Late In-Stent Restenosis of a Saphenous Vein Graft Treated with High Pressure Balloon Dilatation and Drug Eluting Balloon Dilatation: Case Report.

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Marek Rogowski, Kaffer Kara This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3413348/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2024 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted 5 You are reading this latest preprint version Abstract Introduction In the modern interventional treatment of degenerated saphenous vein grafts, the use of both bare metal and drug eluting stents have been described so far. Drug eluting balloons have been increasingly used in cases of in-stent restenosis and to some extent denovo stenosis of native coronary vessels. Based on pure logic approach, the use of drug eluting balloons in in-stent restenosis of the saphenous vein graft may be of great interest. Still, few high-quality data on this subject exist and no general recommendations can be made. Case presentation This paper illustrates a typical case of a symptomatic late in-stent restenosis of a saphenous vein graft occurred 15 months after a percutaneous coronary intervention with implantation of two drug eluting stents. Intravascular ultrasound revealed a mixture of stent underexpansion and severe neointima. This was treated safely with a prolonged high pressure balloon dilatation followed by dilatation with a drug eluting balloon. The primary result was very good. During the intervention the patient remained asymptomatic and was discharged the next day on dual anti-platelet therapy. During the 10-month follow-up the patient remained asymptomatic. Conclusion This case demonstrates the usefulness and clinical safety of drug eluting balloons in treating in-stent restenosis in the saphenous vein grafts. in-stent restenosis intravascular ultrasound saphenous vein graft case report INTRODUCTION Despite the ongoing clinical and technical development, in-stent restenosis (ISR) illustrates the most common treatment failure after coronary interventions, occurring in up to 15% of all interventional cases [ 2 , 5 ]. This has been demonstrated, in turn, to be associated with worse patients’ outcome and higher mortality rates [ 1 , 7 ]. Percutaneous coronary interventions (PCI) of the saphenous vein grafts (SVG) are known to have a higher risk of restenosis and cardiovascular events (as compared to PCI in native arteries) [ 8 ]. The overall benefit of using saphenous vein grafts has been critically discussed as approximately half of the grafts remain occluded within the first ten years after bypass surgery. This may be attributed to acute thrombosis, vascular inflammation and accelerated atherosclerosis [ 4 ]. In case of any ISR, the current guidelines recommend new generation DES and/or drug eluting balloons [ 9 ]. Whereas most available data apply to native arteries, no large high-quality data concerning the optimal management of ISR in SVG exist. This paper describes a typical case of symptomatic late ISR in the SVG due to a mixture of stent underexpansion and neotima presence. CASE PRESENTATION A male patient, aged 54, was referred to our institution to perform a diagnostic coronary angiography. The gentleman complained of typical angina pectoris CCS 3 for 4 weeks. The referring cardiologist diagnosed a slightly reduced ejection fraction with new inferior hypokinesia. The medical history encompassed, apart from well-controlled hypertension, diabetes on insulin and hyperlipidemia, a severe coronary artery disease with prior coronary artery bypass grafting (2017, LIMA to LAD, RITA as T graft to CX and single venous graft to the distal RCA). During the coronary angiography (2021), chronic obstruction of arterial grafts and native RCA was revealed (with the patent saphenous graft). The native LAD and CX were treated with a balloon dilatation and three drug eluting stents were implanted. The last coronary angiography (2022) showed a very good result of the LAD and CX stents, but a subtotal obstruction of the proximal part of the saphenous graft to the RCA. This was treated successfully with direct implantation of two drug eluting stents in the suck-U-surge technique. On the diagnostic coronary angiogram, a subtotal in-stent stenosis of the proximal part of the saphenous graft to the RCA with TIMI 1 flow was diagnosed (Picture 1). Both, the LAD and CX showed a very good long-term PCI result. The native RCA showed a very long (> 50 mm) proximal chronic in-stent occlusion, with a blunt proximal cap, severe calcification and complex anatomy (J-CTO score with at least 4 points). At this stage, a decision was taken to re-treat the saphenous graft and, in case of PCI failure, to perform the recanalization of the native RCA. After successful wiring the distal vessel, intravascular ultrasound was planned but failed due to subtotal occlusion. After a single balloon dilatation (NC 3,0x20 mm, 16 atm, 10 s) and implementation of a second wire (‘buddy wire technique’), IVUS was possible and revealed the underlying mechanism of the late in-stent stenosis: a mixture of stent underexpansion and neoatherosceloris (Picture 2). This was treated with a prolonged high pressure balloon dilation (NC 3,5x20 mm, 24 atm, 20 s; NC 4,0x20 mm, 24 atm, 20 s) followed by a dilatation with a drug-eluting balloon (4,0x20mm, 12 atm, 60 s). The primary acute result was good, both on the angiogram and IVUS (Picture 3). Post-PCI the patient stayed one night in the intermediate care unit and was discharged the next day on the dual antiplatelet therapy (for 6 months). The follow-up was taken over by the referring cardiologist. In the following 10 months the patients has remained asymptomatic. DISCUSSION In-stent-restenosis in the SVG occurs in up to 21% of cases [ 11 ]. The late ISR seems to be dominated by various biological patterns including chronic inflammation and accelerated neoatherosclerosis [ 6 ]. The proper management of this condition has not been established so far. Worse still, clinical event rates after any ISR intervention in the SVG are usually high and may be associated with poorer prognosis [ 5 ].. From the practical point of view, the interventional management of lesions in the SVG may be extremely challenging due to high rates of distal embolization and no reflow. The routine use of distal protection devices has been demonstrated to bring no benefit [ 4 ]. Certain unique techniques such as Suck-U-Surge method were described and can be useful in selected cases [ 10 ]. The pre- and/or post-conditioning with GP IIB/IIIa inhibitors such as eptifibatide was used in the past but its general efficacy and safety could not be demonstrated in larger groups [ 1 ]. The issue of ISR in the SVG may increase the complexity of the possible treatment strategies. The reported case illustrates that the use of drug eluting balloons seems to be a safe and effective treatment option. During the prolonged dilatation the patient remained asymptomatic. Neither hemodynamic deterioration nor slow flow was observed. Declarations Funding: no external funding, self-funding only Conflicts of interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethics approval: no applicable. Consent to participate: not applicable Written consent for publication: was obtained from the patient and is available on request. Availability of data and material: on special request, all the collected data can be available. Code availability: not applicable. Author’ contributions: MR: main conception of the paper, wrote the paper, performed the literature search. KK: contributed to the main theoretical background, verified the literature search, supervised the project. All authors discussed the results and contributed to the final manuscript. References Xenogiannis I, Rangan BV, Uyeda L, Banerjee S, Edson R, Bhatt DL, Goldman S, Holmes DR Jr, Rao SV, Shunk K, Mavromatis K, Ramanathan K, Bavry AA, McFalls EO, Garcia S, Thai H, Uretsky BF, Latif F, Armstrong E, Ortiz J, Jneid H, Liu J, Aggrawal K, Conner TA, Wagner T, Karacsonyi J, Ventura B, Alsleben A, Lu Y, Shih MC, Brilakis ES. In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial). Am J Cardiol. 2022 Jan 1;162:24-30. doi: 10.1016/j.amjcard.2021.09.024. Epub 2021 Nov 1. PMID: 34736721. IJsselmuiden AJJ, Simsek C, van Driel AG, Bouchez D, Amoroso G, Vermeersch P, Karjalainen PP. Comparison between the STENTYS self-apposing bare metal and paclitaxel-eluting coronary stents for the treatment of saphenous vein grafts (ADEPT trial). Neth Heart J. 2018 Feb;26(2):94-101. doi: 10.1007/s12471-017-1066-0. PMID: 29255998; PMCID: PMC5783891. Brilakis ES, Edson R, Bhatt DL, Goldman S, Holmes DR Jr, Rao SV, Shunk K, Rangan BV, Mavromatis K, Ramanathan K, Bavry AA, Garcia S, Latif F, Armstrong E, Jneid H, Conner TA, Wagner T, Karacsonyi J, Uyeda L, Ventura B, Alsleben A, Lu Y, Shih MC, Banerjee S; DIVA Trial Investigators. Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial. Lancet. 2018 May 19;391(10134):1997-2007. doi: 10.1016/S0140-6736(18)30801-8. Epub 2018 May 11. PMID: 29759512; PMCID: PMC6402785. Colleran R, Kufner S, Mehilli J, Rosenbeiger C, Schüpke S, Hoppmann P, Joner M, Mankerious N, Fusaro M, Cassese S, Abdel-Wahab M, Neumann FJ, Richardt G, Ibrahim T, Schunkert H, Laugwitz KL, Kastrati A, Byrne RA; ISAR-CABG Investigators. Efficacy Over Time With Drug-Eluting Stents in Saphenous Vein Graft Lesions. J Am Coll Cardiol. 2018 May 8;71(18):1973-1982. doi: 10.1016/j.jacc.2018.03.456. PMID: 29724350. Lichtenwalter C, de Lemos JA, Roesle M, Obel O, Holper EM, Haagen D, Saeed B, Iturbe JM, Shunk K, Bissett JK, Sachdeva R, Voudris VV, Karyofillis P, Kar B, Rossen J, Fasseas P, Berger P, Banerjee S, Brilakis ES. Clinical presentation and angiographic characteristics of saphenous vein graft failure after stenting: insights from the SOS (stenting of saphenous vein grafts) trial. JACC Cardiovasc Interv. 2009 Sep;2(9):855-60. doi: 10.1016/j.jcin.2009.06.014. PMID: 19778774. Wolny R, Mintz GS, Matsumura M, Ishida M, Fan Y, Fall KN, Parikh MA, Rabbani LE, Ali ZA, Karmpaliotis D, Kirtane AJ, Moses JW, Maehara A. Intravascular Ultrasound Assessment of In-Stent Restenosis in Saphenous Vein Grafts. Am J Cardiol. 2019 Apr 1;123(7):1052-1059. doi: 10.1016/j.amjcard.2018.12.030. Epub 2019 Jan 4. PMID: 30642605. Xenogiannis I, Zenati M, Bhatt DL, Rao SV, Rodés-Cabau J, Goldman S, Shunk KA, Mavromatis K, Banerjee S, Alaswad K, Nikolakopoulos I, Vemmou E, Karacsonyi J, Alexopoulos D, Burke MN, Bapat VN, Brilakis ES. Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies. Circulation. 2021 Aug 31;144(9):728-745. doi: 10.1161/CIRCULATIONAHA.120.052163. Epub 2021 Aug 30. PMID: 34460327. Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF, Pichard AD, Kent KM, Stone GW, Leon MB. Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. Circulation. 1999 Nov 2;100(18):1872-8. doi: 10.1161/01.cir.100.18.1872. PMID: 10545431. Lin L, Lu W, Wang X, Pan L, Wang X, Zheng X, Li R, Shan Y, Peng M, Qiu C. Short-term outcomes of drug-coated balloon versus drug-eluting stent for de novo saphenous vein graft lesions in coronary heart disease. Front Cardiovasc Med. 2023 Mar 6;10:982880. doi: 10.3389/fcvm.2023.982880. PMID: 36950290; PMCID: PMC10025469. Resch M, Ostheim P, Endemann DH, Debl K, Buchner S, Birner C, Maier LS, Kerber S, Luchner A, Griese DP. Drug Coated Balloon Is Less Effective for Treatment of DES In-Stent Restenosis Both in Native Coronary Arteries and Saphenous Vein Grafts: Results From a Bicenter Registry. J Interv Cardiol. 2016 Oct;29(5):461-468. doi: 10.1111/joic.12324. Epub 2016 Aug 1. PMID: 27477024. Kuna C, Wiedenmayer N, Bradaric C, Presch A, Voll F, Kufner S, Ibrahim T, Schunkert H, Laugwitz KL, Cassese S, Kastrati A, Wiebe J. Ten-year outcomes after percutaneous coronary intervention of in-stent restenosis in saphenous vein grafts. Catheter Cardiovasc Interv. 2023 Oct;102(4):646-654. doi: 10.1002/ccd.30807. Epub 2023 Aug 21. PMID: 37605515. Pictures Pictures 1-3 are available in the Supplementary Files section. Supplementary Files CAREchecklistISR.docx ISRPictures.docx Cite Share Download PDF Status: Published Journal Publication published 13 Jan, 2024 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted Editorial decision: Major revisions 03 Dec, 2023 Reviewers agreed at journal 15 Nov, 2023 Reviewers invited by journal 11 Oct, 2023 Editor assigned by journal 10 Oct, 2023 First submitted to journal 05 Oct, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3413348","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":239339595,"identity":"ed38e184-7691-403b-b36a-d3f005da69f9","order_by":0,"name":"Marek Rogowski","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYJADZoaEChDF3ECKljMgipEULYxtIJqAFt32sw8/fNxjY9cvkf7Y4OG82mj+dqCWHxXbcGoxO5NuLDnjWVryzBk5xgmJ247nzjjM2MDYc+Y2bi0H0tiYeQ4cTja4ncN8IHHbsdwGoBZmxjY8Ws4/g2lJf3wgcc6x3PkEtdyA2GJncDsB6LCGmtwNhLU8Y5accSAtQXL+G2ODhGMHcjcCtRzE65fzaYwfPhywsefnOf5Y8kdNXe6884cPPvhRgVsLDCQ2QOjDYPIAQfVAYA+l64hRPApGwSgYBSMMAAB09F8pUBh35AAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-5830-3969","institution":"AKH Hagen: Agaplesion Allgemeines Krankenhaus Hagen gGmbH","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Marek","middleName":"","lastName":"Rogowski","suffix":""},{"id":239339596,"identity":"b56169d9-55d4-44e1-8da5-fa1c2312d395","order_by":1,"name":"Kaffer Kara","email":"","orcid":"","institution":"Ruhr-Universität Bochum: Ruhr-Universitat Bochum","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kaffer","middleName":"","lastName":"Kara","suffix":""}],"badges":[],"createdAt":"2023-10-05 13:01:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3413348/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3413348/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s42399-023-01636-4","type":"published","date":"2024-01-13T15:01:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49628867,"identity":"3e66d64f-21ca-443a-8f9e-9f3ae684f771","added_by":"auto","created_at":"2024-01-15 15:09:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":162970,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3413348/v1/8cea3179-52f3-43b6-a881-86bd06a6cb82.pdf"},{"id":44566523,"identity":"fce8f1c2-b664-4110-8bf3-23625c748a7f","added_by":"auto","created_at":"2023-10-13 09:08:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":193689,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistISR.docx","url":"https://assets-eu.researchsquare.com/files/rs-3413348/v1/73b99276d94903aa53ebc5ea.docx"},{"id":44566524,"identity":"64061731-6d48-41a7-b077-c71ce858d14a","added_by":"auto","created_at":"2023-10-13 09:08:49","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":37722559,"visible":true,"origin":"","legend":"","description":"","filename":"ISRPictures.docx","url":"https://assets-eu.researchsquare.com/files/rs-3413348/v1/779fefbaddd02fc55ea77ff7.docx"}],"financialInterests":"","formattedTitle":"Late In-Stent Restenosis of a Saphenous Vein Graft Treated with High Pressure Balloon Dilatation and Drug Eluting Balloon Dilatation: Case Report.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDespite the ongoing clinical and technical development, in-stent restenosis (ISR) illustrates the most common treatment failure after coronary interventions, occurring in up to 15% of all interventional cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This has been demonstrated, in turn, to be associated with worse patients\u0026rsquo; outcome and higher mortality rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePercutaneous coronary interventions (PCI) of the saphenous vein grafts (SVG) are known to have a higher risk of restenosis and cardiovascular events (as compared to PCI in native arteries) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The overall benefit of using saphenous vein grafts has been critically discussed as approximately half of the grafts remain occluded within the first ten years after bypass surgery. This may be attributed to acute thrombosis, vascular inflammation and accelerated atherosclerosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn case of any ISR, the current guidelines recommend new generation DES and/or drug eluting balloons [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Whereas most available data apply to native arteries, no large high-quality data concerning the optimal management of ISR in SVG exist.\u003c/p\u003e \u003cp\u003eThis paper describes a typical case of symptomatic late ISR in the SVG due to a mixture of stent underexpansion and neotima presence.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA male patient, aged 54, was referred to our institution to perform a diagnostic coronary angiography. The gentleman complained of typical angina pectoris CCS 3 for 4 weeks. The referring cardiologist diagnosed a slightly reduced ejection fraction with new inferior hypokinesia.\u003c/p\u003e \u003cp\u003eThe medical history encompassed, apart from well-controlled hypertension, diabetes on insulin and hyperlipidemia, a severe coronary artery disease with prior coronary artery bypass grafting (2017, LIMA to LAD, RITA as T graft to CX and single venous graft to the distal RCA). During the coronary angiography (2021), chronic obstruction of arterial grafts and native RCA was revealed (with the patent saphenous graft). The native LAD and CX were treated with a balloon dilatation and three drug eluting stents were implanted. The last coronary angiography (2022) showed a very good result of the LAD and CX stents, but a subtotal obstruction of the proximal part of the saphenous graft to the RCA. This was treated successfully with direct implantation of two drug eluting stents in the suck-U-surge technique.\u003c/p\u003e \u003cp\u003eOn the diagnostic coronary angiogram, a subtotal in-stent stenosis of the proximal part of the saphenous graft to the RCA with TIMI 1 flow was diagnosed (Picture 1). Both, the LAD and CX showed a very good long-term PCI result. The native RCA showed a very long (\u0026gt;\u0026thinsp;50 mm) proximal chronic in-stent occlusion, with a blunt proximal cap, severe calcification and complex anatomy (J-CTO score with at least 4 points). At this stage, a decision was taken to re-treat the saphenous graft and, in case of PCI failure, to perform the recanalization of the native RCA.\u003c/p\u003e \u003cp\u003eAfter successful wiring the distal vessel, intravascular ultrasound was planned but failed due to subtotal occlusion. After a single balloon dilatation (NC 3,0x20 mm, 16 atm, 10 s) and implementation of a second wire (\u0026lsquo;buddy wire technique\u0026rsquo;), IVUS was possible and revealed the underlying mechanism of the late in-stent stenosis: a mixture of stent underexpansion and neoatherosceloris (Picture 2). This was treated with a prolonged high pressure balloon dilation (NC 3,5x20 mm, 24 atm, 20 s; NC 4,0x20 mm, 24 atm, 20 s) followed by a dilatation with a drug-eluting balloon (4,0x20mm, 12 atm, 60 s). The primary acute result was good, both on the angiogram and IVUS (Picture 3).\u003c/p\u003e \u003cp\u003ePost-PCI the patient stayed one night in the intermediate care unit and was discharged the next day on the dual antiplatelet therapy (for 6 months).\u003c/p\u003e \u003cp\u003eThe follow-up was taken over by the referring cardiologist. In the following 10 months the patients has remained asymptomatic.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn-stent-restenosis in the SVG occurs in up to 21% of cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The late ISR seems to be dominated by various biological patterns including chronic inflammation and accelerated neoatherosclerosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The proper management of this condition has not been established so far. Worse still, clinical event rates after any ISR intervention in the SVG are usually high and may be associated with poorer prognosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]..\u003c/p\u003e \u003cp\u003eFrom the practical point of view, the interventional management of lesions in the SVG may be extremely challenging due to high rates of distal embolization and no reflow. The routine use of distal protection devices has been demonstrated to bring no benefit [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Certain unique techniques such as Suck-U-Surge method were described and can be useful in selected cases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The pre- and/or post-conditioning with GP IIB/IIIa inhibitors such as eptifibatide was used in the past but its general efficacy and safety could not be demonstrated in larger groups [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The issue of ISR in the SVG may increase the complexity of the possible treatment strategies.\u003c/p\u003e \u003cp\u003eThe reported case illustrates that the use of drug eluting balloons seems to be a safe and effective treatment option. During the prolonged dilatation the patient remained asymptomatic. Neither hemodynamic deterioration nor slow flow was observed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003col\u003e\n \u003cli\u003eFunding: no external funding, self-funding only\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConflicts of interest: On behalf of all authors, the corresponding author states that there is no conflict of interest.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEthics approval: no applicable.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConsent to participate: not applicable\u003c/li\u003e\n \u003cli\u003eWritten consent for publication: was obtained from the patient and is available on request.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAvailability of data and material: on special request, all the collected data can be available.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCode availability: not applicable.\u003c/li\u003e\n \u003cli\u003eAuthor\u0026rsquo; contributions:\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eMR: main conception of the paper, wrote the paper, performed the literature search. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKK: contributed to the main theoretical background, verified the literature search, supervised the project.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors discussed the results and contributed to the final manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eXenogiannis I, Rangan BV, Uyeda L, Banerjee S, Edson R, Bhatt DL, Goldman S, Holmes DR Jr, Rao SV, Shunk K, Mavromatis K, Ramanathan K, Bavry AA, McFalls EO, Garcia S, Thai H, Uretsky BF, Latif F, Armstrong E, Ortiz J, Jneid H, Liu J, Aggrawal K, Conner TA, Wagner T, Karacsonyi J, Ventura B, Alsleben A, Lu Y, Shih MC, Brilakis ES. In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial). Am J Cardiol. 2022 Jan 1;162:24-30. doi: 10.1016/j.amjcard.2021.09.024. Epub 2021 Nov 1. PMID: 34736721.\u003c/li\u003e\n \u003cli\u003eIJsselmuiden AJJ, Simsek C, van Driel AG, Bouchez D, Amoroso G, Vermeersch P, Karjalainen PP. Comparison between the STENTYS self-apposing bare metal and paclitaxel-eluting coronary stents for the treatment of saphenous vein grafts (ADEPT trial).\u0026nbsp;Neth Heart J. 2018 Feb;26(2):94-101. doi: 10.1007/s12471-017-1066-0. PMID: 29255998; PMCID: PMC5783891.\u003c/li\u003e\n \u003cli\u003eBrilakis ES, Edson R, Bhatt DL, Goldman S, Holmes DR Jr, Rao SV, Shunk K, Rangan BV, Mavromatis K, Ramanathan K, Bavry AA, Garcia S, Latif F, Armstrong E, Jneid H, Conner TA, Wagner T, Karacsonyi J, Uyeda L, Ventura B, Alsleben A, Lu Y, Shih MC, Banerjee S; DIVA Trial Investigators. Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial.\u0026nbsp;Lancet. 2018 May 19;391(10134):1997-2007. doi: 10.1016/S0140-6736(18)30801-8. Epub 2018 May 11. PMID: 29759512; PMCID: PMC6402785.\u003c/li\u003e\n \u003cli\u003eColleran R, Kufner S, Mehilli J, Rosenbeiger C, Sch\u0026uuml;pke S, Hoppmann P, Joner M, Mankerious N, Fusaro M, Cassese S, Abdel-Wahab M, Neumann FJ, Richardt G, Ibrahim T, Schunkert H, Laugwitz KL, Kastrati A, Byrne RA; ISAR-CABG Investigators. Efficacy Over Time With Drug-Eluting Stents in Saphenous Vein Graft Lesions.\u0026nbsp;J Am Coll Cardiol. 2018 May 8;71(18):1973-1982. doi: 10.1016/j.jacc.2018.03.456. PMID: 29724350.\u003c/li\u003e\n \u003cli\u003eLichtenwalter C, de Lemos JA, Roesle M, Obel O, Holper EM, Haagen D, Saeed B, Iturbe JM, Shunk K, Bissett JK, Sachdeva R, Voudris VV, Karyofillis P, Kar B, Rossen J, Fasseas P, Berger P, Banerjee S, Brilakis ES. Clinical presentation and angiographic characteristics of saphenous vein graft failure after stenting: insights from the SOS (stenting of saphenous vein grafts) trial.\u0026nbsp;JACC Cardiovasc Interv. 2009 Sep;2(9):855-60. doi: 10.1016/j.jcin.2009.06.014. PMID: 19778774.\u003c/li\u003e\n \u003cli\u003eWolny R, Mintz GS, Matsumura M, Ishida M, Fan Y, Fall KN, Parikh MA, Rabbani LE, Ali ZA, Karmpaliotis D, Kirtane AJ, Moses JW, Maehara A. Intravascular Ultrasound Assessment of In-Stent Restenosis in Saphenous Vein Grafts. Am J Cardiol. 2019 Apr 1;123(7):1052-1059. doi: 10.1016/j.amjcard.2018.12.030. Epub 2019 Jan 4. PMID: 30642605.\u003c/li\u003e\n \u003cli\u003eXenogiannis I, Zenati M, Bhatt DL, Rao SV, Rod\u0026eacute;s-Cabau J, Goldman S, Shunk KA, Mavromatis K, Banerjee S, Alaswad K, Nikolakopoulos I, Vemmou E, Karacsonyi J, Alexopoulos D, Burke MN, Bapat VN, Brilakis ES. Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies.\u0026nbsp;Circulation. 2021 Aug 31;144(9):728-745. doi: 10.1161/CIRCULATIONAHA.120.052163. Epub 2021 Aug 30. PMID: 34460327.\u003c/li\u003e\n \u003cli\u003eMehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF, Pichard AD, Kent KM, Stone GW, Leon MB. Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome.\u0026nbsp;Circulation. 1999 Nov 2;100(18):1872-8. doi: 10.1161/01.cir.100.18.1872. PMID: 10545431.\u003c/li\u003e\n \u003cli\u003eLin L, Lu W, Wang X, Pan L, Wang X, Zheng X, Li R, Shan Y, Peng M, Qiu C. Short-term outcomes of drug-coated balloon versus drug-eluting stent for \u003cem\u003ede novo\u003c/em\u003e saphenous vein graft lesions in coronary heart disease.\u0026nbsp;Front Cardiovasc Med. 2023 Mar 6;10:982880. doi: 10.3389/fcvm.2023.982880. PMID: 36950290; PMCID: PMC10025469.\u003c/li\u003e\n \u003cli\u003eResch M, Ostheim P, Endemann DH, Debl K, Buchner S, Birner C, Maier LS, Kerber S, Luchner A, Griese DP.\u0026nbsp;Drug Coated Balloon Is Less Effective for Treatment of DES In-Stent Restenosis Both in Native Coronary Arteries and Saphenous Vein Grafts: Results From a Bicenter Registry.\u0026nbsp;J Interv Cardiol. 2016 Oct;29(5):461-468. doi: 10.1111/joic.12324. Epub 2016 Aug 1. PMID: 27477024.\u003c/li\u003e\n \u003cli\u003eKuna C, Wiedenmayer N, Bradaric C, Presch A, Voll F, Kufner S, Ibrahim T, Schunkert H, Laugwitz KL, Cassese S, Kastrati A, Wiebe J. Ten-year outcomes after percutaneous coronary intervention of in-stent restenosis in saphenous vein grafts. Catheter Cardiovasc Interv. 2023 Oct;102(4):646-654. doi: 10.1002/ccd.30807. Epub 2023 Aug 21. PMID: 37605515.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Pictures","content":"\u003cp\u003ePictures 1-3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"in-stent restenosis, intravascular ultrasound, saphenous vein graft, case report","lastPublishedDoi":"10.21203/rs.3.rs-3413348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3413348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn the modern interventional treatment of degenerated saphenous vein grafts, the use of both bare metal and drug eluting stents have been described so far. Drug eluting balloons have been increasingly used in cases of in-stent restenosis and to some extent denovo stenosis of native coronary vessels. Based on pure logic approach, the use of drug eluting balloons in in-stent restenosis of the saphenous vein graft may be of great interest. Still, few high-quality data on this subject exist and no general recommendations can be made.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase presentation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis paper illustrates a typical case of a symptomatic late in-stent restenosis of a saphenous vein graft occurred 15 months after a percutaneous coronary intervention with implantation of two drug eluting stents. Intravascular ultrasound revealed a mixture of stent underexpansion and severe neointima. This was treated safely with a prolonged high pressure balloon dilatation followed by dilatation with a drug eluting balloon. The primary result was very good. During the intervention the patient remained asymptomatic and was discharged the next day on dual anti-platelet therapy. During the 10-month follow-up the patient remained asymptomatic.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis case demonstrates the usefulness and clinical safety of drug eluting balloons in treating in-stent restenosis in the saphenous vein grafts.\u003c/p\u003e","manuscriptTitle":"Late In-Stent Restenosis of a Saphenous Vein Graft Treated with High Pressure Balloon Dilatation and Drug Eluting Balloon Dilatation: Case Report.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-13 09:08:41","doi":"10.21203/rs.3.rs-3413348/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revisions","date":"2023-12-04T03:11:17+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2023-11-15T16:19:48+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-11T10:28:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-10T04:29:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2023-10-06T02:41:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b327053d-c94c-4f75-b7df-a1cb53960713","owner":[],"postedDate":"October 13th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-15T15:07:03+00:00","versionOfRecord":{"articleIdentity":"rs-3413348","link":"https://doi.org/10.1007/s42399-023-01636-4","journal":{"identity":"sn-comprehensive-clinical-medicine","isVorOnly":false,"title":"SN Comprehensive Clinical Medicine"},"publishedOn":"2024-01-13 15:01:45","publishedOnDateReadable":"January 13th, 2024"},"versionCreatedAt":"2023-10-13 09:08:41","video":"","vorDoi":"10.1007/s42399-023-01636-4","vorDoiUrl":"https://doi.org/10.1007/s42399-023-01636-4","workflowStages":[]},"version":"v1","identity":"rs-3413348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3413348","identity":"rs-3413348","version":["v1"]},"buildId":"qQ7_6M8ijIrYJ9CiyUnPg","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}