Unstable Saphenous Vein Graft Atheroma in Patients With Stable Angina Pectoris
Although saphenous vein grafts (SVGs) are widely used as conduits for coronary artery bypass grafting (CABG), SVG atheroma following CABG remains one of the major concerns. However, the morphological characteristics of old SVGs are not fully understood, especially in patients with stable angina pectoris. We imaged 9 consecutive SVGs in patients with stable angina pectoris using optical coherence tomography and coronary angioscopy. The clinical, optical coherence tomography, and coronary angioscopy characteristics of the SVGs are summarized in the Table. Multimodality imaging observations were performed in 4 SVGs without stenosis (nonculprit) and in 5 SVGs with significant stenosis before percutaneous coronary intervention (culprit). The graft age of the 7 SVGs (old SVGs) was >10 years, and the remaining 2 SVGs (young SVGs) were aged <1 year. Regardless of whether the SVG was a culprit, a thrombus was observed in all old SVGs. Most of the old SVGs had lipid plaque with macrophage accumulation on optical coherence tomography and fragile yellow plague on coronary angioscopy, suggestive of active atheroma. Moreover, optical coherence tomography–derived thin-cap fibroatheroma and plaque rupture were detected in 3 of 4 of the culprit old SVGs (Figure 1) and in 1 nonculprit old SVG (Figure 2). In contrast, these unstable plaque morphologies were not detected in the young SVGs (Figure 3). Advanced vulnerability is a feature of old SVGs, even in patients in a stable clinical condition. This suggests that careful long-term follow-up and management are important for patients with old SVGs. Furthermore, our case series had one more clinical implication at the time of redo CABG. Perioperative myocardial infarction following redo CABG is one of the leading contributors of in-hospital mortality, and it has been recognized embolization from atheromatous SVGs was associated with this unfavorable outcome.1,2 Therefore, management of SVGs is an important issue during redo CABG. Our case series demonstrated that SVGs had active atheroma and thrombus even with no severe obstruction. Although the management of SVGs during redo CABG is still under debate, surgeons should pay the best attention to the manipulation of old SVGs during redo CABG, irrespective of angiographic findings.
The Data Supplement is available at http://circinterventions.ahajournals.org/lookup/suppl/doi:10.1161/CIRCINTERVENTIONS.116.004692/-/DC1.
- © 2017 American Heart Association, Inc.