TRANSLUMINAL EXTRACTION CATHETER ATHERECTOMY FOLLOWED BY IMMEDIATE STENTING IN TREATMENT OF SAPHENOUS-VEIN GRAFTS

Objectives. The purpose of this study was to evaluate the effectivenes s of transluminal extraction catheter (TEC) atherectomy followed by im mediate Palmaz-Schatz coronary stenting of coronary bypass vein grafts . Background. Degeneration of saphenous vein coronary bypass grafts ha s become a common problem. Repeat bypass surgery is associated with gr eater risk and a poorer outcome than the initial operation. Moreover, percutaneous interventional procedures in vein grafts have been associ ated with high procedural complication rates, including distal emboliz ation, and high restenosis rates. TEC atherectomy may reduce distal em bolization, and stenting may reduce restenosis rates. Methods. We eval uated the procedural, hospital and clinical outcomes of TEC atherectom y followed by immediate Palmaz-Schatz coronary stenting of 53 vein gra fts in 49 consecutive patients, The strategy was to limit instrumentat ion to extraction debulking and to stabilizing the site with stent dep loyment before using balloon dilation for optimal gain in lumen diamet er. Results. Results are shown as mean value (95% confidence interval [CI]). The mean graft age was 9.2 years (95% CI 7.9 to 10.5), and 1.0 (95% CI 1 to 1) TEC cutter (2.2 mm [95% CI 2.1 to 2.3]) and 1.7 (95% C I 1.4 to 2.0) Palmaz-Schatz coronary stents/vein graft were used. The procedural success rate was 98%, with a minimal lumen diameter at base line of 1.3 mm (95% CI 1.1 to 1.5), increasing to 3.9 mm (95% CI 3.6 t o 4.2) (p < 0.05) after the TEC-stent procedure. Procedural complicati ons occurred infrequently: graft perforation in 1 (2%) of 53 patients and distal embolization in 1 (2%) of 53 (same patient). In hospital co mplications included non-Q wave myocardial infarction in two patients and death after a successful procedure in three (6%) (n = 1 each: mass ive bleeding from the catheter site; sepsis; and acute myocardial infa rction with asystole in the distribution of the stented vessel). The e vent free survival rate to hospital discharge was 90%. Clinical follow -up (13 months [95% CI 11 to 15]) was available for all patients. Ther e mere five (11%) revascularization procedures (three bypass grafts an d two percutaneous transluminal coronary interventions), four (9%) non fatal myocardial infarctions and five (11%) deaths, for a cumulative r ate of 28% for any adverse outcome occurring in 13 of 46 patients. Con clusions. TEC atherectomy followed by immediate Palmaz-Schatz coronary stenting of stenoses in old (>9 years) saphenous vein grafts can be s uccessfully performed, with a low incidence of procedural and hospital complications. Clinical restenosis rates are low and less than those previously reported; however, late morbid cardiac events are still fre quent in this high risk group of patients. These observational finding s suggest that this technique may improve percutaneous management of v ein graft disease, but optimal long-term management strategies remain to be determined. (C) 1997 by the American College of Cardiology.