"Pharmacologic" distal protection using prophylactic, intragraft nicardipine to prevent no-reflow and non-Q-wave myocardial infarction during elective saphenous vein graft intervention.

Background: Coronary saphenous vein bypass graft (SVG) stenting has been associated with up to a 30% rate of no-reflow or myocardial infarction (MI) when performed without distal protection.
Methods: We evaluated the technique using prophylactic pharmacologic arteriolar vasodilatation with intracoronary nicardipine followed by immediate direct stenting for the treatment of degenerated coronary SVGs without mechanical distal protection. Data were collected from 83 consecutive elective SVG interventions in 68 patients. Quantitative coronary angiographic measurements were performed by the Borgess angiographic core lab. Electrocardiograms (ECGs), CPKs, and CPK-MBs were obtained preprocedure and at 12 to 18 hours after the intervention. Follow-up data at 30 days were obtained in 67/68 (98%) patients.
Results: The average graft age was 11.9 +/- 6.6 years with thrombus in 26/83 vessels (31%). The primary adverse endpoint of total CPK >3 times the upper limit of normal (ULN), or CPK-MB >3 times the ULN were seen in 1/68 (1.5%) and 3/68 (4.4%) patients, respectively. No-/slow-reflow was observed transiently in 2/83 SVG interventions (2.4%). Of the patients, 1/68 had persistent, minor ECG changes after stenting (1.4%). No patient had a Q-wave MI. Inhospital major adverse cardiac events (MACE) (death, MI, repeat TLR) were observed in only 3/68 patients (CPK-MB elevation). There were no additional MACE events (0/68) from hospital discharge to 30 days.
Conclusions: (1) Prophylactic vasodilatation with intragraft nicardipine followed by direct stenting appears to be a safe and effective means of performing elective SVG revascularization; (2) this approach may provide a simple and time- and cost-effective alternative or adjunct to mechanical distal protection for elective SVG interventions.