A Multicenter, Randomized Trial of Coronary Angioplasty Versus Directional Atherectomy for Patients With Saphenous Vein Bypass Graft Lesions

Abstract

Atherectomy of de novo vein graft lesions was associated with improved initial angiographic success and luminal diameter but also with increased distal embolization. There was no difference in 6-month restenosis rates, although primary atherectomy patients tended to require fewer target-vessel revascularization procedures.

Prevention of Distal Embolization During Coronary Angioplasty in Saphenous Vein Grafts and Native Vessels Using Porous Filter Protection

“…10 -12 Repeat bypass operation is associated with a significant risk for the patient, 13 leaving percutaneous angioplasty as the best alternative for many patients. As a result, new devices have been developed to limit distal embolization; these include the intracoronary administration of urokinase, 14 extraction coronary atherectomy, 15 directional coronary atherectomy, 16 laser angioplasty, 17,18 ultrasound thrombolysis, 19 and AngioJet rapid thrombectomy. 20,21 Unfortunately, these techniques have generally failed to reduce distal embolization adequately.…”

Recognition of the Importance of Embolization in Atherosclerotic Vascular Disease

“…20 In the subsequent CAVEAT-II trial of saphenous vein graft intervention, the MI rates were considerably higher at 15% and 24%, respectively. 21 This finding set off a debate as to whether there was any clinical significance of the "enzyme leaks," "infarctlets," "CK bumps," "CK efflux events," or "microinfarcts." 22 In the long-term follow-up of CAVEAT, there was a significant excess of mortality for atherectomy, 23 and most patients who died in this group had experienced a periprocedural non-STsegment-elevation MI.…”

Plaque Excision Combined With Stent Placement

“…4 Although initial angiographic success was superior in the DCA arm, there was no significant difference in either angiographic restenosis rates (45.6% for DCA versus 50.5% for PTCA) or target reintervention (18.6% for DCA versus 26.2% for PTCA, Pϭ0.09). Disturbingly, distal embolization, a serious complication of vein graft intervention, was substantially higher in patients undergoing DCA (13.4% for DCA versus 5.1% for PTCA, Pϭ0.012).…”