PCI of aged saphenous vein bypass grafts: easy as 1-2-3

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @DocSavageTJU

Case description

PCI of older saphenous vein grafts (SVG) is associated with a high risk of procedural complications due to their propensity for distal embolization. Distal protection devices, microvascular vasodilators (such as nicardipine), and direct stenting have all been used to reduce the risks of embolization and no-reflow during SVG procedures.

We present a case which illustrates that, by combining these techniques, PCI can be safely and easily performed for complex SVG disease.

The patient was a 55-year-old man with a subtotal lesion in a 15-year-old SVG to the RCA (Figure 1). 

PCI was performed with left radial artery access and a 6 Fr multipurpose guiding catheter. Intracoronary nicardipine (200 mcg) was administered prior to distal deployment of a FilterWire (Boston Scientific, Marlborough, MA, USA).

IVUS demonstrated an eccentric bulky lesion with a prominent area of attenuated plaque, suggestive of friable lipid core (Figure 2).

Direct stenting was then performed with a single inflation of a 4.5 mm Synergy drug-eluting stent (Figure 3).

Post-PCI IVUS confirmed an excellent result with this “one-and-done” approach (Figure 4). 

There were no ischemic complications or no-reflow, and the patient was discharged to home later the same day.

Concluding remarks

PCI of older SVG is often approached with trepidation due to the high risk of complications. A strategy which combines prophylactic intracoronary vasodilators, distal protection, and direct stenting can make the procedure as easy as 1-2-3.