Saphenous vein graft intervention discussion on acute vein graft occlusion intervention.

We read with interest the State-of-the-Art paper on saphenous vein graft (SVG) intervention by Lee et al. (1), and commend the authors for a comprehensive review. We would like to highlight that the review failed to mention the management of ST-segment elevation myocardial infarction due to acute SVG occlusion. Retrospective data (2,3) have confirmed his area remains a particularly high-risk subset of SVG intervenion, with 30-day mortality at 14.3% and major adverse cardiac vents rate of 36.8% at 1 year. These are significantly worse than ontemporary outcomes of acute coronary syndrome from coronary rtery culprit lesions. We previously presented (4) a case of an 4-year-old patient with an ST-segment elevation myocardial nfarction of a thrombotic occlusion in the SVG to the posterior escending artery, during which difficulty was encountered in estoring and maintaining flow in the culprit vessel. Significant ffort was focused on preventing no-reflow with: 1) continuation of he upstream tirofiban infusion; and 2) manual (Export catheter, edtronic Inc., Minneapolis, Minnesota) and mechanical thromectomy (Angiojet rheolytic thrombectomy catheter, Medrad Inc., arrendale, Philadelphia). A distal embolic protection device Emboshield Abbott Vascular, Santa Clara, California) was delivred distal to the culprit lesion before the placement of a bareetal stent. The stent nonetheless led to no-reflow, necessitating reatment with adenosine, verapamil, and nitrate intracoronary nfusion through a local delivery balloon (ClearWay RX, Atrium edical, Hudson, New Hampshire). The final result was TIMI Thrombolysis In Myocardial Infarction) flow grade 3 with no ocal complication. A 12-month clinical follow-up revealed no eintervention or rehospitalization. We feel that acute SVG occlusion deserves a special mention. here is currently little data applicable to this group of patients, as irtually all trials on the aforementioned pharmacotherapy (i.e., Ib/IIIa inhibitors, adenosine, verapamil) and devices (thrombus spiration and distal embolic protection) excluded patients with cute SVG occlusion. The significant thrombus burden in the ulprit vessel makes a satisfactory procedural outcome difficult and he resulting compromised epicardial flow impairs long-term utcome (5). It is not foreseeable that robust evidence-based uidelines will ever become available given this relatively infreuent occurrence. Interventional cardiologists may be resigned to xtrapolate data from research on SVG and acute coronary yndrome interventions and be resourceful in approaching these esions using all the tools that are available in interventional ardiology.