Case Report
Acta Cardiol Sin 2008;24:169-73
Saphenous Vein Graft Dissection Using the
GuardWire Distal Protection Balloon
Po-Ching Chou, Chi-Hung Huang, Eng-Thiam Ong and Herng-Cheng Chiou
The higher rate of periprocedural adverse events and lower rate of event-free survival of saphenous vein graft (SVG)
intervention compared with native coronary artery intervention is primarily due to distal embolization. Distal
embolic protection devices have been shown to reduce the incidence of no flow/slow flow and procedure related
myocardial infarction during percutaneous intervention of diseased SVGs. The GuardWireÒ system is a temporary
distal balloon occlusion and aspiration device for distal embolic protection. Inflation of the distal elastomeric
compliant balloon of the GuardWire system prevents debris embolization downstream and is supposedly atraumatic
to the vessel wall. We report the inadvertent dissection of an SVG by GuardWire balloon inflation.
Key Words:
Distal protection device · Saphenous vein graft · Coronary artery disease
INTRODUCTION
meric compliant balloon of the GuardWire system prevents debris embolization downstream and is supposedly
atraumatic to the vessel wall.8 We report the inadvertent
dissection of an SVG by GuardWire balloon inflation.
Distal embolization of atheromatous and thrombotic
material is primarily responsible for the higher rate of
periprocedure adverse events and decreased event-free
survival after saphenous vein graft (SVG) intervention
compared with native coronary artery intervention. 1,2
Distal embolic protection devices have been shown to
reduce the incidence of no flow/slow flow and procedure-related myocardial infarction during percutaneous
intervention for diseased SVGs. 3,4 Such devices also
have been employed in many vascular interventions, including those of native coronary arteries, carotid arteries, and renal arteries.5-7 The GuardWireÒ system is a
temporary distal balloon occlusion and aspiration device
approved by the US Food and Drug Administration for
distal embolic protection. Inflation of the distal elasto-
CASE REPORT
A 79-year old man with coronary artery disease
(CAD; left main and triple-vessel disease) and a history
of coronary artery bypass graft (CABG) surgery (SVG to
left anterior descending artery; SVG to obtuse marginal
artery, and posterior descending artery) in 1995, presented with a one-month history of exertional dyspnea.
Electrocardiogram (ECG) revealed normal sinus
rhythm, with ischemic changes noted in the inferior
leads. A Thallium-201 single-photon emission computed
tomography (Tl-201 SPECT) myocardial perfusion scan
showed inferior (basal level) and anterolateral (apical
level) reversible perfusion defects and an apical fixed
defect. Angiography revealed the distal left main artery
to be 80% stenotic, the proximal left anterior descending
(LAD) artery 90% stenotic, the ostial left circumflex
(LCx) artery 90% stenotic, the proximal right coronary
artery (RCA) 100% stenotic, and the SVG to the LAD
Received: November 1, 2007 Accepted: February 1, 2008
Division of Cardiology, Department of Internal Medicine, Cathay
General Hospital, Taiwan.
Address correspondence and reprint requests to: Dr. Chi-Hung
Huang, Division of Cardiology, Department of Medicine, Cathay
General Hospital, No. 280, Section 4, Jen-Ai Road, Taipei 106,
Taiwan. Tel: 886-2-2708-2121 ext. 3116; Fax: 886-2-707-4949;
E-mail: [email protected]
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Po-Ching Chou et al.
ischemic relief. Angiography confirmed successful stent
deployment in the middle stenotic segment of the SVG
to the PDA with TIMI grade 3 flow (Figure 2).
The distal balloon was then repositioned at the site
just proximal to that of stent deployment and was again
inflated to 5 mm in diameter (Figure 3). A 3.0 ´ 33-mm
ZETA stent (Guidant, Santa Clara, CA) was deployed
directly in the proximal stenotic segment at 12 atm. The
distal GuardWire balloon was again deflated after manual aspiration with the Export catheter. The ischemic interval was less than 3 minutes.
Post-procedural angiography revealed a filling de-
completely occluded ostially. In addition, the SVG to the
obtuse marginal (OM) artery anastomosis was totally occluded, and the SVG to the posterior descending artery
(PDA) was diffusely degenerate and 90% stenotic in the
proximal segment, as well as 90% stenotic in the middle
region, with TIMI grade 2 to 3 flow (Figure 1). A left
ventricular (LV) angiogram demonstrated an ejection
fraction of 55%.
Based on the ECG and Tl-201 SPECT myocardial
perfusion scan, PCI of the SVG PDA was elected. Because of potentially significant atheromatous plaque and
thrombus in the degenerated SVG and attendant high
risk for distal embolization, it was decided to perform
percutaneous revasculization with the GuardWire distal
protection device.
Intravenous heparin was used to maintain an activated clotting time (ACT) between 250 and 300 seconds.
After prepping the patient in the usual sterile manner, a 7
French right Judkin guide catheter was introduced into
the SVG to the PDA. The GuardWire was negotiated
through the proximal and middle stenoses and was
placed in the distal vein graft segment. The distal protection balloon was inflated to 5 mm in diameter, and successful dye stasis was achieved. A 3.5 ´ 28-mm VISION
stent (Guidant, Santa Clara, CA) was deployed directly
in the middle stenotic segment at 12 atmospheres (atm).
After removal of debris with manual aspiration using the Export catheter (Medtronic Inc., Santa Rosa,
CA), the distal balloon was deflated for intermittent
Figure 2. Angiography after distal stenting of SVG to the PDA
(arrow).
Figure 1. Saphenous vein graft (SVG to PDA) angiography before
stenting (arrows show target lesions).
Figure 3. The “landing zone” of the distal occlusion balloon for
proximal stenting of SVG to the PDA (arrow).
Acta Cardiol Sin 2008;24:169-73
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Saphenous Vein Graft Dissection
after discharge, he was enjoying event-free recovery.
fect at the site of the distal protection balloon and TIMI
grade 2 flow (Figure 4). The ACT was within the target
range (i.e., 286 seconds), and the filling defect persisted
despite the intragraft injection of 200 mg nitroglycerine
and repeated aspiration with the Export catheter. Thus, a
3.5 ´ 15-mm VISION stent was deployed at the site of
the filling defect under the protection of a distal occlusion balloon (Figure 5). Final angiography found no evidence of a filling defect, and TIMI grade 3 flow was
noted (Figure 6).
The patient tolerated the procedures well and was discharged 2 days later in stable condition. Twelve months
DISCUSSION
Figure 4. The angiographic filling defect identified after proximal
stenting of SVG to the PDA (arrow).
The distal embolic GuardWire temporary occlusion
system is a 190 cm-long, 0.014-inch (outside diameter)
hollow guidewire with a central lumen connected to an
elastomeric compliant distal occlusion balloon. The sizes
of the distal occlusion balloon range from 2.5 to 5 mm in
length and 3 to 6 mm in diameter. Nominal size is
reached at an inflation pressure of 2 atm. During in vitro
testing of this balloon, porcine coronary artery segments
were found to have denuded endothelium when the vessel wall was assessed using scanning electron microscopy.9 Endothelial denudation may be associated with
vessel thrombosis and restenosis.10
While adverse effects related to compliant low-pressure balloons have been reported (including thrombus
formation or plaque compression in SVGs and restenosis
or aneurysm formation at the site of the balloon inflation
in native coronary arteries), other studies report that
angiographically normal segments of native coronary arteries or SVGs do not develop acute or mid-term adverse
events at the sites of balloon inflation.8,11-15 In addition
to technical reasons for adverse events (e.g., choosing
too large a balloon, or over-inflating the device), it is
possible that the discrepancy between these above-cited
reports is related to the presence of angiographically vis-
Figure 5. Bail-out stenting for the filling defect at the site of the distal
embolization balloon placement (arrow).
Figure 6. Final angiography showing TIMI grade 3 flow without no
evidence of a residual filling defect (arrow).
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Po-Ching Chou et al.
the authors of this report suggest regarding appropriate
“landing zone” selection. In this regard, intravascular ultrasound (IVUS) has emerged as an attractive and complementary diagnostic tool, with the unique ability to visualize the coronary wall in vivo. This is certainly an important topic worthy of further study, particularly since
the use of the distal occlusion balloon is anticipated to
increase over the next several years.12
ible atherosclerotic disease.
In the case presented herein, the unexpected angiographic filling defect at the site of the distal occlusion
balloon inflation could have resulted from either plaque
dissection, plaque shift, focal spasm, localized calcium
or thrombus formation.16 Since the filling defect developed under adequate anticoagulation, and persisted following the intragraft injection of 200 mg nitroglycerine
and repeated aspiration with the Export catheter, it was
concluded that a plaque dissection, rather than thrombus
formation, had occurred. Additionally, IVUS has been
able to discriminate the features that do not require intervention (localized calcium or no abnormality) from
those that warrant further stenting (plaque dissection or
thrombus). 17 The filling defect was successfully managed via stenting, which also supports the diagnosis of
dissection of the distal region of the diseased SVG to the
PDA.
Pregowski et al. suggested that plaque rupture may
be a part of the natural history of vein graft disease, and
that plaque rupture may correlate with graft aging. Furthermore, degeneration or lumen compromise may not
always be evident angiographically.18 Vein graft atheromas have also been shown to contain foam cells and inflammatory cells with a poorly developed or absent fibrous cap, making the grafts prone to rupture.19,20 As a
result, it can be challenging to identify diseased segments of SVGs that may be more friable than non-diseased SVG or native tissue via angiography. Thus, selection of a safe “landing zone” for distal occlusion balloon
placement is clinically challenging, and the potential for
adverse consequences if an inappropriate “landing zone”
is selected exists.
Yamaguchi et al. have described four techniques to
protect against aneurysm formation at the site of the distal occlusion balloon.13 These techniques are also useful
for minimizing chances of dissecting diseased SVGs.
First, an export aspiration catheter can be employed to
estimate the vessel size and direct appropriate balloon
size and volume. Second, the distal embolization balloon
should be filled slowly and just until antegrade flow has
stopped. Third, the distal protection balloon should not
be placed at a site that is calcified or plaque-rich. Finally, it is imperative to maintain the distal protection
balloon stationary at all times.
The third point described above is similar to what
Acta Cardiol Sin 2008;24:169-73
CONCLUSION
We have reported herein the inadvertent dissection
of the distal region of a diseased SVG to the PDA following the use of the GuardWire distal embolization system during the PCI for diseased SVGs. This report highlights the importance of not over-inflating the distal occlusion balloon, and in selecting a non-diseased segment
of the diseased vessel as a safe “landing zone” in which
to place the balloon. This report is clinically relevant
given that the use of distal occlusion balloons is anticipated to increase in coming years.
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