Staged revascularization in patients with acute coronary syndromes due to saphenous vein graft failure and chronic total occlusion of the native vessel

Percutaneous coronary intervention of saphenous vein graft (SVG) lesions can be challenging due to high risk for acute and long-term complications. Treating the corresponding native coronary artery lesion(s) is preferable, but may not be feasible in the acute setting, due to high technical difficulty, especially when the native coronary lesion is a chronic total occlusion (CTO). We describe a novel concept of "staged revascularization" in patients presenting with an acute coronary syndrome due to SVG failure, whose native coronary artery supplied by the SVG has a CTO. In the first stage, the culprit SVG lesion is treated restoring flow to the supplied myocardium and minimizing the extent of myocardial injury. During the second stage (typically few weeks later), revascularization of the corresponding native coronary artery lesion(s) is performed, often using the initially treated SVG for retrograde crossing of the native coronary artery CTO. We describe two cases of non-ST segment elevation acute myocardial infarction due to SVG failure that were treated with "staged revascularization": the culprit SVG was initially treated followed by staged revascularization of the corresponding native coronary artery CTO. Staged revascularization of SVG lesions causing acute coronary syndromes may allow optimization of both acute and long-term outcomes