The Winking Saphenous Vein Graft: Acute Aorto-Vein Graft Anastomotic Torsional Kink causing Dynamic Systolic Compression Complicating Vein Graft PCI Dr Anthony Wassef, MD, FRCPC Dr Farrukh Hussain, MD, FRCPC University of Manitoba Winnipeg, Manitoba, Canada

Disclosers None

Introduction Coronary Artery Bypass Surgery (CABG) done with saphenous vein grafts (SVG) has good long term patency 65-80% remain patent five years, 50-60% at 7-10 years, and 50% at 15 years Early graft failure is usually due to technical failure (kinks due to length, vein pathology, narrow veins) or poor run off Occlusion within the first year occurs due to platelet aggregation and endothelial dysfunction Graft failure after the first year is often due to neointimal hyperplasia and lipid deposition 1. Harskamp RE, et al. Ann Surg. 2013 May;257(5):824-33. 2. Motwani JG, Topol EJ. Circulation. 1998;97(9):916.

Introduction In patients with saphenous vein graft stenosis, percutaneous revascularization is indicated to improve symptoms after a trial of medical therapy Here we present an unusual cause of ostial graft stenosis that was incidentally discovered on final FFR assessment after mid and distal saphenous vein graft percutaneous intervention 1. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Levine GN et al. Circulation. 2011;124(23):e574.

Case 81 yo Female with CCS class IV angina on optimal medical therapy History of 3 vessel CAD treated 12 years prior with CABG x 3 Left Internal Mammary Artery to Left Anterior Descending SVG to the obtuse marginal coronary artery (OM) SVG to the distal right coronary Artery Myocardial perfusion imaging revealed inducible ischemia in the infero-lateral wall The patient was referred for coronary angiography

Systole Diastole SVG to OM demonstrated diffuse disease with distal 99% stenosis (yellow arrow) as well as isolated systolic compression at the aortic anastomosis (blue arrow) with luminal obliteration

Case – Angioplasty of Mid to Distal SVG to OM The graft was engaged with a 6 Fr left coronary bypass guide Wire was passed distally into the native OM The saphenous vein graft was stented with 3 Xience drug eluting stents (2.75 x 15, 2.75 x 38 and 2.75 x 38) Angiography after the stenting demonstrated ongoing systolic compression of the origin of the saphenous vein graft at the aorta (blue arrow)

Case - FFR FFR assessment of the proximal saphenous vein graft just distal to the lesion but prior to the stented section Unusual pattern of predominantly systolic gradient with little diastolic gradient Also respiratory variation noted FFR = 0.79 without vasodilator challenge.

Case – Angioplasty and Stent of Ostial Kink PCI to the ostial saphenous vein graft was performed with a Resolute Integrity drug eluting stent. TIMI III flow was present post angioplasty with no complications Fluoroscopy of the stent demonstrated that the stented saphenous vein graft had an acute angulation (blue arrows) off the aorta as the cause of the systolic compression The patient had no further chest pain.

Case – Final Results

Conclusion In this case we report an unusual late cause of saphenous vein graft stenosis – systolic compression of the graft ostium secondary to acute angle anastomosis. This patient had concomitant coronary artery disease which after successful angioplasty still had an FFR gradient This case demonstrates that the angiographer should be aware of causes of late saphenous vein stenosis other than neo-intimal hyperplasia Furthermore FFR is an important tool in assessing both coronary and graft stenosis. Recognition of systolic vs diastolic gradients in FFR is paramount

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