PCI in Saphenous Vein Grafts: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 46: Line 46:
Currently, the [[FDA]] has approved five embolic protection devices in the United States.  Specifically, these devices include one distal occlusion device, three filters, and one proximal occlusion device.  
Currently, the [[FDA]] has approved five embolic protection devices in the United States.  Specifically, these devices include one distal occlusion device, three filters, and one proximal occlusion device.  


The FDA-approved distal occlusion device is called the PercuSurge Guardwire, which entails inflating a balloon distal to the [[stenosis]] to occlude flow, thereby trapping the debris and [[vasoactive]] substances and preventing them from flowing downstream.  Due to its small size, it requires little landing zone to deploy.  The SAFER trial<ref name="pmid11901037">{{cite journal |author=Baim DS, Wahr D, George B, ''et al.'' |title=Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts |journal=Circulation |volume=105 |issue=11 |pages=1285–90 |year=2002 |month=March |pmid=11901037 |doi= |url=}}</ref> showed that when compared to conventional guidewires, balloon occlusion devices (PercuSurge Guardwire) reduced the rates of infarction and [[no-reflow]] after intervention.
The FDA-approved distal occlusion device is called the PercuSurge Guardwire, which entails inflating a balloon distal to the [[stenosis]] to occlude flow, thereby trapping the debris and [[vasoactive]] substances and preventing them from flowing downstream.  Due to its small size, it requires little landing zone to deploy.  The SAFER trial<ref name="pmid11901037">{{cite journal |author=Baim DS, Wahr D, George B, ''et al.'' |title=Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts |journal=Circulation |volume=105 |issue=11 |pages=1285–90 |year=2002 |month=March |pmid=11901037 |doi= |url=}}</ref> showed that when compared to conventional guidewires, balloon occlusion devices (PercuSurge Guardwire) reduced the rates of infarction and [[no-reflow]] after intervention.  Despite its advantages, the PercuSurge Guardwire is not an option for all, as some patients may not tolerate the necessary 3-5 minutes of [[ischemic]] time associated with this device.  Additionally, it is known to cause both [[hemodynamic]] and arrhythmic complications.





Revision as of 15:22, 28 May 2010

WikiDoc Resources for PCI in Saphenous Vein Grafts

Articles

Most recent articles on PCI in Saphenous Vein Grafts

Most cited articles on PCI in Saphenous Vein Grafts

Review articles on PCI in Saphenous Vein Grafts

Articles on PCI in Saphenous Vein Grafts in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on PCI in Saphenous Vein Grafts

Images of PCI in Saphenous Vein Grafts

Photos of PCI in Saphenous Vein Grafts

Podcasts & MP3s on PCI in Saphenous Vein Grafts

Videos on PCI in Saphenous Vein Grafts

Evidence Based Medicine

Cochrane Collaboration on PCI in Saphenous Vein Grafts

Bandolier on PCI in Saphenous Vein Grafts

TRIP on PCI in Saphenous Vein Grafts

Clinical Trials

Ongoing Trials on PCI in Saphenous Vein Grafts at Clinical Trials.gov

Trial results on PCI in Saphenous Vein Grafts

Clinical Trials on PCI in Saphenous Vein Grafts at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on PCI in Saphenous Vein Grafts

NICE Guidance on PCI in Saphenous Vein Grafts

NHS PRODIGY Guidance

FDA on PCI in Saphenous Vein Grafts

CDC on PCI in Saphenous Vein Grafts

Books

Books on PCI in Saphenous Vein Grafts

News

PCI in Saphenous Vein Grafts in the news

Be alerted to news on PCI in Saphenous Vein Grafts

News trends on PCI in Saphenous Vein Grafts

Commentary

Blogs on PCI in Saphenous Vein Grafts

Definitions

Definitions of PCI in Saphenous Vein Grafts

Patient Resources / Community

Patient resources on PCI in Saphenous Vein Grafts

Discussion groups on PCI in Saphenous Vein Grafts

Patient Handouts on PCI in Saphenous Vein Grafts

Directions to Hospitals Treating PCI in Saphenous Vein Grafts

Risk calculators and risk factors for PCI in Saphenous Vein Grafts

Healthcare Provider Resources

Symptoms of PCI in Saphenous Vein Grafts

Causes & Risk Factors for PCI in Saphenous Vein Grafts

Diagnostic studies for PCI in Saphenous Vein Grafts

Treatment of PCI in Saphenous Vein Grafts

Continuing Medical Education (CME)

CME Programs on PCI in Saphenous Vein Grafts

International

PCI in Saphenous Vein Grafts en Espanol

PCI in Saphenous Vein Grafts en Francais

Business

PCI in Saphenous Vein Grafts in the Marketplace

Patents on PCI in Saphenous Vein Grafts

Experimental / Informatics

List of terms related to PCI in Saphenous Vein Grafts

Cardiology Network

Discuss PCI in Saphenous Vein Grafts further in the WikiDoc Cardiology Network
Adult Congenital
Biomarkers
Cardiac Rehabilitation
Congestive Heart Failure
CT Angiography
Echocardiography
Electrophysiology
Cardiology General
Genetics
Health Economics
Hypertension
Interventional Cardiology
MRI
Nuclear Cardiology
Peripheral Arterial Disease
Prevention
Public Policy
Pulmonary Embolism
Stable Angina
Valvular Heart Disease
Vascular Medicine

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Jason C. Choi, M.D., Xin Yang, M.D.

Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Background

Coronary artery revascularization with saphenous veins (saphenous vein grafts or SVGs) has become a modern surgical standard for the treatment of coronary artery disease. This technique can be employed when a native coronary artery is blocked, thus causing a reduction or obstruction in blood flow. Cardiac surgeons use the sutured graft to connect the aorta to the coronary artery beyond the area of obstruction, so that blood flow may resume.

Despite their ability to restore blood flow, SVGs commonly encounter stenosis problems. The incidence of SVG stenosis is 15-30% one year after surgery, and it increases to 50% 10 years after surgery. Several factors contribute to stenosis of saphenous vein grafts, including intimal hyperplasia, plaque formation, and graft remodeling. Additionally, arterialization of the graft accelerates atherosclerosis. Furthermore, atheroma found in SVGs are more friable (easily break into small pieces) and more prone to thrombus than plaques found in native vessels. Another reason why SVGs are more susceptible to thrombotic occlusion is that they lack side branches.

Although intervention on a chronic total occlusion of a SVG may seem like an effective treatment strategy, it is best avoided.

Goals of Treatment

Primarily, the goal should be to detect and treat a SVG stenosis early in the development of ischemia while the SVG is still patent. As long as the SVG is not completely occluded, intervention can be performed.

Two additional overall goals of treating SVG stenosis include the resolution of symptomatic ischemia and the prevention/treatment of distal embolization.

Treatment Options

There are many different choices to consider when deciding the most appropriate treatment for SVG stenosis, including PTCA, PCI with bare metal or drug-eluting stents, PCI with covered stents, embolic protection devices, debulking/thrombus removal, and surgical revascularization.

Percutaneous Transluminal Coronary Angioplasty (PTCA)

PTCA has high initial revascularization success rates in the treatment of SVG stenosis. However, it is also associated with high rates of periprocedural complications, including acute vessel closure secondary to dissection and in-situ thrombosis. Additional complications include distal embolization and no reflow, which can lead to periprocedural infarction.

In modern interventional cardiology, PTCA is not often used as the sole means of treatment for SVG stenosis. Instead, stenting has become the cornerstone of treatment, while the use of PTCA has been limited to pre-dilation and post-dilation.

PCI with Bare Metal Stents (BMS) or Drug-eluting Stents (DES)

Most current vein graft treatment strategies utilize PCI with stents (BMS or DES), since stenting is a superior treatment when compared to PTCA alone. As demonstrated in the Saphenous Vein De Novo (SAVED) Trial, the use of stents is associated with higher revascularization success rates, decreased restenosis rates, and improved clinical outcomes when compared to PTCA. [1] Generally, DES are preferred over BMS, since DES are associated with reduced rates of restenosis and target vessel revascularization.

Despite their higher success rates, stents are not immune to restenosis. Predictors for restenosis include long stent length, multiple stents, overlapping stents, smaller vessel size, diabetes mellitus, and stenosis at the coronary or aortic anastomosis.

PCI with Covered Stents

Theoretically, stents covered with a polymer membrane would have higher success rates than standard BMS and DES. One would expect covered stents to effectively trap friable atheroma and isolate the graft lumen from the diseased wall, thereby reducing incidence of restenosis, distal embolization, and no reflow in comparison to traditional stents. However, the RECOVERS[2] (The Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts) and STING[3](STents IN Grafts) trials did not show any advantage in using covered stents when compared to bare metal stents for SVG lesions.

Embolic Protection Devices

During PCI of SVGs, atheroembolic debris can be liberated. This debris contains vasoactive substances that can contribute to no reflow, which can in turn considerable increase the risk of major adverse clinical events (MACE)[4]. Fortunately, embolic protection devices help capture this debris and improve outcomes in PCI for SVG stenosis. Therefore, they should be utilized in the intervention of most SVG lesions.

Currently, the FDA has approved five embolic protection devices in the United States. Specifically, these devices include one distal occlusion device, three filters, and one proximal occlusion device.

The FDA-approved distal occlusion device is called the PercuSurge Guardwire, which entails inflating a balloon distal to the stenosis to occlude flow, thereby trapping the debris and vasoactive substances and preventing them from flowing downstream. Due to its small size, it requires little landing zone to deploy. The SAFER trial[5] showed that when compared to conventional guidewires, balloon occlusion devices (PercuSurge Guardwire) reduced the rates of infarction and no-reflow after intervention. Despite its advantages, the PercuSurge Guardwire is not an option for all, as some patients may not tolerate the necessary 3-5 minutes of ischemic time associated with this device. Additionally, it is known to cause both hemodynamic and arrhythmic complications.


Template:SIB

Template:WikiDoc Sources Template:Mdr

  1. Savage MP, Douglas JS, Fischman DL; et al. (1997). "Stent placement compared with balloon angioplasty for obstructed coronary bypass grafts. Saphenous Vein De Novo Trial Investigators". N. Engl. J. Med. 337 (11): 740–7. PMID 9287229. Unknown parameter |month= ignored (help)
  2. Stankovic G, Colombo A, Presbitero P; et al. (2003). "Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: the Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts (RECOVERS) Trial". Circulation. 108 (1): 37–42. doi:10.1161/01.CIR.0000079106.71097.1C. PMID 12821546. Unknown parameter |month= ignored (help)
  3. Schächinger V, Hamm CW, Münzel T; et al. (2003). "A randomized trial of polytetrafluoroethylene-membrane-covered stents compared with conventional stents in aortocoronary saphenous vein grafts". J. Am. Coll. Cardiol. 42 (8): 1360–9. PMID 14563575. Unknown parameter |month= ignored (help)
  4. Salloum J, Tharpe C, Vaughan D, Zhao DX (2005). "Release and elimination of soluble vasoactive factors during percutaneous coronary intervention of saphenous vein grafts: analysis using the PercuSurge GuardWire distal protection device". J Invasive Cardiol. 17 (11): 575–9. PMID 16264199. Unknown parameter |month= ignored (help)
  5. Baim DS, Wahr D, George B; et al. (2002). "Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts". Circulation. 105 (11): 1285–90. PMID 11901037. Unknown parameter |month= ignored (help)