Transradial Management of Saphenous Vein Bypass Graft Disease Using Rheolytic Thrombectomy and Coronary Stenting

Key words: bypass graft, distal protection, intervention With the large number of patients who have had coronary bypass surgery in the past 20 years, management of recurrent ischemia in patients with venous bypass graft disease is a major challenge. Atherosclerotic disease in saphenous vein grafts (SVBG) is characterized by diffuse, friable, ulcerated plaques with a propensity for rupture and clot formation.^1,2 Intervention in these diseased grafts is associated with significant periprocedural major adverse coronary events (MACE) due to embolization of this material.^3–7 Contemporary management usually requires the use of large-bore catheters. The present case describes a successful long-term result using 6 French (Fr) catheters via the transradial approach. Case Report A 67-year-old diabetic male who underwent coronary bypass surgery in 1993 presented with a non-Q wave myocardial infarction (peak total CPK, 1575 units). Echocardiography revealed significant left ventricular dysfunction with an ejection fraction of 30%. The patient stabilized with medical management and cardiac catheterization was performed. All three native coronaries were occluded. A left internal mammary artery graft to the left anterior descending coronary artery was normal. The SVBG to the left circumflex was insignificantly diseased. The SVBG to the right coronary artery (RCA) contained a subtotal stenosis in the proximal third of the graft with diffuse intraluminal filling defects present throughout the length of the graft (Figure 1). The patient was referred to our institution for interventional management. After confirmation of a patent ulnar artery and palmar arch utilizing Doppler evaluation, a 6 Fr Daig sheath (St. Jude Medical, Minneapolis, Minnesota) was introduced into the left radial artery. The patient was anticoagulated with 12.8 ml of intravenous bivalirudin (Angiomax, The Medicines Company, Cambridge, Massachusetts) and placed on a 30 cc/hour drip. A 6 Fr Zuma II AR2 guiding catheter (Medtronic, Minneapolis, Minnesota) was advanced to the ascending aorta and engaged in the ostium of the RCA SVBG without difficulty. A 0.014´´ extra-support Trooper guidewire (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) was advanced through the body of the graft and positioned in the distal RCA. After pretreatment with 0.5 mg atropine for bradycardia prophylaxis, a 4 Fr Angiojet XMI thrombectomy catheter (Possis Medical, Minneapolis, Minnesota) was inserted. Four separate passes were made throughout the entire length of the graft for a total treatment time of 90 seconds. Initial TIMI grade II flow in the graft rapidly improved to grade III after administration of 200 µg diltiazem into the graft. Angiography revealed a significant reduction in the intraluminal filling defects, but diffuse luminal irregularities and the proximal severe stenosis persisted (Figure 2). Stenting of the bypass graft was then performed utilizing two self-expanding 4.0 x 47 mm Wallstents (Boston Scientific/Scimed, Inc.). Post-delivery inflations were performed with a 4.0 x 20 mm Viva balloon (Boston Scientific/Scimed, Inc.) to a maximum of 10 atmospheres within the stented segments. Angiography at the conclusion of the procedure revealed a widely patent graft without residual defects or stenosis, and TIMI grade III flow (Figure 3). The guide catheter and radial sheath were removed and a Radstat radial compression device (Merit Medical, Salt Lake City, Utah) was affixed to the left wrist. Total procedure time was 58 minutes; fluoroscopy time was 20 minutes. Subsequent serial enzymes remained negative, and the patient convalesced uneventfully. He was discharged 2 days later on Plavix 75 mg po qd in addition to his pretreatment medications. The patient underwent repeat cardiac catheterization 6 months after the initial procedure. The saphenous vein graft was widely patent without stenosis and appeared identical to Figure 3. Discussion The present case describes the successful treatment of a severely diseased saphenous vein bypass graft using rheolytic thrombectomy followed by coronary stenting. The 4 Fr Angiojet XMI catheter, continued miniaturization of coronary stent delivery systems, and larger lumen for 6 Fr guide catheters allowed the case to be performed from the transradial approach. Large numbers of patients who have undergone coronary bypass surgery in the past 30 years are now presenting with recurrent ischemic symptoms.8 Saphenous vein graft attrition is well documented. Ten years after surgery, only 60% of these grafts are patent and only 50% of the patent grafts are free from significant disease.^9–11 Early SVBG failure is due to thrombotic occlusion or fibrointimal hyperplasia, but late failure is secondary to vein graft arteriosclerosis.¹¹ This disease tends to be diffuse with inflammation, foam cells and multi-nucleated giant cells laden with lipids. The fibrous cap is either thin or absent, and thrombus is often present.^1,2 Coronary intervention is associated with a high incidence of distal embolization; indeed, intravascular filters positioned distal to SVBG interventions have collected debris in virtually every case.^12,13 Coronary intervention in these diseased vein grafts should therefore be accompanied by therapeutic measures to deal with distal embolization.¹⁴ Intracoronary administration of urokinase, platelet glycoprotein IIb/IIIa receptor antagonists, extraction coronary atherectomy, directional coronary atherectomy and laser angioplasty have all failed as adjunctive measures.^7,15–18 More recently, various distal protection devices such as the PercuSurge guard wire (PercuSurge, Minneapolis, Minnesota) and porous filter devices have had encouraging results in preventing this distal embolization.^13,19 However, to date, these devices necessitate the use of large-bore guide catheters. Rheolytic thrombectomy may also have a role in managing vein graft disease.²⁰ The VeGAS trial showed that patients randomized to Angiojet treatment had higher procedural success with a lower incidence of MACE as compared to intracoronary urokinase.^21–23 Whether or not the Angiojet catheter removes atherosclerotic debris in addition to thrombus has not been evaluated. Furthermore, a direct comparison between Angiojet and PercuSurge in the management of SVBG disease has not been performed. Indications for performing saphenous vein graft intervention from the transradial approach are largely related to operator experience with this technique. The benefits of this approach have been previously described.^24–26 However, learning curve issues, aortoiliac disease and the need for distal protection are important considerations in making a final decision about access site. It should be emphasized that left saphenous vein graft interventions are best performed from the left radial artery, as in this case. Our technique for left radial interventions has been previously described.^{4–6,27–29} The present case describes successful removal of extensive intraluminal filling defects in a diseased SVBG with the 4 Fr Angiojet XMI catheter. Coronary stenting was then performed without MACE. A 6 Fr guide system was used and the procedure was performed transradially. Angiography 6 months later revealed a patent graft without restenosis. Conclusion Successful treatment of saphenous vein graft disease involves a multifaceted approach to prevent distal embolization. We describe a case performed transradially through a 6 Fr guide catheter.

1. Virmani R, Atkinson JB, Forman M. Aortocoronary saphenous vein bypass grafts. Cardiovasc Clin 1988;18:41–62. 2. Douglas JS. Percutaneous intervention in patients with prior coronary bypass surgery. In: Topol EJ (ed). Textbook of Interventional Cardiology. Philadelphia: WB Saunders Company, 1994: pp. 339–354. 3. Wong SC, Baim DS, Schatz RA, et al. Acute results and late outcomes after stent implantation in saphenous vein graft lesions: The multicenter USA Palmaz-Schatz stent experience. J Am Coll Cardiol 1995;26:704–712. 4. Keely EC, Velez CA, O’Neill W, Safian RD. Long-term clinical outcome and predictors of major adverse cardiac events after percutaneous interventions on saphenous vein grafts. J Am Coll Cardiol 2001;38:659–665. 5. Ho KK, Carrozza JP, Pompa JJ, et al. Creatine-kinase MB isoform (CB-MB) elevations following single-vessel percutaneous revascularization of saphenous vein grafts. Circulation 1998;98:153. 6. Nishida T, Colombo A, Briguori C, et al. Contemporary percutaneous treatment of saphenous vein graft stenosis. Immediate and late outcomes. J Invas Cardiol 2000;12:505–512. 7. Moses JW, Moussa I, Pompa JJ, et al. Risk of distal embolization and infarction with transluminal extraction atherectomy in saphenous vein grafts and native coronary arteries. Cathet Cardiovasc Intervent 1999;47:149–154. 8. Willman VL. Aortocoronary bypass with saphenous vein graft. JAMA 1996;276:1521–1525. 9. Nwasokwa ON. Coronary artery bypass graft disease. Ann Int Med 1995;123:528–533. 10. Campeau L, Enjalbert M, Lesperance J, et al. The relation of risk factors to the development of atherosclerosis in saphenous vein bypass grafts and the progression of disease in the native circulation: A study 10 years after aortocoronary bypass surgery. N Engl J Med 1984;311:1329–1332. 11. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease: Pathogenesis, predisposition, and prevention. Circulation 1998;97:916–931. 12. Sutsch G, Kiowski W, Luscher TF, et al. Use of an emboli containment and retrieval system during percutaneous coronary angioplasty in native coronary arteries. Schweiz Med Wochenschr 2000;130:1135–1145. 13. Eberhard G, Gerckens U, Yeung AC, et al. Prevention of distal embolization during coronary angioplasty in saphenous vein graft and native vessels using porous filter protection. Circulation 2001;104:2436–2441. 14. Baim DS, Carrozza JP Jr., Kuntz RE, Laham R. Managing the embolization problem during saphenous vein graft intervention. Cathet Cardiovasc Intervent 1999;47:155–156. 15. Hartman J, McKeever L, Teran J. Prolonged infusion of urokinase for recanalization of chronically occluded aortocoronary bypass graft. Am J Cardiol 1988;61:189–191. 16. Safian RD, Grines CL, May MA, et al. Clinical and angiographic results of transluminal extraction coronary atherectomy in saphenous vein bypass grafts. Circulation 1994;89:302–312. 17. Holmes DR Jr., Topol EJ, Califf RM, et al. The CAVEAT-II Investigators. A multicenter, randomized trial of coronary angioplasty versus directional atherectomy for patients with saphenous vein bypass graft lesions. Circulation 1995;91:1966–1974. 18. Bittl JA, Sanborn TA, Yardley DE, et al., for the Coronary Angioplasty Registry. Predictors of outcome of percutaneous excimer laser coronary angioplasty of saphenous vein bypass graft lesions. Am J Cardiol 1994;74:144–148. 19. Carlino M, De Gregorio J, Di Marco C, et al. Prevention of distal embolization during saphenous vein graft lesion angioplasty: Experience with a new temporary occlusion and aspiration system. Circulation 1999;99:3221–3223. 20. Rosenschein U, Gaul G, Erbel R, et al. Percutaneous transluminal therapy of occluded saphenous vein grafts: Can the challenge be met with ultrasound thrombolysis? Circulation 1999;99:26–29. 21. Ramee SR, Baim DS, Pompa JJ, et al. A randomized prospective multicenter study comparing intracoronary urokinase to rheolytic thrombectomy with the POSSIS Angiojet catheter for intracoronary thrombus. Final results of the VeGAS 2 trial (Abstr). Circulation 1998;98(Suppl I):I-437. 22. Cohen DJ, Ramee S, Baim DS, et al. Economic assessment of rheolytic thrombectomy versus intracoronary urokinase for treatment of extensive intracoronary thrombus: Results from a randomized clinical trial. Am Heart J 2001;142:648–656. 23. Kuntz RE, Baim DS, Cohen DJ, et al. A trial comparing rheolytic thrombectomy to intracoronary urokinase for coronary and vein graft thrombus: Results of the vein graft Angiojet study (VeGAS 2). Am J Cardiol 2001. 24. Louvard Y, Lefévre T, Allain A, Morice M. Coronary angiography through the radial of the femoral approach: The CARAFE study. Cathet Cardiovasc Intervent 2001;52:181–187. 25. Kiemeneij F, Laarman GJ, Slagboom T, van der Wieken R. Outpatient coronary stent implantation. J Am Coll Cardiol 1997;29:323–327. 26. Lotan C, Hasin Y, Mosseri M, et al. Transradial approach for coronary angiography and angioplasty. Am J Cardiol 1995;76:164–167. 27. Mann T, Cubeddu G, Schneider J, Arrowood M. Left internal mammary artery intervention: The left radial approach with a new guide catheter. J Invas Cardiol 2000;12:298–302. 28. Mann T, Cowper PA, Peterson ED, et al. Transradial coronary stenting: Comparison with femoral access closed with an arterial suture device. Cathet Cardiovasc Intervent 2000;49:150–156. 29. Mann T, Cubeddu G, Bowen J, et al. Stenting in acute coronary syndromes: A comparison of radial versus femoral access sites. J Am Coll Cardiol 1998;32:572–576.