Recanalization of Chronic Total Occlusions in Patients With Previous Coronary Bypass Surgery and Consideration of Retrograde Access via Saphenous Vein Grafts

Abstract

Background-The prevalence of native coronary chronic total occlusions (CTOs) after coronary artery bypass grafts (CABGs) is higher than in non-CABG population. We examined outcomes of CTO percutaneous coronary intervention (PCI) post-CABG versus without CABG. Then, we looked at feasibility and outcomes of retrograde CTO PCI via patent or occluded saphenous vein graft. Methods and Results-We compared patient and procedural characteristics of 470 CTO cases treated from January 2010 to December 2015 depending on history of CABG. We assessed major adverse cardiac events, including cardiac death, myocardial infarction, ischemia-driven target-vessel revascularization, or reocclusion 1 year after successful CTO PCI in patients treated before February 2015. Post-CABG patients (175 cases) had a higher J-CTO score (2.5 versus 2.1; P=0.002). In-hospital complications were similar, although the incidence of contrast-induced nephropathy was higher in post-CABG patients (4.6% versus 1%; P=0.01). With multivariable analysis, post-CABG status was associated with higher incidence of 1-year major adverse cardiac event (hazards ratio=2.2; P=0.02). As a second level analysis, we looked at the feasibility and safety of CTO PCI via saphenous vein grafts (19% of post-CABG cases) versus collateral channels (36%) versus with an antegrade-only approach (45%), and assessed short-term outcomes and complications. High success was achieved in the saphenous vein graft group. In-hospital events were similar in the 3 groups. Conclusions-Post-CABG CTO PCI is associated with similar high success and low complications compared with CTO PCI in patients who never had CABG. However, it is associated with higher recurrent events at 1 year. To achieve high success rate, use of saphenous vein grafts as retrograde conduits seems to be safe and effective. (Circ Cardiovasc Interv. 2016;9:e003515.

Procedure failure of chronic total occlusion percutaneous coronary intervention in an algorithm driven contemporary Asia‐Pacific Chronic Total Occlusion Club (APCTO Club) multicenter registry

“…Prior CABG had been shown as an independent predictor for procedure in other registries . However, similar rate of technical success in post‐CABG cases had been shown in others studies . The prevalence of post CABG cases in our cohort (6% cases) may be too small to draw a conclusion regarding this.…”

“…11,19 However, similar rate of technical success in post-CABG cases had been shown in others studies. 13,20,21 The prevalence of post CABG cases in our cohort (6% cases) may be too small to draw a conclusion regarding this.…”

Retrograde recanalization of a nonchronic total occlusion lesion

“…In our case we used the second obtuse as the initial retrograde limb followed by part of the SVG and then into the first obtuse marginal. An alternative approach would have been the use of the occluded limb of the SVG graft . It was prioritized lower as there was no clear aortic stump and the vessel had been occluded greater than 5 years; probing to find the graft origin would increase the risk of embolizing an aortic plaque with potential for a stroke.…”

Chronic Total Occlusion Percutaneous Coronary Intervention: Evidence and Controversies

“…Saphenous vein grafts80 and septal collaterals are the preferred pathways for retrograde crossing, because they are easier to cross and carry lower risk for complications 74, 76, 79. Dautov et al assessed the safety and effectivity of the septal surfing technique in 240 retrograde PCIs, showing successful septal crossing in 81% of the cases 81.…”

“…Use of septal collaterals was associated with longer procedure (197.0AE84.6 versus 184.6AE81.4 minutes; P=0.063) and fluoroscopy (97.2AE51.9 versus 87.1AE41.4 minutes; P=0.007) times but had a lower rate of non-Q-wave MI (0.1% versus 1.1%; P=0.021) and channel injuries (1.1% versus 3.8%; P=0.005) compared with use of epicardial collaterals. 79 Saphenous vein grafts 80 and septal collaterals are the preferred pathways for retrograde crossing, because they are easier to cross and carry lower risk for complications. 74,76,79 Dautov et al assessed the safety and effectivity of the septal surfing technique in 240 retrograde PCIs, showing successful septal crossing in 81% of the cases.…”