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Saphenous venous graft (SVG) intervention is a challenge as distal embolization is common resulting in slow or no-reflow, periprocedural myocardial infarction and high in-hospital mortality. Unfortunately, there is no specific treatment for distal embolization except its prevention. Of the many pharmacological methods and device-based approaches for distal protection during PCI, guidelines have endorsed the use of embolic protection devices whenever feasible. However, use of embolic protection devices is not without complications and increases the procedural time and cost for the patient. This study aims to determine the incidence and predictors of distal embolization following SVG stenting.
A retrospective observational study of patients who have undergone percutaneous interventions of the saphenous venous graft at our institute from 2010 to 2015. Baseline clinical, demographic data and in-hospital events are obtained by independent hospital records review and intervention details from recorded angiograms. Univariate analysis and binary logistic regression for events and predictors were done using Mini tab version 17. Further analysis was done by chi-square testing. Odds ratio and 95% confidence intervals were calculated. A p-value of <0.05 was considered significant.
The study population included 177 lesions in 140 patients. Mean age was 61 ± 9 years and 89% were men. Hypertension was seen in 82.7%, diabetes in 60.4% and smoking in 39.5%. The average age of the graft was 8.2 ± 4 years. Indications for revascularization were an acute coronary syndrome in 49.2%. Angiographic success was achieved in 94.2%. No reflow/slow flow occurred in 5.7% and periprocedural MI was seen in 9.2%. Distal embolic protection device was used in 9.2%, and GP2b3a inhibitor in 20.7%. Multivariate analysis showed a correlation between events with implantation of DES (p=0.03), stent length (p=0.02) and size of a stent (p=0.04). Univariate analysis showed trend towards correlation between event and acute coronary syndrome (P-Value=0.08), stenting (P-Value=0.07), DES (P-Value=0.002) and stent length (p-value=0.03). When further analyzed by chi-square testing, only stent length (>15 mm) was an independent predictor of distal embolization. No correlation between distal embolization and age of patient, sex, hypertension, diabetes, smoking, left the ventricular function, an age of graft, direct stenting, use of an embolic device and GP2b3a inhibitors was observed.
De novo SVG lesions can be stented with a high rate of angiographic and procedural success. The risk of distal embolization can be minimized by choosing to implant a stent, drug eluting stents, and shorter stents. Stent length is the only independent predictor of distal embolization. SVG interventions can be safely done in the absence of embolic protection devices irrespective of the graft age.