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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3919_Библиотеки_им_академика_М_И_Перельмана
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https://t.me/med1917
Percutaneous revascularization of grafts provides
the interventionist with a very diverse range of
technical challenges. Perhaps because of the
propensity for vein grafts to develop friable
atheromatous material and thrombus, even the
most apparently straightforward case carries with
it the risk of sudden loss of flow due to distal
embolization. Such considerations have led to a
keen interest into methods for minimizing this,
such as direct stenting, and devices for inter-
cepting emboli before they reach the distal
coronary. Recently occluded grafts containing a
large burden of thrombus can be especially diffi-
cult to clear efficiently. Grafts are often performed
upon patients who are at higher than average risk
for major complications. Extensive areas of
disease are often involved, prompting questions
about the optimum length to cover with stent and
whether some types of stent are especially
suitable. The longer term outcome of stented
grafts is also less clear than for native vessels.
Another area of technical challenge is the stent-
ing of a native coronary via a graft, perhaps the
ultimate example being the LAD via a LIMA graft.
Finally, increasingly we are being presented with
grafts whose access may be difficult or unusual.
In this chapter we present a range of graft
cases with which we aim to explore these techni-
cal challenges.
Comments have been obtained from
Christopher J White, Christian W Hamm,
Stephan Baldus, Christopher SR Baker and
Martin T Rothman.
Case 1. Grafts
54-year-old man. Hypertension; family history;
hypercholesterolaemia. Presented with limiting
exertional angina. 1984 CABG (vein grafts to
LAD, OM, and RCA).
7
Graft disease
Figure 7.1
LAD graft angiogram. a) Mid-graft stenosis. b) Result.
a b
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Catheter findings:
Good LV; occluded RCA;
significant LMS and proximal LAD disease; vein
graft to LAD 80% mid vessel stenosis; occluded
VGs to OM and RCA.
Procedure:
Left graftseeker (8F) guide; 0.014⬙
high torque floppy wire. Pre-dilatation with
3.0 mm monorail balloon. Segment stented with
ACS MULTI-LINK
®
3.5 mm ⫻ 25 mm to 12 atm.
Christopher J White:
I think that serious consideration should have
been given to performing redo CABG with
arterial conduits in this relatively young man
with preserved LV function. Even after success-
ful SVG–LAD intervention he will have continued
ischaemia of the inferior wall, and with such old
grafts the likelihood of failure due to either in-
stent restenosis or the development of a new
lesion is more than 50% at 1 year. Repeat bypass
offers him the best chance of ‘complete’ revas-
cularization and sustained clinical improvement.
In selecting a guiding catheter for a cranially
oriented take-off of a vein graft, I would prefer
an Amplatz shape, perhaps AL1 or AL1.5 or a
‘hockeystick’, which would allow a more coaxial
alignment of the guiding catheter and ostium of
the graft. I prefer an 8F guide when delivering
‘Palmaz’ biliary stents to vein grafts, but I prefer
a large lumen (> 0.66⬙) 6F guiding catheter to
deliver coronary stents.
I have a general preference for ‘stiffer’ extra
support-type guidewires, which I believe aid
delivery and trackability of stents into vein grafts.
When using low profile coronary stents in
lesions such as this, it is appropriate to attempt
avoidance of pre-dilatation to minimize the risk
of distal embolization during withdrawal.
I prefer to use longer, rather than shorter
stents for vein graft disease. We know from IVUS
and angioscopic imaging that the vein graft is
diffusely diseased which makes complete cover-
age of the lesion the goal. The frequent occur-
rence of ‘new’ lesions during follow-up of vein
graft stents supports the strategy of complete
coverage rather than ‘spot’ stenting.
78 GRAFT DISEASE
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Case 2. Grafts
48-year-old man. Hypercholesterolaemia. CABG
surgery 1988 (VGs to RCA and OM, LIMA to
LAD). Limiting exertional angina.
Catheter findings:
LV good; LAD occluded proxi-
mally; circumflex occluded proximally; severe
native RCA disease; VG to RCA patent with good
run off; LIMA to LAD patent with good run off; I
stump; VG to OM as shown.
Procedure:
Left graftseeker guide (8F); 0.014⬙
high torque floppy wire. 4.0 mm monorail
balloon followed by NIR 4.0 mm ⫻ 16 mm stent
mounted on a 5.0 mm ByPass Speedy balloon
deployed at 12 atm.
CASE 2. GRAFT DISEASE 79
a b
c d
Figure 7.2
OM graft angiogram. a,b) Distal stenosis. c,d) Result.
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Christopher J White:
I would consider using a Palmaz ‘biliary’ stent in
this lesion instead of expanding a coronary stent
to its upper limits. I would not favour graft recon-
struction with a Wallstent
®
in this diffuse non-
obstructive disease until there are convincing
data that there is a true benefit.
Prevention of distal emboli is a challenging
problem. I treat most vein graft lesions with
abciximab (Reopro
®
) which does not prevent
emboli from occurring but may minimize the
sequelae of prolonged no-reflow. I avoid exces-
sively high (> 1 2 atm) balloon inflation
pressures in vein grafts to minimize distal
emboli. We are currently gaining experience
with the Percusurge device (Fig. 7.3a), which
blocks run-off of embolic material with a distal
occlusion balloon and then allows aspiration
and removal of the material. The left panel
shows the baseline angiogram with a tight
proximal stenosis in the body of a vein graft,
the middle panel shows the Percusurge balloon
inflated (arrows). Aspiration of debris proximal
to the balloon can take place through the
catheter. The right panel shows the final result
after stent placement and removal of the
Percusurge catheter.
The distal location of the lesion in case 2
would make positioning and inflating of the
Percusurge occlusion balloon difficult, and may
well preclude its use in this case.
80 GRAFT DISEASE
abc
Figure 7.3
RCA angiogram. a) Lesion in proximal RCA. b) Distal position of Percusurge balloon seen at arrows. c) Result.
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Case 3. Grafts
68-year-old man. Ex-smoker; high cholesterol.
CABG surgery 8 years earlier: jump graft from
diagonal to LAD; vein graft to RCA.
Stable angina.
Catheter findings:
Moderate LV; patent vein
grafts but lesion in LAD beyond insertion.
Procedure:
Left graftseeker guide (8F); 0.014⬙
high torque floppy wire; 2.5 mm Bypass Speedy
balloon. Cordis CrossFlex™ 3.0 mm ⫻ 15 mm
stent.
Christopher J White
With the small size of the native LAD (< 2.5 mm),
I would try to avoid placing a stent. If it becomes
necessary to stent a 2.5 mm vessel, I prefer
slotted tubular stents which generally have a
lower profile than coil stents, and in smaller
vessels yield a larger post-stent MLD owing to
less recoil. I prefer a stiffer-bodied guidewire to
aid trackability of the balloons and stent to these
distal lesions. Alternatively, a balloon-on-a-wire
system, such as the ACE (Scimed) balloon, works
very well in these potentially difficult to reach
lesions.
CASE 3. GRAFT DISEASE 81
a b
Figure 7.4
LAD graft angiogram. a) Lesion in native LAD. b) Result.
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Case 4. Grafts
65-year-old man. Ex-smoker; hypertension.
CABG surgery 1991 (vein grafts to LAD and RCA).
Recurrent stable angina.
Catheter findings:
Well preserved LV function;
both grafts patent, but occlusion of native LAD
beyond anastomosis.
Procedure:
JR4 8F guide; 0.014⬙ high torque
floppy wire backed-up with 1.5 mm over-the-wire
balloon for disobliteration, then 2.5 mm monorail
balloon. Not stented.
Christopher J White:
My initial wire selection would have been an
exchange length extra-support guidewire to facil-
itate potential stent placement. If that failed to
cross, my second choice would be a coated wire
such as the Choice-PT™ (Scimed) or Crosswire™
(Cordis) also using an over-the-wire balloon for
support. I would favour a 6F guiding catheter
unless rotational atherectomy was being consid-
ered, although the 1.5 mm burr may be used in
a large-lumen (> 0.66⬙) guiding catheter.
The best current evidence demonstrates a
superior outcome when total occlusions are
treated with stents.
1
The limitation in this case is
the size of the target artery. I would have tried very
hard to place a 3 mm balloon-expandable stent in
this lesion. If, at the beginning of the procedure, I
felt the vessel was too small to stent, I would
strongly consider using rotational atherectomy to
‘debulk’ the total occlusion as an adjunct to
balloon dilatation. While the angiographic appear-
ance of the result obtained with balloon alone in
this case is excellent, this is the exception rather
than the rule in treating total occlusions.
82 GRAFT DISEASE
a b
Figure 7.5
LAD angiogram. a) Total occlusion of native vessel. b) Result.
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Case 5. Grafts
58-year-old man. Ex-smoker; hypertension.
CABG 1987: vein grafts to LAD, OM, and RCA.
Recurrent symptoms and investigation at a
different hospital led to referral for redo CABG.
Presented with unstable angina with anterior T
wave changes and lateral ST depression.
Catheter findings:
Occluded LMS; dominant RCA
with tight distal stenosis; VG to LAD occluded
with thrombus; vein graft to OM contained
significant ostial and mid-vessel stenoses;
VG to RCA had significant stenosis distally. LV
moderate.
Procedure:
• LAD vein graft: left graftseeker 8F guide;
0.014⬙ high torque floppy wire. Multiple infla-
tions along graft and at anastomosis with
3.0 mm monorail balloon. Three stents:
distally 3.5 mm ⫻ 28 mm Guidant Duet at
anastomosis overlapped in graft by Guidant
Duet 4.0 mm ⫻ 23 mm. From ostium into graft
a Guidant Duet 4.0 mm ⫻ 28 mm stent was
deployed, crossing the line of occlusion.
• OM vein graft: left graftseeker 8F guide; 0.014⬙
high torque floppy wire. Pre-dilatation of mid-
vessel stenosis with 3.5 mm monorail balloon
followed by 4.0 mm ⫻ 28 mm Guidant Duet
stent. More proximal lesion directly stented
using Guidant Duet 4.0 mm ⫻ 23 mm.
• RCA VG: Amplatz Left Guide (8F); 0.014⬙ high
torque floppy wire. Direct stent with 3.5 mm ⫻
13 mm Guidant Duet.
Abciximab (ReoPro
®
).
CASE 5. GRAFT DISEASE 83
a b
Figure 7.6a–g
a) Total occlusion of proximal LAD graft. b) Result of disobliteration and distal stent.
continued
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84 GRAFT DISEASE
c d
e f
Figure 7.6
continued
c) Result of LAD graft. d) Ostial and mid-graft disease. e) Result of proximal and mid-graft stenting. f) RCA graft
lesion (arrow).
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Christopher J White:
Intervention for acute coronary ischaemia is
appropriate in this case, although in this
relatively young man with 12-year-old vein
grafts, redo bypass surgery with arterial conduits
would have the advantage of greater durability
than can be achieved with percutaneous inter-
vention in degenerated vein grafts.
I agree with the strategy of treating multiple
vessels at one sitting: as long as each result is
excellent, I would not hesitate to continue on to
the next vessel. For thrombosed vein grafts,
particularly those with a large thrombus burden,
my approach is to use aspiration thrombectomy
with the Angiojet™ (Possis; Figs 7.6
*
,
* *
) followed
by balloon dilatation and primary stent place-
ment.
Fig. 7.6
*
is the baseline angiogram of a throm-
bus filled graft.
Angiogram of the excellent result following
Possis Angiojet™ and stent placement of mid-
graft lesion.
CASE 5. GRAFT DISEASE 85
g
*
**
Figure 7.6
continued
g) Result of RCA graft stenting.
*
,
**
) Aspiration
thrombectomy with the Angiojet™.
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