Cath Lab Digest

Clinical History

A 78-year-old male with no known coronary disease presented with worsening congestive heart failure symptoms. He previously had bypass surgery. His presentation revealed his saphenous vein graft to the circumflex was widely patent a year before. He presented with angina and inferior lateral ischemia. A diagnostic study was performed. His right coronary artery was stented at 2 focal areas, and he was brought back for intervention 3 days later. We did both the initial procedure as well as the follow-up procedure via the right radial artery.

Instead of just performing balloon angioplasty, we performed suction thrombectomy with an Export^® catheter (Medtronic CardioVascular, Minneapolis, Minnesota) removing massive amounts of red and white thrombus. Following the removal, TIMI flow was 3. We attempted to place an Abbott embolic protection device (Abbott Vascular, Abbott Park, Illinois); however, it was too stiff to be able to be placed in the bypass graft. Balloon angioplasty using the suck-u-surge technique was then performed.^1,2

Following this, normal TIMI 3 flow was noted. The patient was discharged the following day. Thrombectomy with the suck-u-surge technique is effective in saphenous vein graft stenosis when an embolic protection device cannot be passed.

Figure 1. The angiogram showing the total occlusion of the saphenous vein graft

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Figure 2. The saphenous vein graft to the circumflex was crossed with a Transit™ catheter (Cordis, Bridgewater, New Jersey) and Whisper^® wire (Abbott Vascular, Abbott Park, Illinois)

Figure 3a. The technique performing with negative suction and a guiding catheter at the time of balloon inflation

Figure 3b. A stent is deployed with negative suction

 Figure 4. Angiogram confirms placement in bypass graft

Figure 5. A 3.5 x 30 mm Endeavor^® stent (Medtronic, Inc., Sunnyvale, California) was placed using the suck-u-surge technique

Figure 6. Final result

 References

1. Morales PA, Heuser RR. Guiding catheter aspiration to prevent embolic events during saphenous vein graft intervention. J Interv Cardiol 2002;15:491–498.
2. Heuser RR. Letter to the Editor. Contemporary Use of Embolic Protection Devices in Saphenous Vein Graft Interventions: Insights from the Stent of Saphenous Vein Grafts Trial. Catheter Cardiovasc Interv 2011;77:594.

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Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally-recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of America’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Chief of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters, stents and other medical devices, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 70 pharmaceutical products, and has participated in more than 150 research studies. He has authored over 400 articles, textbooks and medical manuscripts, and is frequently invited to international medical conferences to present the findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship, at The Johns Hopkins Hospital in Baltimore, Maryland.