Saphenous Vein Graft Intervention: The "EPD Gap" and How it Can be Approached With a Simple Technique

Dear Editor:

We read with interest the article by Soverow and Lee in the December 2014 issue of the Journal of Invasive Cardiology describing the treatment of saphenous vein graft (SVG) lesions.¹

We suggest another option to prevent embolic events with SVG percutaneous coronary intervention. We have utilized a method that we call the suck-u-surge technique. We first described this in 2002, in a case where embolic protection was not available at the hospital where we performed the procedure.^2-4 We recently described a patient we treated with an occluded saphenous vein graft utilizing this technique (Figure 1).⁵ 

A 60-year-old gentleman presented with angina and a mild reversible defect in the lateral and infralateral segment. The patient underwent 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. He presented with mild angina. The angiogram showed the internal mammary to be patent and the ramus, which was previously patent in a study the year prior, now had a focal stenosis. Left ventricular function was maintained, with an ejection fraction of 60%.

We became a radial-first lab in April of 2010, and do virtually all of our coronary cases via the right or left radial artery.  As mentioned, we developed a technique where we performed suction thrombectomy during deployment of the stent to minimize embolic phenomena.  

This case shows the successful use of the radial approach in percutaneous coronary intervention. After this intervention, normal TIMI-3 flow was noted. The patient was discharged the following day. Thrombectomy with the suck-u-surge technique in this case illustrates this new technique via the radial approach.⁶

As this case illustrates, when embolic protection is not possible, physicians can use this fairly simple technique in order to achieve embolic protection.

References

1. Soverow J, Lee MS. Saphenous vein graft intervention: status report 2014.  J Invasive Cardiol. 2014:26:659-667.
2. Morales PA, Heuser RR. Guiding catheter aspiration to prevent embolic events during saphenous vein graft intervention. J Intervent Cardiol. 2002;15:491-498.
3. Shaia N, Heuser RR. Distal embolic protection for SVG interventions: can we afford not to use it? J Intervent Cardiol. 2005;18:481-484.
4. Cragun D, Heuser RR. Embolic protection devices in saphenous vein graft interventions. J Intervent Cardiol. 2006;19:525-529.
5. Heuser RR. An alternative to complex saphenous vein graft intervention with a covered stent: the suck-u-surge technique. Cath Lab Digest.  January 2015.
6. Heuser RR. Suck-u-surge via the radial route. Vasc Dis Manage. Blog, August 2011.

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From St. Luke’s Medical Center, Professor of Medicine, University of Arizona, College of Medicine — Phoenix, Phoenix, Arizona. 

Address for correspondence: Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, Chief of Cardiology, St. Luke’s Medical Center, Professor of Medicine, University of Arizona, College of Medicine — Phoenix 555 N. 18th Street, Suite 300, Phoenix, AR 85006. Email: rheuser@iasishealthcare.com