Discussion

Article Outline

• Copyright

Dr Kubaska III (Orange, Calif). Dr Schneider and his group have presented a retrospective study comparing long-term results of treating vein graft stenoses using cutting balloon angioplasty vs more traditional treatments of open surgical revision and standard balloon angioplasty. Cutting balloon angioplasty has been shown in this study to be superior to standard balloon angioplasty and to have comparable 4-year stenosis-free patency rates vs open surgical revision of 62% vs 74%, respectively. These findings indicate that cutting balloon angioplasty is competitive with open surgical revision in the initial treatment of infrainguinal vein graft stenosis.

The Achilles heel compromising long-term patency of infrainguinal vein bypass grafts is the development of stenoses from intimal hyperplasia at the anastomotic or mid-graft locations associated with vein valves. Using standard duplex imaging surveillance protocols, stenosis can be localized and scheduled for treatment prior to graft failure, thereby improving patency and longevity of the graft.

I have a few questions for the authors. With cutting balloon technology greatly changing over the period of the study, do you think that this may have influenced the technical success of these procedures and ultimately the long-term outcomes of the procedures?

Have you used other types of cutting balloons or scoring balloons prior to standard balloon angioplasty? At our institution, we have recently started using the AngioSculpt [AngioScore Inc, Fremont, Calif], a scoring balloon, to treat stenosis of infrainguinal cryopreserved vein grafts, which are known to be prone to recurrent stenosis with favorable results.

Did you find that lesions in the body of the graft which are usually associated with vein valves more or less difficult to treat than anastomotic lesions and why?

And finally, do you think with the addition of antiplatelet agents such as clopidogrel in conjunction with aspirin, the patency rates following percutaneous interventions have improved over the past decade? Could you comment on preprocedural administration of Plavix [Sanofi-Aventis, Bridgewater, NJ], duration of the antiplatelet therapy, and in cases where patients do not tolerate long-term antiplatelet drug administration?

I thank the program committee for the privilege of discussing this paper and the authors for sending me their manuscript well before the meeting for my review. Thank you.

Dr Schneider. Balloon angioplasty is definitely better now than it was in the mid to late '90s. Part of it is the equipment—the devices that we have available—and the other is the pharmacological manipulation that goes with it. However, vein graft lesions have not changed. My impression before we did this study was that balloon angioplasty gives you a great result about a third of the time and you cannot really figure out why. A third look great after balloon angioplasty and a third look like you didn't do anything and a third look like you ripped it. The nice thing about cutting is that the vein graft lesion is usually a focal lesion, which is nice for endo, and by cutting it first it gives you the ability to open it without ripping it.

So, well what about balloon angioplasty? Results of a very contemporary series might be better, and if it were, it would probably be because of statins and antiplatelet agents and other factors. Basic balloon mechanics have not changed. The results of balloon angioplasty for vein graft lesions in this series was right in line with many series that have been performed in the past 10 years. I do not think that we will go back to balloon angioplasty for vein graft lesions. The reason is that the additional risk of cutting angioplasty is low and because the cutting provides a coordinated cut whereas the angioplasty will always be a little bit random.

About scoring balloons—the thing I like about the scoring balloons is that you can get them in longer segments. This is a piece of metal sort of intertwined around the outside of the balloon. Maybe that will work nicely for diffuse tibial lesions, but we have not tried them in the vein graft stenoses.

The lesions in the body of the graft: It is not a huge number but we looked hard and really could not find a difference between the different locations of the lesions and how they responded.