CORRESPONDENCE: LETTER TO THE EDITOR
Percutaneous Intervention in Saphenous Vein Bypass Graft DiseaseCase Against the Use of Drug-Eluting Stents
Darpan Bansal, MD,
Rajesh Sachdeva, MD, FACC and
Jawahar L. Mehta, MD, PhD, FACC*
* Cardiovascular Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72205 (Email: mehtajl{at}uams.edu).
Saphenous vein grafts (SVGs) tend to degenerate over time, and almost one-half develop significant stenosis and nearly 40% are completely occluded within 1 decade (1). Use of balloon angioplasty alone without stenting for treatment of SVG disease is associated with poor short-term and long-term outcome (2). Use of bare-metal stents (BMS) is associated with restenosis rates as high as 50% at 6 months (3). Lately, drug-eluting stents (DES) have been used for the treatment of SVG disease.
In contrast to the native coronary arteries, in which restenosis after percutaneous coronary intervention (PCI) is mainly due to intimal hyperplasia, restenosis in SVG involves cellular hyperplasia, progression of atherosclerosis, local inflammatory reaction to stent struts, and thrombosis. These observations suggest that it may not be wise to extend the seemingly better short- and midterm results seen with PCI for treatment of native coronary artery disease to the treatment of SVG disease. We have recently looked at the data in our institution in 109 patients with SVG disease who received BMS or DES. During a follow-up period of 33 months, we found that the incidence of major adverse cardiac events (MACE) was much higher in patients treated with DES. We found that there was initially a benefit in terms of MACE in patients who received DES compared with the benefit seen in patients receiving BMS, but thereafter we noticed a late catch-up phenomenon (Fig. 1).
In this regard, Chu et al. (4) in a small study showed that although there were no differences in DES and BMS used for the treatment of SVG disease, the incidence of MACE increased from 6 months to 1 year after PCI in the BMS group, and the DES group had a much more pronounced increase in MACE in the same time frame. The secondary post-hoc data from the delayed RRISC (Reduction of Restenosis In Saphenous vein grafts with Cypher Stent) trial (5) also showed that over a median follow-up of 32 months, use of BMS was associated with significantly lower long-term mortality than the use of DES in SVG disease. The use of DES in the SVG disease needs to be re-examined.
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- Fitzgibbon G, Kafka H, Leach A, et al. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5065 grafts related to survival and reoperation in 1,388 patients during 25 years J Am Coll Cardiol 1996;28:616-626.[Abstract]
- Plokker HW, Meester BH, Serruys PW. The Dutch experience in percutaneous transluminal angioplasty of narrowed saphenous veins used for aortocoronary arterial bypass Am J Cardiol 1991;67:361-366.[CrossRef][ISI][Medline]
- de Jaegere PP, van Domburg RT, Feyter PJ, et al. Long-term clinical outcome after stent implantation in saphenous vein grafts J Am Coll Cardiol 1996;28:89-96.[Abstract]
- Chu WW, Rha SW, Kuchulakanti PK, et al. Efficacy of sirolimus eluting stents compared with bare metal stents for saphenous vein graft intervention Am J Cardiol 2006;97:34-37.[ISI][Medline]
- Vermeersch P, Agostoni P, Verheye S, et al. Increased late mortality after sirolimus-eluting stents versus bare-metal stents in diseased saphenous vein grafts: results from the randomized DELAYED RRISC trial J Am Coll Cardiol 2007;50:261-267.[Abstract/Free Full Text]
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