Note: The two cases in this commentary were originally published at “Vascular
Access: The VDM Clinician Blog”, available at vasculardiseasemanagement.com/blogs.
Disclosure: Dr. Heuser reports no conflicts of interest regarding the content herein.
Dr. Richard R. Heuser can be contacted at rheuser@phoenixheartcenter.com.

We read with interest Mr. Merschen’s article a few months ago describing the use of a PTFE-covered stent.¹ 

The concept of polytetrafluoroethylene (PTFE)-covered stenting was first reported 20 years ago.² In 1993, along with Dr. Ted Diethrich, we treated a patient with a homemade covered stent at a site of a complex aneurysmal lesion in a saphenous vein graft. 

At the time, we had had experience with covered stents in the femoral arteries and were convinced that the use of this homemade covered stent could perhaps inhibit intimal hyperplasia. 

It was felt that the barrier might reduce embolic phenomena; however, the amount of embolic material that was showered in every procedure performed with this high-profile device was immediately apparent. 

The approval of the PTFE-covered stent was based on our original design and not only was intimal hyperplasia not reduced, but embolic phenomena continued to occur.^3,4,5 With the commercialization of PTFE-covered stents, all centers performing intervention have some sort of covered stent to treat dissection, tears, etc., but it is important to note that there are limitations with a covered stent.

One option for distal lesions in a saphenous vein graft, as in Mr. Merschen’s case, is embolic protection. 

Yet as was mentioned in his case, embolic protection was not possible with this distal lesion. Another option is the use of the suck-u-surge technique, first described in 2002 in a case where embolic protection was not available.^6,7,8 

This technique involves performing suction thrombectomy during deployment of the stent to minimize embolic phenomena. We recently described a patient with an occluded saphenous vein graft that was treated utilizing this technique.9 As of April 2010, our lab became “radial first”, so nearly all of our coronary cases are done via the right or left radial artery. 

In the following case, the use of thrombectomy with the suck-u-surge technique was performed via the radial approach.⁹

Case 1: Suck-u-surge technique with the radial approach

A 60-year-old gentleman presented with angina and a mild reversible defect in the lateral and infralateral segment. 

He had undergone coronary bypass 25 years ago and had a previous patent internal mammary vessel with a 100% occlusion of the right coronary with a patent graft to the ramus and internal mammary to the left anterior descending coronary artery. 

He presents with mild angina.

 The angiogram shows the internal mammary to be patent and the ramus, previously patent in a study the year before, with a focal stenosis. Left ventricular function was maintained with an ejection fraction of 60% (Figures 1-7). 

The suck-u-surge technique was utilized (Figures 8-9). Upon completion, normal TIMI-3 flow was noted. 

The patient was discharged the following day.Thrombectomy with the suck-u-surge technique is also effective in saphenous vein graft stenosis when an embolic protection device cannot be passed.¹⁰

Case 2: Suck-u-surge technique when embolic protection is not possible

A 78-year-old gentleman with no known coronary disease presented with worsening congestive heart failure symptoms. 

He is status post previous bypass. 

A year before his presentation, his saphenous vein graft to the circumflex was widely patent. He presented with angina and inferior lateral ischemia. A diagnostic study was performed. His right coronary artery was stented at two focal areas, and he was brought back for intervention three days later. 

The initial procedure as well as the follow-up procedure was performed via the right radial artery. Following the intervention (Figures 10-14), normal TIMI-3 flow was noted. The patient was discharged the following day.  

As these two cases illustrate, when embolic protection is not possible, physicians can use this fairly simple technique in order to prevent distal embolization. Although we do not disagree with the utilization of a covered stent for a complex lesion, sometimes the use of a covered stent with the possibility of restenosis or thrombosis is not necessary.

References

1. Merschen R, Fenning RS, Wascho R, Goldberg S. SVG to circumflex stenting with significant distal and proximal disease: a complex case utilizing a covered stent. Cath Lab Digest. 2014 Jan; 22 (1). Available online at https://www.cathlabdigest.com/articles/SVG-Circumflex-Stenting-Significant-Distal-Proximal-Disease-Complex-Case-Utilizing-Covered-. Accessed January 5, 2015.
2. Heuser RR, Diethrich EB, Papaoglou C, Reynolds GT. Endoluminal grafting for percutaneous aneurysm exclusion in an aortocoronary saphenous vein graft: the first clinical experience. J Endovasc Surg. 1995; 2: 81-88.
3. Stone GW, Goldberg S, O’Shaughnessy C, Midei M, Siegel RM, Cristea E, et al. 5-year follow-up of polytetrafluoroethylene-covered stents compared with bare-metal stents in aortocoronary saphenous vein grafts the randomized BARRICADE (barrier approach to restenosis: restrict intima to curtail adverse events) trial. JACC Cardiovasc Interv. 2011 Mar; 4(3): 300-309. DOI: 10.1016/j.jcin.2010.11.013.
4. Schächinger V. Hamm CW, Münzel AT, Haude M, Baldus S, Grube E, et al. STENTS (Stents IN Grafts) Investigators. A randomized trial of polytetrafluoroethylene-membrane-covered stents compared with conventional stents in aortocoronary saphenous vein grafts. J Am Coll Cardiol. 2003 Oct 15; 42(8): 1360-1369.
5. Blackman DJ, Choudhury RP, Banning AP, Channon KMJ. Failure of the Symbiot PTFE-covered stent to reduce distal embolization during percutaneous coronary intervention in saphenous vein grafts. J Invasive Cardiol. 2005 Nov; 17(11): 609-612.
6. Morales PA, Heuser RR. Guiding catheter aspiration to prevent embolic events during saphenous vein graft intervention. J Interv Cardiol. 2002 Dec; 15(6): 491-497.
7. Shaia N, Heuser RR. Distal embolic protection for SVG interventions: can we afford not to use it? J Interv Cardiol. 2005 Dec; 18(6): 481-484.
8. Cragun DT, Heuser RR. Embolic protection devices in saphenous vein graft interventions. J Interv Cardiol. 2006; 19(6): 525-529.
9. Heuser RR. Suck-u-surge via the radial route. Vascular Disease Management Blog, August 2011. Available online at https://www.vasculardiseasemanagement.com/content/suck-u-surge-radial-route. Accessed January 5, 2015.
10. Heuser RR. Suck-u-surge revisited.  Vascular Disease Management Blog, August 2011. Available online at https://www.vasculardiseasemanagement.com/content/suck-u-surge-revisited. Accessed January 5, 2015.