p.38 抽出テキスト
Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e55 CLINICAL STATEMENTS AND GUIDELINES burr that rotates at high speeds. Although older studies have shown that the use of rotational atherectomy is associated with increased rates of restenosis3 and increased late lumen loss,1 RCTs have demonstrated enhanced stent delivery and expansion in heavily calcified vessels with rotational atherectomy as compared with the use of conventional balloons1 or cutting or sculpting balloons.2 For this reason, despite the lack of data to support improved long-term outcomes with rotational atherectomy, rotational atherectomy remains an important tool in certain situations to properly “prepare” a lesion for stenting. 2. Orbital atherectomy has many features in common with rotational atherectomy and has similar clinical indications for use.4,5 Cutting balloons6 and scoring balloons7 section atheromatous plaque through a technique called balloon atherotomy, but their value may be limited to the technical advantage of slipping less often than conventional balloons in ostial lesions or lesions associated with ISR. Excimer laser coronary angioplasty uses a photo-acoustic mechanism11 that may facilitate the treatment of calcified lesions or nonexpandable stents.12,13 In certain lesion subsets, such as stent underexpansion that cannot be dilated with high-pressure balloon inflations, highenergy laser angioplasty can disrupt the calcific lesion beneath the stent struts and facilitate stent expansion.14 The evidence base for additional techniques to modify calcified or fibrotic lesions, including atherectomy, cutting balloons, or laser, are limited to registry studies and case series.10 Other potentially emerging modalities include intracoronary lithotripsy.8,15 10.6 Treatment of Saphenous Vein Graft (SVG) Disease (Previous CABG) Recommendations for Treatment of SVG Disease (Previous CABG) Referenced studies that support the recommendations are summarized in Online Data Supplement 28. COR LOE Recommendations 2a B-R 1. In select patients with previous CABG undergoing PCI of a SVG, the use of an embolic protection device, when technically feasible, is reasonable to decrease the risk of distal embolization.1-3 2a B-NR 2. In patients with previous CABG, if PCI of a diseased native coronary artery is feasible, then it is reasonable to choose PCI of the native coronary artery over PCI of the severely diseased SVG.4-6 3: No Benefit C-LD 3. In patients with a chronic occlusion of a SVG, percutaneous revascularization of the SVG should not be performed.7,8 Synopsis In patients with previous CABG undergoing PCI of an SVG, the incidence of MACE is significantly higher than those with native coronary artery PCI because of the higher risk of procedural complications, including the noreflow phenomenon and periprocedural MI.6 Compared with native coronary arteries, atherosclerotic plaques in SVGs are more diffuse, with thinner, more friable fibrous caps that increase the risk of distal debris embolization during PCI.9 In several large prospective registries, patients who underwent SVG PCI were more likely to have no-reflow,5 stent thrombosis, ischemia-driven target-vessel revascularization, increased overall adjusted MACE, and increased risk of death4,5,10 in long-term follow-up than were those who underwent non-SVG PCI. Recommendation-Specific Supportive Text 1. The term “embolic protection devices” refers to the group of devices designed to prevent distal embolization. The SAFER (Saphenous vein graft Angioplasty Free of Emboli Randomized) trial comparing the outcomes of SVG PCI with the use of an embolic protection device (Medtronic Guardwire, Minneapolis, MN) with conventional stenting of the SVG demonstrated a significant reduction in the primary endpoint of death, MI, emergency bypass, or target-lesion revascularization at 30 days with the GuardWire distal protection device.1 A subsequent study comparing different embolic protection devices reported noninferiority of the FilterWire EX device (Boston Scientific, Marlborough, MA) to the GuardWire.2 In contemporary PCI, embolic protection devices are used in only 14% to 21% of patients,11,12 and only the filter-based devices are currently in use. Observational studies exploring the “real-world” benefits of embolic protection devices provide conflicting findings, with 1 study showing no benefit of embolic protection devices and another showing significant harm when embolic protection devices are not used.11,12 A meta-analysis of 2 randomized studies and 6 observational reports showed no benefit with the use of embolic protection devices, although selection biases and unmeasured confounders are important limitations of these observational studies.13 2. In patients with previous CABG who require PCI, two-thirds of these procedures are performed on the native artery instead of the bypass graft.4,5 Although there are no randomized studies comparing PCI of a diseased native artery with PCI of an SVG, observational studies have shown that intervening in a native coronary artery instead of an SVG is associated with improved outcomes. In a large prospective registry, patients with prior CABG who underwent SVG PCI had higher rates of cardiac death, stent thrombosis, ischemia-driven target-vessel revascularization, and overall MACE at 2 years than did those who underwent PCI of the native vessel.10 The risk of MACE remained elevated Downloaded from http://ahajournals.org by on October 7, 2026