ABSTRACT: This report describes the simultaneous use of both peripheral and coronary distal protection techniques to prevent no-reflow phenomena in a large sequential saphenous vein graft. The use of a large peripheral stent allowed for simultaneous distal protection while advancing the larger-lumen stent over both wires, resulting in safe deployment.

       Advancing technologies have allowed percutaneous interventional procedures to safely and efficaciously treat challenging stenoses in the coronary and peripheral vascular systems. The embolization of soft atherosclerotic debris in the treatment of degenerated saphenous vein grafts has long been recognized as a cause of no-reflow and increased morbidity and mortality.¹ The use of distal protection devices to trap embolic debris during the treatment of diseased vessels has decreased the occurrence of no-reflow and improved major adverse clinical event rates.^2,3 We describe a unique approach to treating a complex lesion in a saphenous vein graft using a combined coronary and peripheral approach.

       Case Report. A 68-year-old male with prior coronary artery bypass grafting developed angina pectoris 23 years after surgery. A nuclear stress test revealed anterior ischemia. He had a single sequential vein graft (SVG) with a side-side

Figure 1

Sequential SVG with significant stenosis proximal to the side-to-side anastomosis of the LAD and end-to-side insertion of the PDA (notice the previously placed Wallstent).

anastomosis to the left anterior descending artery (LAD), and an end-side anastomosis to the distal right coronary artery (RCA). Six years prior to this presentation, the distal portion of the graft was treated with a 6.0 x 40 mm Magic Wallstent (Boston Scientific, Natick, Massachusetts). Diagnostic coronary angiography via the femoral artery (6 Fr) revealed a patent SVG with a significant lesion in the proximal portion of the vessel supplying the LAD and a patent stent distally (Figure 1). The RCA distal to the graft was diffusely diseased but patent. Left ventricular function was normal. The native RCA and LAD were chronically occluded proximally and the circumflex (nondominant) was patent. The graft diameter was estimated at 6.0 mm. Distal embolization resulting in no-reflow was a concern, so the patient was treated with intravenous heparin to

Figure 2

Sequential SVG with both the FilterWireEX (A), AccuNet (B), and prior Wallstent (C) before stent placement.

maintain an activated clotting time of 250 seconds, combined with eptifibatide. Distal protection of the LAD was performed using a FilterWireEX (Boston Scientific), and the distal portion of the SVG was protected with an AccuNet device (Guidant Corp., Indianapolis, Indiana) (Figure 2). With both distal protection devices in place, a 6.0 x 57 mm (0.35 inch compatible) Express Stent (Boston Scientific) was advanced over both wires without a guide catheter and advanced to the diseased portion of the SVG using fluoroscopic landmarks. The stent was deployed at 8 atm and postdilated with a 6.0 mm balloon. After removal of the balloon, a 6 Fr guide catheter was advanced over the distal protection devices and the FilterWireEX and AccuNet systems were retrieved. Small but noticeable debris was present in both devices. Final angiography revealed a

Figure 3

Angiogram showing the results of successful deployment of the Express stent and removal of both distal protection devices.

widely patent SVG and normal (TIMI 3) flow (Figure 3). The patient was discharged the following day without cardiac enzyme elevation and a normal electrocardiogram, and remains free of clinical angina at 6 months.

       Discussion. The treatment of complex saphenous vein graft disease with percutaneous intervention has allowed patients to undergo successful treatment without repeat surgery. The challenges associated with this treatment involve preventing the complications that can occur in severely diseased SVGs. Distal emboli causing no-reflow with subsequent infarction and poor clinical outcome have resulted in the development of devices to trap emboli and protect the distal circulation during complex interventions of SVGs. Since distal protection was first described in SVGs,^2,3 devices have been developed for the treatment of carotid arteries.^4,5 The initial devices were balloon occlusive devices over an angioplasty wire preventing distal embolization of debris and removal of embolic debris through a suction catheter. The development of expandable filter nets over an angioplasty wire have allowed distal protection without occlusion.
       We used the FilterWireEX to protect the LAD (despite the current recommendations for use in SVG interventions only, we were concerned that distal emboli could result in LAD compromise). To adequately protect the 6.0 mm distal SVG and obtain complete coaptation of the vessel wall by a filter to trap potential emboli, we used the larger AccuNet device designed for carotid stenting. Since the SVG was 6.0 mm, a 0.35 inch compatible peripheral stent allowed for advancement over both wires and safe deployment of the stent in a severely diseased segment of the SVG. The presence of atherosclerotic debris in both filter devices strongly suggests that the possibility of no-reflow was prevented by using this technique.
       We feel that this procedure is a great example of the use of both peripheral and coronary techniques to safely and effectively treat a severe stenosis in a large SVG.