Acute Vein Graft Closure: A High Risk Subset of Saphenous Vein Graft Intervention

Case

A 77-year-old gentleman with a history of hypertension, hyperlipidemia, renal insufficiency, and coronary artery disease, status post bypass x4 in 2009 presented to the hospital at 3 am with chest pain for approximately three and half hours prior to admission with inferior ST elevations. He was brought emergently to the cath lab.

Access was obtained via the left radial artery. Angiographically, the right coronary artery (RCA) appeared to be 100% occluded in the proximal portion. There were bridging collaterals (right-right) with late filling of the distal vessel (also some left-to-right collaterals were noted from the septals, but did not appear to make a direct connection) (Figures 1-2). The vein graft to the RCA was 100% occluded (Figure 3). The left internal mammary artery to the left anterior descending coronary artery (LIMA to the LAD) was patent without evidence of any significant left-to-right collaterals to the LIMA.

Given the patient’s angiographic findings and ongoing chest pain it was decided to perform revascularization. The RCA graft was an 8-year-old graft and given that it was completely occluded, we felt it might be better to try and recanalize the native RCA chronic total occlusion (CTO). We upsized to a 7-French sheath in the radial and used an Amplatz left (AL)1 guide (Figure 4). The right groin was accessed with a micropuncture, and a 5-French sheath was placed for a contralateral injection and set up for possible antegrade dissection re-entry. A FineCross (Terumo) and a Gaia second (Asahi Intecc) were used to penetrate the proximal cap. We then changed to a Fielder XT wire (Abbott Vascular) and got to knuckle into the vessel distal to the reconstitution to set up for dissection re-entry in the mid RCA. The wire, however, entered the true lumen. There was a secondary lesion distal by the bifurcation, which we were unable to cross, but injection confirmed that we were in the lumen (Figure 5). We tried to advance the FineCross, which would not go across. Typically, we use a 0.9 excimer laser (Spectranetics) to cross the lesion in this situation; however, the laser was not powered on at this time and given the acute situation, we used a series of balloons during the 5-minute warm-up for the laser. A 1.5 Euphora (Medtronic) was able to enter into the proximal portion of the lesion (but not fully cross). At that point, we inflated and used a 1.5 x 20 mm mini-Trek (Abbott Vascular), which did cross. Once we crossed with the mini-Trek, we then took a 2.0 x 30 mm balloon and subsequently took a 2.5 x 20 mm balloon, predilated, and confirmed the vessel size by intravascular ultrasound (IVUS). There was improvement in EKG changes. We predilated with a 3.5 x 15 mm AngioSculpt (Spectranetics) at high pressure and positioned a 4.0 x 38 mm Synergy extending from the proximal and mid vessel. The stent was deployed at 14 atmospheres and the proximal portion postdilated with a 4.0 x 8 mm NC Trek at 22 atmospheres to 4.5 mm. 

Angiography revealed TIMI-3 flow with a bifurcation lesion involving the posterior descending artery (PDA) and posterior left ventricular branch (PLV) (Figures 6-7). However, we did not know patient’s creatinine at this point, native flow in the vessel had been restored with filling of both vessels, and the patient had resolution of pain and EKG improvement. Therefore, we elected to leave it alone and planned to stage him for intervention during the hospitalization, if warranted.

Discussion

Approximately 10-15% of saphenous vein grafts fail within 1 year and 50% by ten years. Loss of the vasa vasorum at harvesting, inflammatory mediators, and exposure to arterial pressures promote accelerated rates of atherosclerosis, neointimal hyperplasia, and thrombosis.¹ Percutaneous coronary intervention (PCI) of vein grafts is associated with a higher rate of periprocedural myocardial infarction (MI), target vessel revascularization, and mortality compared to native vessel intervention.^2,3 This is likely the result of increased comorbidities in patients with a history of bypass, as well as the risk of embolization of atherothrombotic debris.⁴ Thus, patients with acute MI from vein graft occlusion represent a high risk subset in an already high risk population. Despite the fact that patients with a history of prior coronary bypass represent 3% of all MIs⁵, there is not robust data in the literature with regards to treating patients with acute vein graft closure. Most of the trials on pharmacotherapy or devices excluded patients with acute vein graft closure. Two smaller trials have confirmed this area remains a particularly high risk subset of saphenous vein graft intervention (higher risk population). Gaglia et al performed a retrospective analysis of patients presenting with a ST-elevation MI or non-ST elevation MI comparing culprit saphenous vein graft intervention vs native vessel intervention with 30-day mortality at 14.3% vs 8.4%, and a major adverse cardiac event rate of 36.8% vs 24.5% at 1 year.⁶ Abdel-Karim et al reviewed the acute and long-term outcomes of patients with acute vein graft occlusion. They found that at 1 and 3 years, respectively, that mortality was 8% and 42%, an acute coronary syndrome occurred in 15% and 41%, and repeat coronary revascularization was required in 28% and 38%.⁷ Therefore, it is reasonable to perform native vessel revascularization in this setting when feasible. Studies have shown that native vessel PCI is associated with more favorable outcomes compared to saphenous vein graft intervention.^8-10 In the study by Abdel Karim et al, native vessel chronic total occlusion (CTO) revascularization was attempted in three patients and successful in two patients. 

In this case, a Gaia wire was used to penetrate the proximal cap, which was then switched to a Fielder XT with the intent to set up for a dissection re-entry procedure. The Gaia family of wires (Asahi Intecc) is a new generation of CTO guidewires that have a composite-core, dual-coil construction designed to enhance torquability and maneuverability to cross long occlusions. However, they require slower, more precise manipulation as compared with currently available guidewires. Although the occlusion length was not too long, we felt it may be quicker to use the CrossBoss and Stingray (Boston Scientific) to facilitate re-entry; fortunately, the wire re-entered at the distal cap. It certainly would have been reasonable to continue in an antegrade fashion with the Gaia wire as well.  There are three crossing strategies typically used for CTO crossing at present: antegrade wire escalation, antegrade dissection re-entry, and retrograde crossing. An abundance of wires are available for CTO lesions; however, many expert operators recommend using a limited selection. Typically, in the hybrid algorithm, antegrade wire escalation starts with a polymer-jacketed, tapered-tip soft guidewire (Fielder XT), followed by a polymer-jacketed stiff guidewire (Pilot 200 [Abbott Vascular] seems to be preferred, especially if the vessel course is ambiguous) or a stiff, non-jacketed tapered-tip guidewire (Confianza Pro 12 guidewire [Asahi Intecc]) preferred if the occlusion path is clear.^11-13

The Gaia guidewires represent a new class of CTO wires: composite core and dual coil. They have stiff, tapered tips with several innovations that differentiate them from traditional CTO guidewires. The tip is a micro-cone tapered tip for smooth lesion entry. The tip core is round instead of being flat, and has a composite core consisting of a stainless steel, tube-rope coil with a traditional spring coil on the outside (composite-core, dual-coil construction). The distal coil consists of six wires instead of one wire and has ten times more torque force, enabling improved 1:1 torque transmission. The distal 1 mm tip is preshaped to a 45° angle, and has excellent shape memory and retention. The modifications allow the wire tip to deflect away from hard tissue and subintimal layers for better intimal tracking. These novel guidewires have been available in the United States since 2014.¹⁴

References

1. Harskamp RE, Lopes RD, Baisden CE, de Winter RJ, Alexander JH. Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions. Ann Surg. 2013; 257(5): 824-833.
2. Frimerman A, Rechavia E, Eigler N, Payton MR, Makkar R, Litvack F. Long-term follow-up of a high risk cohort after stent implantation in saphenous vein grafts. J Am Coll Cardiol. 1997; 30: 1277-1283. 
3. Watson PS, Hadjipetrou P, Cox SV, Pyne CT, Gossman DE, Piemonte TC, Eisenhauer AC. Angiographic and clinical outcomes following acute infarct angioplasty on saphenous vein grafts. Am J Cardiol. 1999; 83: 1018-1021.
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6. Gaglia MA, Jr, Torguson R, Xue Z, et al. Outcomes of patients with acute myocardial infarction from a saphenous vein graft culprit undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv. 2011; 78: 23-29.
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8. Yamaji K, Kimura T, Nobuyoshi M, on behalf of j-Cypher Registry; Saphenous vein graft intervention versus percutaneous coronary intervention for the native coronary artery in patients with prior coronary artery bypass grafting. Eur Heart J. 2013; 34 (suppl_1).
9. Brilakis ES, O’Donnell CI, Penny W, et al. Percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. JACC Cardiovasc Interv. 2016; 9: 884-893.
10. Brilakis ES, Rao SV, Banerjee S, et al. Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2011; 4: 844-850.
11. Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Waltham, MA: Elsevier, 2013. 
12. Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012; 5: 367-379.
13. Christopoulos G, Menon RV, Karmpaliotis D, et al. The efficacy and safety of the “hybrid” approach to coronary chronic total occlusions: insights from a contemporary multicenter US registry and comparison with prior studies. J Invasive Cardiol. 2014; 26: 427-432.
14. Khalili H, Vo MD, Brilakis ES. Initial experience with the Gaia composite core guidewires in coronary chronic total occlusion crossing. J Invasive Cardiol. 2016; 28(2): E22-E25.

Disclosure: Dr. Zaheed Tai reports the following: speaker/proctor for Terumo, Spectranetics, Boston Scientific, and Abiomed.  

Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.