CLINICAL AND ANGIOGRAPHIC RESULTS OF TRANSLUMINAL EXTRACTION CORONARYATHERECTOMY SAPHENOUS-VEIN BYPASS GRAFTS

Background Transluminal extraction coronary (TEC) atherectomy is a rel atively new device that has recently been approved by the Food and Dru g Administration. Because of its ability to aspirate clot and atheroma tous material, TEC atherectomy may be useful in patients with stenoses in saphenous vein bypass grafts. Methods and Results TEC atherectomy was performed on 158 saphenous vein graft lesions in 146 consecutive p atients with a mean age of 65+/-8 years (78% men). Clinical indication s for atherectomy included stable angina (37%), unstable angina (54%), and postinfarction angina after recent (<1 month) myocardial infarcti on (8%). Patients with acute myocardial infarction and target vessels <2 mm in diameter were excluded. The mean age of the bypass graft was 8.3+/-3.0 years, and 17% were diffusely diseased and degenerated. Comp lex lesion morphology included total occlusion (6%), eccentricity (64% ), ulceration (18%), and thrombus (28%). The TEC atherectomy cutter wa s successfully advanced through 144 lesions (91%), but technical failu res occurred in 14 lesions (9%), and these were subsequently managed b y successful balloon angioplasty. Quantitative angiography revealed an increase in lumen diameter from 0.9+/-0.5 mm, to 1.5+/-0.7 mm after T EC atherectomy, to 2.3+/-0.8 mm after percutaneous transluminal corona ry angioplasty (PTCA) (P<.001), which corresponded to decreases in dia meter stenosis from 75+/-14%, to 58+/-20% after TEC atherectomy, to 36 +/-22% after PTCA (P<.001). Device success was achieved in 39.2% (post -TEC atherectomy decrease in diameter stenosis greater than or equal t o 20%), and procedural success was achieved in 84% (final diameter ste nosis <50% in the absence of a major complication). Angiographic compl ications were evident in 33 lesions (20.7%) immediately after TEC athe rectomy and in 8 lesions (5%) after PTCA, including distal embolizatio n (11.9%), no-reflow (8.8%), and abrupt closure (5.0%), but no perfora tions. Adjunctive PTCA (and other medical therapy) successfully manage d 61% of angiographic complications. Serious clinical complications in cluded in-hospital death in 3 patients (2.0%), emergency bypass surger y in 1 patient who died (0.7%), Q wave myocardial infarction in 3 pati ents (2.0%), non-Q wave myocardial infarction in 4 patients (2.7%), va scular injury requiring surgical repair and/or blood transfusion in 9 patients (6.1%), and hemorrhagic cerebral infarction in 4 patients (2. 7%). Using a composite clinical end point defined as in-hospital death , emergency bypass surgery, or myocardial infarction, the strongest in dependent correlate (P<.001) of a severe clinical complication was the development of one or more serious angiographic complications (no-ref low distal embolization, or abrupt closure) immediately after TEC athe rectomy. Complete clinical follow-up was available in 118 (92%) of 128 eligible patients at an interval of 6.0+/-2.5 months after discharge. Late cardiac outcome included recurrent angina treated with medical t herapy (18%), repeat percutaneous intervention on the original target lesion (26%), repeat coronary artery bypass surgery (5%), Q wave myoca rdial infarction (4%), and late cardiac death (7%). Angiographic follo w-up in 105 (80%) of 132 eligible lesions revealed a restenosis rate o f 69% (defined as a diameter stenosis >50%), including 30 lesions (29% ) with total occlusion of the original lesion. Conclusions In patients with stenoses in saphenous vein bypass grafts, TEC atherectomy is lim ited by the frequent need for adjunctive balloon angioplasty to achiev e adequate lumen enlargement and to manage TEC atherectomy-induced com plications. Although the incidence of serious clinical complications i s similar to that of other percutaneous interventions in vein grafts, there is a high incidence of restenosis and late vessel occlusion. Pro spective randomized studies are needed to determine the best revascula rization strategy for high-risk patients with old degenerated vein gra fts.