Treatment of Saphenous Vein Graft Disease: “Never Ending Story” of the “Eternal Return”

Published by Kowsar. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The long-term failure of the saphenous vein graft (SVG), when used for surgical coronary revascularization, is a consequence of accelerated atherosclerosis and inti-mal fibrosis. The incidence of SVG occlusion has been reported to be as high as 41% in the first year (1). In the majority of the cases, SVG percutaneous intervention is the treatment of choice with respect to the high risk of mortality and morbidity of the repeated surgery; in addition, it accounts for approximately 5% to 10% of the cath lab patients (2). In comparison with percutaneous coronary intervention (PCI), SVG intervention is technically challenging and associated with higher rates of periprocedural myocardial infarction (MI), in-hospital mortality, restenosis, and occlusion because of the soft atheromatous and thrombotic debris that develop when SVGs deteriorate (3). Even the rate of stent failure is significantly higher due to the progression of disease outside the stented segment; thus, PCI of native coronary artery lesions should be pursued when feasible. A common complication of SVG intervention is the dis-tal embolization from a typically friable plaque. This may result in the slow flow phenomenon in approximately 10% to 15% of cases and is associated with periprocedural angina and ST-segment changes (4). Although usually transient and perhaps hard to predict, the rate of peri-procedural MI can be as high as 30% and the in-hospital mortality is tenfold as high as PCI (5). Lesion length, greater angiographic degeneration of SVGs, and larger estimated plaque volume have been identified as pre-dictors of 30-day major adverse cardiac events (MACE) after SVG intervention (6). This may be explained by the fact that the greater the amount of plaque is, the greater the likelihood of distal embolization after intervention would be, which might lead to MI. Conceivably, the success of the intervention in a chronically occluded SVG is poor; thus, it should be avoided in favor of the PCI for native coronaries (7). The concept of plaque sealing, i.e. pro-phylactically stenting of intermediate lesions, has been investigated with inconclusive results (8). The same is true for the ideal antithrombotic regimen during the intervention , although the use of bivalirudin in a subset of the ACUITY study seemed to offer better safety profile in comparison …