects of early SVG failure on major clinical events remain undefined in contemporary patient populations. We sought to examine the relation between early SVG failure and long-term outcomes after CABG. Using the Duke Cardiovascular Databank, we examined baseline clinical and angiographic characteristics and clinical outcomes among patients who underwent catheterization 1 to 18 months after their first CABG from 1986 to 2004. Patients were classified on the basis of their worst SVG stenosis as having no (<25%), noncritical (25% to 74%), critical (75% to 99%), or occlusive (100%) SVG disease. Our primary outcome measure was the composite of death, myocardial infarction, or repeat revascularization after catheterization. Of 1,243 patients included in the analysis, 27.9% had no, 11.9% had noncritical, 20.8% had critical, and 39.3% had occlusive SVG disease. At 10 years, the corresponding adjusted composite event rates were 41.2%, 56.2%, 81.2%, and 67.1%, respectively (p <0.0001). Most events occurred immediately after catheterization in patients with critical and occlusive SVG disease and were primarily repeat revascularization. On multivariate analysis, critical, nonocclusive SVG disease was the strongest predictor of the composite outcome (hazard ratio 2.36, 95% confidence interval 2.00 to 2.79, p <0.0001). In conclusion, in contemporary clinical practice, early SVG failure is associated with worse long-term outcomes after CABG.     

Exercise‐induced saphenous vein graft spasm prevented by stenting

Recurrence of anginal symptoms following coronary artery bypass surgery is usually secondary to graft closure or progression of native vessel disease. The present case demonstrates severe exercise‐induced saphenous vein graft (SVG) spasm associated with transmural ischemia refractory to maximal vasodilator therapy. Symptoms resolved and exercise electrocardiography normalized following stenting of SVG regions demonstrating spasm. © 2017 Wiley Periodicals, Inc.     

Sex-associated differences in clinical outcomes after coronary stenting in patients with diabetes mellitus

PURPOSE: It has been suggested that the influence of diabetes on cardiovascular mortality is sex dependent. We undertook this study to determine whether there were sex-related differences in 1-year clinical outcomes following coronary artery stenting in diabetic patients. METHODS: The study included 4460 consecutive patients (1084 women) who underwent coronary artery stenting for stable or unstable angina, of whom 970 (22%) had diabetes. Six-month follow-up angiography was performed in 3452 patients (77.4%). The primary endpoint was the combined incidence of major adverse cardiac events (death, myocardial infarction, and target vessel revascularization). RESULTS: Diabetes was associated with a significant increase in the combined incidence of death, myocardial infarction, and target vessel revascularization at 1 year in women; this incidence was greater in diabetic women than in nondiabetic women (26.9% [84/312] vs. 18.9% [146/772]; odds ratio [OR] = 1.5; 95% confidence interval [CI]: 1.2 to 2.0; P = 0.002). The primary endpoint appeared to be similar in men regardless of diabetes status (24.6% [162/658] with diabetes vs. 23.3% [634/2718] without diabetes; OR = 1.07; 95% CI: 0.90 to 1.27; P = 0.43). There was a significant interaction between diabetes and sex in both unadjusted (P = 0.03) and adjusted (P = 0.04) analyses, with diabetes having a greater negative effect in women than in men for major adverse cardiac events after coronary stenting. CONCLUSION: In patients who underwent coronary artery stenting, the increased risk of adverse cardiac events associated with diabetes was more pronounced in women than in men.     

Perforation of saphenous vein graft during coronary stenting: A case report

We report on a case of coronary perforation during stenting of a saphenous vein graft with a biliary stent. Sealing of the perforation was achieved with another biliary stent deployed within the first stent at the site of the perforation, and with prolonged balloon inflation. This case illustrates that vein graft perforation can occur with coronary stenting, and could potentially be treated with prolonged balloon inflation and/or stenting at the site of the first stent. © 1996 Wiley-Liss, Inc.     

Carotid stenting in high-risk patients: early and late outcomes

Purpose: Some patients with severe carotid stenosis have anatomical or clinical comorbidities that place them at high risk for carotid endarterectomy (CEA). The early and late outcomes after carotid artery stenting (CAS) were evaluated in patients at high risk for CEA. Methods: Between 2002 and 2009, 186 patients were enrolled in a high‐risk CAS institutional registry. The primary outcome was major adverse cardiac and cerberovascular events (MACCEs) at 30 days, including death, stroke, and myocardial infarction. Secondary outcomes were technical, procedural, and clinical success; nonstroke neurological events; and death and ipsilateral stroke at 5 years. Results: Twenty‐five patients (13.2%) were symptomatic. Thirty day MACCE occurred in 2.6%, including death in 1 (0.5%), stroke in 3 (1.6%), and myocardial infraction in 1 (0.5%) patient. Strokes were nonfatal in 3 (1.6%), major in 2 (1.1%), and minor in 1 (0.5%) patients. Other neurological events included transient ischemic attack in 9 (4.7%) and retinal artery occlusion in 2 (1.1%) patients. After stroke, 2 patients had complete resolution of neurological deficit within 30 days, and 1 patient had improvement in neurological deficit. By Kaplan–Meier analysis, all‐cause mortality was 47.5% and ipsilateral stroke was 4.5% at 5 years. Conclusions: In patients who are high risk for CEA, CAS can be performed with low MACCE at 30 days and ipsilateral stroke at 5 years. However, nearly half of these patients die within 5 years from causes unrelated to stroke. (J Interven Cardiol 2011;24:247–253)     

The influence of diabetes mellitus on late clinical outcomes following coronary stent implantation

Diabetic patients have a higher restenosis rate and late morbidity following balloon angioplasty. However, the increased risk of restenosis after coronary stent implantation in diabetic patients is controversial. We compared the quantitative coronary angiographic (QCA) variables between 42 diabetic patients and 71 non-diabetic patients undergoing coronary stent implantation and for 6 months follow-up. Pre-procedural variables were identical in the diabetic and non-diabetic patients. The stent-artery ratio was lower (1.07+/-0.13 vs. 1.13+/-0.13, P=0.020), and acute gain after coronary stenting was lower (1.58+/-0.53 vs. 1.77+/-0.48, P=0.049) in the diabetic patients than in the non-diabetic patients. However, the late lumen loss (0.42+/-0.64 vs. 0.49+/-0.69), loss index (0.28+/-0.49 vs. 0.28+/-0.45), restenosis rate (19 vs. 23%) and target lesion revascularization rate (17 vs. 18%) after 6 months were identical in the diabetic and non-diabetic patients. These results suggest that diabetes itself does not increase stent restenosis.     

Preoperative and operative predictive variables of late clinical events following saphenous vein coronary artery bypass graft surgery

Prediction of late clinical events was studied in a series of 145 patients who had control angiographic studies at one year and between two and 14 years after saphenous vein coronary artery bypass graft surgery. During a mean observation interval of 7.4 years, new narrowing or occlusion occurred in grafts of 59% of the patients and progression in non-bypassed arteries was observed in 66%. One or several of the following events were observed in 56% of the patients: recurrent or worse effort angina, unstable angina, myocardial infarction and heart failure. Unstable angina during follow-up was more frequent in young patients and in those who had this clinical presentation before surgery. The incidence of myocardial infarction was likewise greater in patients who had preoperative unstable angina and in those with four to five risk factors for coronary artery disease, as well as those having a lesser number of inserted grafts. Heart failure was predicted independently by either four to five risk factors, a low left ventricular contraction score or fewer grafts placed at surgery. The number of inserted grafts correlated inversely with any one of the late clinical events.     

Immediate procedural and long-term clinical outcomes following drug-eluting stent implantation to ostial saphenous vein graft lesions

BACKGROUND: Ostial saphenous vein graft (OSVG) lesions were excluded from all the clinical trials demonstrating significantly lower restenosis rates with drug-eluting stents (DES) compared to bare metal stents (BMS). This study aimed to evaluate the efficacy of DES in OSVG lesions by assessing angiographic and 12-month clinical outcomes. METHODS: 70 consecutive patients (70 OSVG lesions) underwent coronary stent implantation between May 2003 and April 2006: 37 lesions received DES and 33 lesions BMS. Endpoints were all cause and cardiovascular mortality, myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), examined separately and as a combined end-point (major adverse cardiac events, MACE). RESULTS: Procedural (94.6% for DES and 87.9% for BMS) and angiographic (100% for DES and 100% for BMS) success did not differ between the two groups. The only in-hospital events were non-Q wave MI (DES 8.1% versus BMS 12.1%, P=0.69). At 30-day follow-up, there were no other events. Overall, at 1-year follow-up, the BMS group had a higher TLR (30.3% versus 5.4%, P=0.015), TVR (33.3% versus 10.8%, P=0.045) and MACE rate (36.4% versus 10.8%, P=0.024) compared to the DES group. CONCLUSIONS: Drug-eluting stent implantation to OSVG lesions achieves better clinical results than BMS but is still associated with a relatively high incidence (10.8%) of revascularization at 1-year follow-up.     

Transradial management of saphenous vein bypass graft disease using rheolytic thrombectomy and coronary stenting

We report a case of successful treatment of a severely diseased saphenous vein graft from the transradial approach. Initial rheolytic thrombectomy was performed followed by coronary stenting through a 6 French guide catheter. Continuing miniaturization of interventional devices increases the utility of the transradial approach.     

Emergent saphenous vein graft stenting for acute occlusion during percutaneous transluminal coronary angioplasty

This report describes the initial use in the United States of emergency intravascular stenting for the treatment of acute coronary occlusion complicating elective saphenous vein graft angioplasty. This case adds further support to the role of the balloon expandable stent as an effective "bail out" device for failed angioplasty.