Embolic protection device use and outcomes in patients receiving saphenous vein graft interventions--a single-center experience.
BACKGROUND
Percutaneous treatment of saphenous vein graft disease is hampered by high rates of periprocedural myocardial infarction (MI). The use of embolic protection devices (EPD) during these interventions is a class IB recommendation when technically feasible, yet they are used routinely in less than half of all cases. Our aim was to explore whether or not the under-utilization of EPDs led to any untoward cardiovascular events.


METHODS
Consecutive vein graft interventions from 2003-2008 were identified and stratified by EPD use. Information pertaining to demographics, comorbidities, medication use, and procedural details was collected. Primary endpoint was to compare the incidence of periprocedural MI, defined as any creatinine kinase-MB fraction elevation greater than 3 times the upper limit of normal between patients who underwent percutaneous coronary intervention (PCI) for saphenous vein grafts (SVG) with EPD versus patients who underwent PCI for SVG without EPD. Secondary endpoints included comparison of the incidence of recurrent ischemia, MI, revascularization (PCI or coronary artery bypass graft [CABG]), and mortality in the above 2 groups by the end of 1 year.


RESULTS
A total of 164 consecutive vein graft interventions were identified. EPDs were used in 71 cases (43.4%). The EPD group was further out since their CABG and had a higher prevalence of hypertension and diabetes. Periprocedural MI occurred in 22 cases; 12 in the non-EPD group and 10 in the EPD group (14.1 vs. 12.9%; P=.82). The composite endpoint of death, MI, or target vessel revascularization at 12 months was significantly lower when EPDs were used (11.3 vs. 25.8%; P=.03). On multivariate analysis, chronic kidney disease increased the risk of periprocedural MI (odds ratio [OR], 5.36; 95% confidence interval [CI], 1.90-15.13; P=.002), whereas the use of beta-blockers was protective (OR, 0.22; 95% CI, 0.07-0.70; P=.011).


CONCLUSIONS
EPD use during vein graft interventions did not improve periprocedural MI rates. However, the composite endpoint of adverse cardiovascular outcomes at 1 year was significantly reduced. EPDs are used in a minority of vein graft interventions. Efforts aimed at improving adherence to EPD use may improve long-term outcomes, though this hypothesis should be tested using prospective, randomized studies.
Department of Internal Medicine, 920 Stanton L. Young Boulevard, WP 3010, Oklahoma City, OK 73104, USA.
Harsh
H
Golwala
Beau M
BM
Hawkins
Stavros
S
Stavrakis
Mazen S
MS
Abu-Fadel
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects*; D003362:Cost-Benefit Analysis; D057505:Embolic Protection Devices / Q000191:economics / Q000706:statistics & numerical data*; D006083:Graft Occlusion, Vascular / Q000401:mortality / Q000628:therapy*; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology*; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation*; D015996:Survival Rate; D016896:Treatment Outcome