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Severe ostial saphenous vein graft disease leading to acute coronary syndromes following proximal aorto-saphenous anastomoses with the symmetry bypass connector device

Is it a suture device or a "stent"?

Jeffrey J. Cavendish, MD^*, William F. Penny, MD, FACC^*, Michael M. Madani, MD, Shahin Keramati, MD^*, Ori Ben-Yehuda, MD, FACC^*, Daniel G. Blanchard, MD, FACC^*, Ehtisham Mahmud, MD, FACC^*, Anthony Perricone, MD and Sotirios Tsimikas, MD, FACC^*,*

^* Department of Medicine, Division of Cardiology, University of California-San Diego, La Jolla, California, USA
Department of Cardiothoracic Surgery, University of California-San Diego, La Jolla, California, USA
San Diego Veterans Administration Medical Center, San Diego, California, USA

View larger version (33K): [in a new window]   Figure 1 This is the appearance of the Symmetry device ex vivo (A), on fluoroscopy viewed perpendicularly to the aorta (B), and in an idealized depiction (C). The hooks attach the saphenous vein graft (SVG) to the device and the nitinol struts anchor the device on the inner and outer walls of the aorta.

View larger version (123K): [in a new window]   Figure 2 This angiogram from the patient in Case 1 was performed five months following coronary artery bypass graft surgery and shows an ostial anastomotic device stenoses of the saphenous vein graft-right coronary artery (A), saphenous vein graft-left circumflex obtuse marginal coronary artery (C), and saphenous vein graft-ramus intermedius (E). Panels B, D, and F show the corresponding angiograms immediately post-percutaneous coronary intervention. The white arrowheads show the position of the Symmetry Bypass Connector device.

View larger version (119K): [in a new window]   Figure 3 This angiogram from the patient in Case 1 was obtained two months following percutaneous coronary intervention of the saphenous vein graft-right coronary artery (A), saphenous vein graft-left circumflex obtuse marginal coronary artery (C), and saphenous vein graft-ramus intermedius (E) and depicts recurrent ostial restenosis but not in the distal parts of the stents. Panels B and D show the corresponding angiograms immediately post-percutaneous coronary intervention (the saphenous vein graft-ramus intermedius could not be recanalized).

View larger version (77K): [in a new window]   Figure 4 This is a coronary angiogram with corresponding intravascular ultrasound of the saphenous vein graft-right coronary artery. Panel A depicts severe neointimal hyperplasia (NIH) at the ostial location. The bright image at 1 to 4 o'clock is the Symmetry device (SD). The lumen (L) is barely visible at 4 to 7 o'clock owing to the extensive presence of NIH and appears as a dark crescent shaped area under the intravascular ultrasound catheter. Panel B shows a well-expanded stent with minimal NIH, and a widely patent lumen. Panel C shows a diffuse moderate-severe NIH in an area just distal to the stent that had progressed angiographically over the last two months. The black arrows indicate the position of the intravascular ultrasound catheter and corresponding image.