Pretreatment with nitroprusside for microcirculatory protection in saphenous vein graft interventions.
ABSTRACT We hypothesized that the prophylactic administration of sodium nitroprusside (NTP) during saphenous vein graft (SVG) PCI would ameliorate the detrimental effects of distal embolization and reduce the frequency and magnitude of post-procedural myonecrosis.
Sixty-four consecutive patients with normal preprocedural cardiac enzymes underwent SVG PCI without embolic protection devices and received prophylactic intragraft NTP before initial device activation. For each case, 2 control patients were selected in reverse chronologic order and were matched for stent use, thromboatherectomy device use, clinical presentation, presence of thrombus and pre-PCI thrombolysis in myocardial infarction (TIMI) flow.
Mean patient age was 66 +/- 10 years, 78% of whom were males. Stent and thromboatherectomy use was 95.3% and 3.1%, respectively in both groups (p = ns). Prior to intervention, TIMI < 3 flow was present in 26.6% of cases and in 24.2% of control patients (p = ns). Thrombus was present in 20.3% of cases and in 19.5% of controls (p = ns). Post-PCI creatinine kinase (CK)-MB elevation > 3 x the upper limit of normal (ULN) occurred in 6.3% of cases vs. 16.4% of controls (p = 0.049) and > 5 x ULN in 1.6% of cases vs.10.9% of controls (p = 0.022). In a multivariate regression model that included stent use, in-stent restenosis, thrombus presence, preprocedural TIMI 3 flow, MI as procedural indication, NTP and glycoprotein IIb/IIIa use, NTP was the only independent and significant predictor of reduced post-procedural CK-MB elevation > 5 x ULN.
Prophylactic administration of intragraft NTP during SVG PCIs results in a lower frequency and magnitude of post-procedural cardiac enzyme elevation.
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ABSTRACT: Coronary artery bypass graft (CABG) surgery remains one of the most widely performed surgical procedures in North America and aortocoronary saphenous vein grafts (SVG) are the most frequently used surgical conduits. Saphenous vein graft disease (SVGD) remains the leading cause of symptomatic coronary artery disease post-CABG. When optimal medical therapy is ineffective, repeat surgery is associated with higher mortality combined with less favorable clinical and angiographic results, thus percutaneous revascularization on SVG is currently the standard of care for the revascularization of saphenous vein graft disease Balloon angioplasty, Bare Metal Stents (BMS), PTFE-covered stents and Drug-Eluting Stents (DES) have been extensively investigated for SVG interventions. Multiple recent randomized trials and meta-analyses have confirmed the pathophysiologic and clinical differences between SVGD and coronary artery disease (CAD). Decisions such as patient selection, premedication, stent and protection device characteristics should be carefully considered to achieve optimal procedural and clinical results. Acute coronary syndromes due to SVG involvement, chronic total occlusions, retrograde approaches and SVG perforation management are newer fields requesting additional research. © 2012 Wiley Periodicals, Inc.Catheterization and Cardiovascular Interventions 07/2012; · 2.51 Impact Factor
Article: Saphenous Vein Graft Interventions.[Show abstract] [Hide abstract]
ABSTRACT: Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) currently accounts for approximately 6 % of all PCIs and is associated with increased risk for distal embolization and subsequent SVG failure compared with native coronary artery PCI. To minimize the risk for distal embolization, embolic protection devices should be used during SVG PCI when technically feasible. To minimize the risk for in-stent restenosis and the need for repeat PCI, drug eluting stents should be utilized in patients without contraindications to long-term antiplatelet therapy. Treating native coronary artery lesions is preferable to SVG PCI when technically feasible.Current Treatment Options in Cardiovascular Medicine 05/2014; 16(5):301.
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ABSTRACT: We sought to examine contemporary practice patterns of saphenous vein graft (SVG) interventions. A link to a 10-item online questionnaire was completed in June 2009 by 275 (7%) of 3,771 US interventional cardiologists surveyed. Sixty-five percent of the respondents use an embolic protection device (EPD) in >75% of SVG interventions. The main reason for not using an EPD was "anatomic difficulties" (55%), followed by device complexity (20%). Filter-based EPDs were the most widely available, well known, and commonly used EPDs, whereas the Guardwire (Medtronic Vascular) was the least commonly used EPD. The main factors underlying EPD selection were lesion location (83%), familiarity with devices (72%), and SVG diameter (64%). Factors that could increase EPD use included availability of simpler to use devices (63%), and more studies demonstrating benefit from EPD use (37%). Compared with interventionalists who used EPDs in most cases (>75%), those who utilized EPDs less frequently were less likely to be familiar with each EPD and had less EPDs available for use. Many interventionalists (84%) administer intragraft vasodilators during SVG interventions, prefer drug-eluting stents (63%) and administer >12 months antiplatelet therapy poststent implantation. During SVG interventions (1) "anatomic difficulties" are the most common reason for not utilizing an EPD; (2) filter-based EPDs are most commonly used; (3) lesion location is the most important factor for EPD selection; (4) availability of simpler to use devices could increase EPD use; and (5) intragraft vasodilators, drug-eluting stents and prolonged antiplatelet therapy are commonly utilized.Catheterization and Cardiovascular Interventions 04/2011; 79(5):834-42. · 2.51 Impact Factor