Angioplasty, stenting, atherectomy, and laser treatment after coronary artery bypass grafting

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Saphenous vein grafts remain an essential part of coronary artery bypass surgery. However, their inferior long-term patency due to graft attrition often means recurrent ischemia or infarction. Repeat surgical revascularization carries a significantly higher morbidity and mortality and is frequently associated with less symptomatic improvement as compared with the initial surgery. Thus, nonsurgical alternatives are preferred in such a situation, particularly when the lesions are technically approachable and amenable to these transcatheter procedures. Traditionally, percutaneous transluminal coronary angioplasty has been the standard approach. However, there are certain shortcomings of this technique, principally its inadequacy in treating certain adverse lesion morphologies. Problems include an appreciable risk of coronary debris embolization and acute complications in old vein grafts, and the prohibitively high restenosis rate for stenoses situated at the ostium or the proximal and middle segments of grafts. Newer, second-generation intravascular techniques such as stents, atherectomy, and laser procedures have been introduced in an effort to overcome these problems. This review presents an update of the results of these new tools together with some suggestions on their clinical utility in a vein graft setting.

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