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The percutaneous treatment of the coronary saphenous bypass grafts (SVG) remains a challenge in interventional cardiology. Treatment of degenerated SVG still involves a high risk of immediate embolic complications, high incidence of target lesion revascularization and progression of the disease on adjacent segments and often difficulty in the evaluation of the caliber and discrepancy in size in presence of aneurysm.
to evaluate if the use of self-expandable stents may offer an advantage compared to balloon-expandable stents. Self-expandable stents may solve the problem of the discrepancy in size, they can be used in presence of aneurysms or of widespread disease implying a lower risk of malapposition, with less acute thrombosis. They don’t require a heavy post-dilatation implying a lower risk of thromboembolism and parietal damage and leading to a reduced risk of in-stent restenosis, edge- restenosis and deterioration of adjacent segments. We called this technique “Soft touch technique” consisting in direct stenting (if possible) and post dilatation limited to the most stenotic portion of the graft using undersized balloons). Self expandable stents increase in diameter in the days following the procedure, this may reduce the incidence of plaque rupture and distal embolization.
Between October 2012 and October 2014 we treated 20 patients. 13 with acute coronary syndrome. Mean age of the grafts: 12 years. In 8 cases we used a distal embolic protection filter. 5 patients had aneurysmatic dilatation of the graft. No major complications occurred. In one case we implanted a balloon expandable stent at distal edge of self-expandable stent for distal dissection of the vessel with a good final result. In one case we implanted a balloon expandable stent to treat one ostial in-stent restenosis due to distortion of the stent struts caused by the guiding catheter. Good angiographic result in all cases (final TIMI flow III). CT angiography performed after 3 months confirmed the patency of the stents. All patients remained asymptomatic during follow-up.
The treatment of degenerated SVG with self-expandable stents and “soft touch technique” may reduce the risk of distal embolization and of periprocedural infarction. This technique, implying a minor parietal trauma, may also reduce the incidence of restenosis and solve the problem of mismatch of caliber and widespread disease. Larger and appropriate studies are needed to determine differences, optimize clinical practice and validate our hypothesis.