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Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%-60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible. [ABSTRACT FROM AUTHOR]

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) evolves rapidly over time. The hybrid approach to CTO PCI is a crossing algorithm that emphasizes dual coronary injection, structured review of the angiogram, and change of crossing strategies in case of failure. Methods: We analyzed the contemporary outcomes from the PROGRESS CTO registry by analyzing the clinical, angiographic and procedural characteristics of 3,571 CTO interventions performed in 3,503 patients enrolled between 2012 and 2018 at 21 centers. Results: Mean patient age was 65±10 years and 85% of the patients were men. A high prevalence of diabetes (42%), heart failure (31%), prior coronary artery bypass graft surgery (32%), prior myocardial infarction (47%), and prior PCI (65%) was observed. The most common CTO target vessel was the right coronary artery (56%), left anterior descending artery (24%), and left circumflex artery (19%). Mean J-CTO and PROGRESS-CTO scores were 2.4±1.3 and 1.3±1.0, respectively. The final successful crossing strategy was antegrade wire escalation in 53%, retrograde in 27%, and antegrade dissection re-entry in 20%. The initial crossing strategy was successful in 56%, however using multiple approaches (Figure), the overall technical and procedural success rate was 87% and 85%, respectively. In-hospital major complications were 2.9%, and consisted of death [0.8%], acute myocardial infarction [1.0%], stroke [0.3%], tamponade requiring pericardiocentesis [0.9%], emergency surgery [0.1%] and repeat PCI [0.3%]. Median contrast volume, air kerma radiation dose, procedure and fluoroscopy time were 260 (194-350) ml, 2.8 (1.6-4.7) Gray, 120 (78-184) and 46 (28-76) minutes, respectively. Conclusions: The hybrid approach to CTO PCI is associated with high overall success and acceptable complication rates in diverse patient populations. [ABSTRACT FROM AUTHOR]

Introduction: The retrograde approach is critical for achieving high success rates in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We compared the clinical, angiographic and procedural outcomes of retrograde (n=1,350) vs. antegrade-only CTO PCIs (n=2,221) in a contemporary multicenter CTO registry. Results: The mean age of patients undergoing retrograde PCI was 65±10 years and 86% were men, with high prevalence of prior myocardial infarction (51%), prior PCI (71%), and coronary artery bypass graft surgery (45%). CTO target vessels with the retrograde approach was the right coronary artery (68%), left anterior descending artery (16%), and left circumflex artery (15%). Lesions undergoing retrograde attempt were longer (42±27 mm vs 28±19 mm, p<0.001), and more likely to have proximal cap ambiguity (54% vs 25%), distal cap at bifurcation (47% vs 25%), diseased distal target vessel (46% vs 24%, p<0.001), and interventional collaterals (79% vs 45%, p<0.001), as compared with antegrade-only cases. The mean J-CTO (3±1 vs 2±1 p<0.001) and PROGRESS CTO complication score (4±2 vs 2±2, p<0.001) was higher in retrograde PCIs. The most commonly used collateral channels were septals (61%), epicardials (33%), saphenous venous grafts (13%) and left internal mammary artery grafts (2%). As lesion complexity increased, successful retrograde crossing was more frequently needed (Figure). The overall technical (81% vs 91%, p<0.001) and procedural (77% vs 90%, p<0.001) success rates were lower with retrograde approach, and patients had higher in-hospital major complications rate than antegrade-only PCIs (5.6% vs 1.1%, p<0.001), due to higher in-hospital mortality (1.5% vs. 0.3%, p<0.001), acute myocardial infarction (2.1% vs 0.3%, p<0.001), repeat PCI (0.7% vs 0.1%, p<0.001), and tamponade requiring pericardiocentesis (1.7% vs 0.3%, p<0.01). Conclusions: The retrograde approach to CTO PCI is commonly required among more complex lesions, which likely explains why it is associated with lower procedural success and higher complication rates. [ABSTRACT FROM AUTHOR]