Percutaneous transluminal coronary angioplasty of native coronary arteries via saphenous vein grafts

We analyzed the immediate and long-term outcome of percutaneous transluminal angioplasty (PTCA) of native coronary arteries via saphenous vein grafts (SVG) in 30 patients. The mean age of the grafts was 69 months. Angioplasty was successful in 27 (90%) patients. One patient died following emergency bypass surgery. There were no distal embolizations and one non-Q myocardial infarction. Follow-up angiography was performed in 12 patients, which revealed restenosis in three patients. At a mean follow-up of 20 months, cumulative survival was 93%. Freedom from myocardial infarction, repeat bypass surgery, and death was 80%. We conclude that PTCA of native coronary arteries via SVG is a safe alternative to repeat CABG in selected patients.     

Progression from stenosis to occlusion in the proximal native coronary artery after coronary artery bypass grafting

Coronary artery bypass grafting (CABG) is an established treatment for multivessel coronary artery disease. However, problematic situations are occasionally encountered after CABG, such as disease progression in the native coronary artery with graft occlusion, which causes difficulty in revascularization. The purpose of this study was to evaluate changes in the native coronary artery after CABG. Between 2009 and 2012 in our institution, 351 patients underwent CABG, and 768 bypass grafts were anastomosed to non-occluded coronary arteries. Of these, 489 bypass grafts had available early postoperative angiographic results (≤6 months) suitable for assessment in this study. We defined malignant graft failure after CABG to be bypass graft occlusion and de novo complete occlusion of the target native coronary artery proximal to the graft anastomosis site. In the early angiographic results, 17 grafts were occluded (17/489; 3.5 %). Two of the grafts displayed malignant graft failure (a saphenous vein graft to the right coronary artery and a saphenous vein graft to the diagonal branch) (2 of 17 occluded grafts, and 2 of 489 studied grafts). Of the patent bypass grafts, 24 involved progression to occlusion in the proximal native coronary artery (19 saphenous vein grafts, 4 left internal thoracic artery grafts, and 1 right internal thoracic artery graft). Malignant graft failure was uncommon during short-term follow-up after CABG. At the same time, disease progression in the proximal native coronary artery from stenosis to occlusion following patent bypass grafting was relatively common, especially for vein grafts.     

Intravascular lithotripsy in saphenous vein grafts and graft stent failure: A case series

The long-term patency of saphenous vein grafts (SVGs) is poor compared to arterial bypass grafts. Re-do coronary artery bypass graft surgery (CABG) is high risk, thus graft failure often requires revascularization with percutaneous coronary intervention (PCI). While PCI to the native vessels is preferable, PCI to SVGs is sometimes necessary despite being associated with a high incidence of stent failure. While early SVG degeneration is associated with friable disease, calcification becomes an increasing problem in older grafts. Intravascular Lithotripsy (IVL) has been demonstrated to be safe and effective in the treatment of calcified native coronary artery disease (CAD). We present the first case series of five patients undergoing PCI to de novo SVG disease or SVG stent failure utilizing IVL for calcium modification.     

Fourteen month follow-up angioscopic findings of a sirolimus-eluting stent implanted in a 15-year-old saphenous vein graft

Saphenous vein grafts (SVGs) are common, as is their degeneration and early failure after coronary artery bypass graft surgery (CABG). Percutaneous SVG intervention with drug-eluting stents (DES) was associated with superior short-term clinical outcomes. However, SVG intervention compared with coronary intervention often results in distal embolisation and periprocedural myocardial infarction. In this case, we discuss 9 and 14 month follow-up neointimal coverage of a DES implanted in a 15 year-old SVG and other morphological changes using angioscopy.     

Midterm results for use of the skeletonized gastroepiploic artery graft in coronary artery bypass.

BACKGROUND: To improve the long-term results of coronary artery bypass grafting (CABG), several arterial conduits have been used, including the skeletonized right gastroepiploic artery (GEA) graft. METHODS AND RESULTS: The skeletonized GEA graft was used for CABG in 223 patients over a 6-year period (208 males, 15 females, mean age 64 years). 1-, 2- and 3-vessel and left main trunk disease was noted in 1, 28, 122 and 72 patients, respectively. Internal thoracic artery, radial artery and saphenous vein grafts were concomitantly used in 217 (97%), 73 (33%) and 41 (18%) patients, respectively, and the mean number of grafts was 3.5. The sites of GEA grafting were 1 anterior descending, 10 diagonal, 97 circumflex, and 185 right coronary arteries, with 154 single in-situ, 33 free and 36 composite grafts, including 56 sequential grafts. There was 1 (0.4%) operative death. New Q wave was noted in 2 (0.9%) patients. Postoperative angiography revealed 97.6% early postoperative (within 1 month) and 91.5% midterm (mean 27 months) patency rates for GEA grafts. The cumulative 4-year patency rate of the skeletonized GEA graft was 86.4%. CONCLUSION: The skeletonized GEA is a safe and effective arterial conduit for CABG.     

Comparison of percutaneous coronary intervention in native coronary arteries vs. bypass grafts in patients with prior coronary artery bypass graft surgery

ObjectiveTo compare the procedural and clinical outcomes of prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) in native arteries vs. bypass grafts.MethodsThe medical and catheterization records and the angiograms of 142 consecutive prior CABG patients who underwent 165 PCI of 247 lesions at our institution between January 1, 2003, and December 31, 2006, were retrospectively reviewed.ResultsMean age was 66±10 years and 99% were men: 79 and 63 patients underwent native coronary or bypass graft PCI, respectively. Compared to patients undergoing bypass graft PCI, those undergoing native coronary artery PCI were younger (mean age 64±10 vs. 68±10 years, P=.008), more likely to present with stable angina (29% vs. 8%, P=<.001), and presented earlier after CABG (after a mean of 9±6 vs. 12±5 years, P<.01). Compared to bypass graft PCI, native coronary PCI was more likely to be performed with drug-eluting stents (88% vs. 57%, P<.001) and was associated with lower risk of no-reflow (3% vs. 24%, P<.001). After a mean follow-up of 2.5±1.1 years, both groups of patients had similar but high incidence of myocardial infarction, repeat PCI, and death.ConclusionsPrior CABG patients undergoing native coronary artery PCI have lower procedural risk, but similar postprocedural clinical outcomes compared to patients undergoing bypass graft PCI. If feasible, native coronary arteries may be the preferred PCI target in prior CABG patients.     

Triple arterial coronary revascularization using the radial artery and bilateral internal mammary arteries versus the gastroepiploic artery and bilateral internal mammary arteries.

Arterial grafts are frequently used in modern coronary artery bypass grafting (CABG) and the benefit of the 2 internal mammary arteries (IMA) has already been established. However, the choice of the third arterial conduit, in addition to the IMA, is controversial. We have retrospectively analized perioperative and the follow-up results of patients who underwent CABG with triple arterial bypass using either the radial artery (RA) or the gastroepiploic artery (GEA) in conjunction with the bilateral IMA (BIMA). Between December 1995 and June 2001, 1,516 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. Among them the RA and BIMA were used in 96 patients (78 males, 18 females; mean age, 63.2+/-6.7 years, group R), and the GEA and BIMA in 123 patients (101 males, 22 females; mean age, 61.0+/-11.6 years, group G). Their perioperative and follow-up data were studied. The preoperative risk factors were similar between the 2 groups, except that there were significantly fewer patients with renal dysfunction in group R. The surgical results did not differ between the 2 groups; however, the GEA was more commonly used for revascularization of the right coronary artery, while the RA was used for the diagonal, circumflex or right coronary arteries. Surgical mortality and morbidity rates were not significantly different. During the follow-up period of 2.3+/-1.6 years, the event-free rates as well as the survival rates were not significantly different. CABG with either the RA or the GEA in conjunction with the BIMA can be performed safely. The surgical results as well as the follow-up results were acceptable and no significant differences between the 2 groups were observed.     

Long-term survival in coronary artery bypass grafting surgery depending on the second conduit used

There is still debate whether radial artery (RA) conduits are better grafts then saphenous vein grafts (SVG) as a second conduit in coronary artery bypass grafting (CABG) surgery. Although it has been confirmed that RA grafts have significantly better patency over years, only some observational studies have associated RA use with reduced all-cause mortality. So far, no randomized controlled trial (CRT) has confirmed significantly better survival for RA graft recipients versus SVG recipients. Therefore, we have to wait for the results of the ongoing ROMA (CRT) study, to draw relevant conclusions about the impact of the second graft on long-term survival in patients undergoing CABG surgery.     

Fistula between right coronary artery vein graft and right atrium as an immediate complication of percutaneous coronary intervention

Fistula between saphenous vein graft (SVG) and a cardiac chamber or structure is a rare complication after coronary artery bypass grafting (CABG). We report the first case of a fistula between SVG and the right atrium (RA) as an immediate complication after a percutaneous coronary intervention (PCI) in an 86-year-old female. She presented with inferior ST-elevation myocardial infarction (STEMI) and was treated with thrombolytic therapy in a peripheral hospital, which was unsuccessful. PCI to SVG to the right coronary (RCA) was complicated by a fistula to RA. Cardiac magnetic resonance (CMR) confirmed the site of the fistula and also presence of a significant arteriovenous (AV) shunt. Reversal of anticoagulation had no effect on fistula closure. Therefore, a covered stent was deployed for closure of the fistula to avoid long-term complications of the significant AV shunt. In summary, the diagnosis and appropriate management of this rare complication is challenging, but excellent result can be achieved by the use of appropriate percutaneous techniques.     

Coronary angioplasty in patients with previous coronary artery bypass grafting.

Between 1982 and 1990, in 134 patients with prior coronary artery bypass grafting and recurrent angina, repeat coronary angiography and balloon angioplasty of stenoses in grafts or native arteries were attempted. Mean age of grafts was 45.6 months, range three days to twelve years. At the time of angioplasty, 6 patients had one-vessel-disease, 33 had two-vessel-disease, and 95 had three-vessel-disease. A total of 182 lesions were dilated: 55 venous grafts, 3 internal mammary artery grafts, and 124 native vessels. Forty-nine of 55 (89%) venous grafts could be successfully dilated, and in 3 internal mammary artery grafts, a stenosis reduction greater than 50% was achieved. In 65 of 88 (74%) grafted native arteries, dilation success was achieved. Twenty-seven of 36 (75%) patients with prior bypass surgery to other arteries had successful angioplasty of nongrafted native arteries. Three patients underwent emergency bypass surgery after dissection and acute occlusion: one of them died in cardiogenic shock secondary to acute myocardial infarction. The angiographic success rate in grafts was slightly higher than in native arteries (90% vs 74%). These data indicate that percutaneous transluminal coronary angioplasty in patients after bypass surgery is possible at a low risk (3%) and constitutes an effective therapy in symptomatic patients.     

Five-year follow-up after long plaque-bridging coronary arteriotomy for diffuse coronary artery disease

Long arteriotomy bridging a stenotic plaque or segment may improve runoff in diffuse coronary artery disease. However, patency might be impaired due to vascular wall pathology. OBJECTIVE: To determine the patency rates of plaque-bridging arteriotomy compared to conventional coronary artery bypass grafting. METHODS: Between May 1995 and December 1998, 104 patients with a mean age of 65 +/- 7 years received a long arteriotomy extending over a heavily plaqued area in an effort to treat their diffuse coronary artery disease. The length of the arteriotomy ranged from 14 mm to 40 mm. We retrospectively analyzed the intra-individual bypass graft patency rates by multidetector-computed tomography or coronary angiography. RESULTS: The mean follow-up was 5 years. There were 5 (4.8 %) early and 10 (9.6 %) late deaths, three non-cardiovascular. Graft patency for internal thoracic artery (ITA) to left anterior descending artery (LAD) (plaque-bridging) was 94.8 %, for saphenous vein graft (SVG) to circumflex artery (CX) (plaque-bridging) 67 %, and SVG to right coronary artery (RCA) (plaque-bridging) 79.5 %. Graft patency for ITA to LAD (conventional) was 94.9 %, for SVG to CX (conventional) 72.4 %, and SVG to RCA (conventional) 75 %. Freedom from angina was 82.8 % (n = 58/70), freedom from myocardial infarction was 95.7 % (n = 67/70), freedom from reintervention was 91.4 % (n = 64/70) and freedom from reoperation was 100 % (n = 70/70). CONCLUSION: Diffuse coronary artery disease can be treated by extending the arteriotomy over the plaques, with graft patency rates comparable to bypass grafts onto less diseased segments.     

An update on internal mammary artery grafting for coronary artery disease

PURPOSE OF REVIEW: To describe recent results regarding the use of the internal mammary artery for coronary artery bypass grafting with emphasis on bilateral internal mammary artery grafting, patency, resistance to atherosclerosis, skeletonisation, composite arterial grafts, flow measurement, vasodilatation, and non-invasive imaging techniques. RECENT FINDINGS: Coronary artery bypass grafting plays an important part in coronary revascularisation and seems to be associated with a survival benefit in comparison with percutaneous coronary intervention. After 10 years, internal mammary arteries demonstrate better patency than vein grafts except when grafting moderately stenosed right coronary arteries. Bilateral internal mammary artery grafting increases survival further, but carries a higher risk of sternal complications. Skeletonisation may reduce this risk. The internal mammary arteries are used increasingly as composite arterial grafts and this technical solution should no longer be considered experimental. Perioperative flow measurement by the transit-time method is recommended while postoperative echocardiography represents an accurate method for evaluation of flow in internal mammary artery grafts. Multi-detector computed tomography allows for accurate assessment of all types of bypass conduits and native coronary arteries. At present, magnetic resonance imaging of internal mammary artery patency and flow is possible. SUMMARY: Newer studies confirm earlier data with respect to improved long-term survival when using internal mammary artery grafting, and this survival benefit is superior to percutaneous coronary intervention treatment. Bilateral internal mammary artery grafting improves survival further. Skeletonisation of the internal mammary artery provides extra length of grafts for complete arterial revascularisation. Non-invasive imaging techniques are increasingly sophisticated and may change the referral pattern for patients with coronary artery disease to either percutaneous coronary intervention or coronary artery bypass grafting.     

No-touch与EVH获取大隐静脉桥血管的近中期临床结果分析

目的 比较no-touch和内窥镜获取（endoscopic vein harvesting, EVH）两种不同的大隐静脉移植物获取方式对冠状动脉旁路移植术（coronary artery bypass grafting, CABG）术后早期临床效果及近中期移植物通畅率的影响。 方法 回顾性分析西安交通大学第一附属医院心血管外科2018年7月至2019年12月行CABG患者151例,其中no-touch技术组获取大隐静脉56例;EVH组获取大隐静脉95例。所有患者采取胸骨正中切口入路,非体外或体外循环辅助下完成搭桥手术。统计两组间平均桥血管远端吻合口数量、左乳内动脉吻合口数量及静脉桥远端吻合数量的差异;分析比较两组术后死亡及早期并发症发生情况以及术后切口并发症如血肿、脂肪液化等差异。患者出院前及术后1年行冠脉动脉CT血管成像检查（CTA）以评估移植血管桥近中期的通畅情况。 结果 No-touch和EVH两组在年龄、性别构成、危险因素、术前诊断类型等方面均无统计学差异。术中两组左乳内动脉吻合口数量及静脉桥远端吻合数量等差异均无统计学意义。两组均无手术死亡。在术后早期并发症方面无显著性差异;但在下肢切口并发症中水肿、切口处麻木、疼痛在no-touch组中尤为显著（P<0.05）。术后冠脉CTA复查提示,术后早期桥血管总体通畅率、两组间左乳内动脉及大隐静脉桥血管通畅率均无差异。术后1年总体桥血管通畅率no-touch组要优于EVH组（P<0.05）,其中左乳内动脉通畅率无差异,大隐静脉桥血管no-touch组通畅率要明显高于EVH组（P<0.05）。 结论 No-touch技术获取静脉桥血管对于CABG患者的近、中期临床效果满意,且中期桥血管通畅率要优于EVH组。该技术可行、安全、有效,值得在CABG中进一步推广。     

Embolic protection devices in saphenous vein graft interventions

Saphenous vein grafts (SVGs) are widely used as aortocoronary conduits during coronary artery bypass surgery and are critical in the high early success of coronary bypass revascularization. Saphenous vein grafts tend to be more prone than native coronary arteries to accelerated atherosclerosis and intimal fibrosis and thus frequently lead to recurrent symptoms and require further revascularization. Percutaneous coronary interventions (PCI) have become the prime means of SVG mechanical revascularization but are plagued by higher complication rates than PCI on native coronaries, largely due to embolic debris mobilized from around the target lesion in the SVG. Several mechanical devices and techniques have been developed to capture this friable material during the PCI before it can embolize; these devices have shown great promise in reducing the morbidity and mortality of these interventions and should be employed routinely.     

Percutaneous intervention for atherosclerotic disease in saphenous vein grafts

The long term benefit of coronary artery bypass surgery (CABG) is limited by development of atherosclerotic disease in the bypass conduits. Percutaneous revascularisation is frequently the preferred method of treated symptomatic saphenous vein graft (SVG) atherosclerotic disease. The immediate and long term results of percutaneous intervention for SVGs is reviewed. Therapeutic considerations as well as novel technical advances are overviewed     

Spontaneous slow flow in the saphenous vein graft: a relevant distinction of macrovascular endothelial dysfunction

Spontaneous slow flow without significant obstructive stenosis, as encountered during diagnostic angiography, has mostly been reported in native coronary arteries. This phenomenon has been associated with angina, myocardial ischemia and infarction. Slow flow and “no-reflow” in saphenous vein grafts (SVG) have mostly been observed during percutaneous interventions as a complication from distal embolization. Spontaneous slow SVG flow, however, is rarely reported and correlation with clinical events not as well documented. A case of spontaneous slow flow in a SVG without significant obstructive lesions is presented, which correlated with the patient's anginal symptoms and ischemia on the stress myocardial perfusion scintigraphy. Percutaneous coronary intervention in the bypassed native coronary artery was successful resulting in the restoration of TIMI-3 coronary flow, resolution of the patient's symptoms, and normalization of the myocardial perfusion defects. The restoration of normal flow through the stented native coronary artery suggested endothelial dysfunction of the initial slow flow state was localized at the macrovascular level, specifically at the SVG conduit. Since bypass graft failure, as with native arterial atherosclerosis, has been attributed to impaired endothelial function at both the macrovascular and microvascular levels, localization of macrovascular endothelial dysfunction in the SVG as shown may be an instructive observation.     

Effect of pravastatin on progression of coronary atherosclerosis in patients after coronary artery bypass surgery.

BACKGROUND: Although the anti-atherosclerotic effects of HMG-CoA reductase inhibitors are well known, their specific effect on saphenous vein grafts after coronary artery bypass graft (CABG) operation is not well documented and has not been studied in Japan, so the aim of the present prospective randomized controlled study involving 27 Japanese institutions was to investigate the effects of pravastatin on the progression of atherosclerosis in such grafts and native coronary arteries after CABG. METHODS AND RESULTS: A total of 303 patients who had undergone CABG were randomly assigned to either the pravastatin group (n =168) or the control group (n = 167). Paired coronary angiograms were obtained at baseline and at the end of 5-year follow-up in 182 (60%) patients. The low-density lipoprotein cholesterol concentration significantly decreased in the pravastatin group from 141.4 mg/dl to 113.7 mg/dl (-19.6%), compared with 141.1 mg/dl to 133.7 mg/dl (-5.2%) in the control group (p < 0.001). Although there was no significant difference in the quantitative coronary angiography measurements between the 2 groups, the global change score indicated a significant pravastatin-mediated reduction in plaque progression (p < 0.01). CONCLUSIONS: Pravastatin can potentially reduce atherosclerotic progression in both the bypass graft and native coronary arteries of patients after CABG.     

Noninvasive assessment of coronary artery bypass graft patency and flow characteristics by electron-beam tomography.

OBJECTIVE: To evaluate the flow characteristics and accuracy for the detection of patent or occluded coronary artery bypass grafts (CABG) with multi-slice flow study of electron-beam tomography (EBT). METHODS: One hundred and twenty-three patients who had undergone CABG surgery were enrolled in this study. Flow datasets were assessed with time-density curves by EBT. The EBT results were blindly compared with post-operative cardiac catheterizations in 26 patients. RESULTS: Image quality was adequate to evaluate in 111 patients (90.2%). Flow curves of bypass grafts were technically adequate in 265 of 309 (85.8%) saphenous-vein grafts (SVG) and 35 of 56 (62.5%) internal mammary artery (IMA) grafts (p < 0.05). In comparison to conventional angiographic results, EBT correctly identified 14 of 16 occluded grafts (sensitivity, 87.5%) and 68 of 75 patent grafts (specificity, 90.7%), yielding an accuracy of 90.1%. The intra-graft flows of the IMA and SVG were 4.9 +/- 2.2 ml/min/g and 6.9 +/- 2.8 ml/min/g, respectively (p < 0.001), which was 31.6 +/- 20.4% and 39.4 +/- 21.9% of the ascending aorta's flow (16.7 +/- 5.0 ml/min/g) (p < 0.001). CONCLUSION: EBT flow study can be used in the assessment of CABG patency and quantification of intra-graft flow of patent CABG vessels.     

Early postoperative balloon coronary angioplasty for failed coronary artery bypass grafting

In a small number of patients, coronary artery bypass grafting (CABG) fails to relieve anginal symptoms. The usefulness of coronary angioplasty for the treatment of early (less than or equal to 90 days) recurrent ischemia after CABG was examined. Forty-five patients were treated from 2 to 90 days after CABG, including 8 patients studied emergently for prolonged ischemic symptoms. One-, 2- and 3-vessel native disease was found in 4, 10 and 31 patients, respectively. At the time of postoperative angiography, the major anatomic mechanism of recurrent ischemia was complete vein graft occlusion in 12 patients (27%), internal mammary artery occlusion in 3 (7%), vein graft stenoses in 13 (29%), internal mammary artery stenoses in 10 (22%), unbypassed disease in 4 (8%) and disease distal to the graft insertion site in 3 (7%). Angioplasty was successful at 91 of 98 sites (93%), including 95% of 41 lesions in native arteries, 89% of 46 lesions in vein grafts and 100% of 11 internal mammary artery lesions attempted. Complete revascularization was achieved in 84% of patients. There were 2 in-hospital deaths and 2 myocardial infarctions. Two additional patients underwent repeat CABG before discharge after uncomplicated but unsuccessful angioplasty. At late follow-up of the 43 survivors (mean 44 months), there were 4 deaths, 2 of which were noncardiac. Repeat CABG was required in only 3 patients and repeat angioplasty was performed in 10. Angina was absent or minimal in 35 patients; 17 patients were employed full time. Thus, percutaneous transluminal coronary angioplasty can relieve myocardial ischemia after unsuccessful CABG in the majority of patients.