**5. Conclusion**

SVG are prone to thrombosis. Microvascular thrombosis can lead to bad outcomes. Using distal embolic protection (**Table 15**) in cardiac vessels interventions has showed benefits in interventions on SVGs especially with thrombotic lesions. The goal of distal embolic protection is to minimize/stop any thrombi from traveling distally to microvasculature. These devices cannot be used for all SVGs interventions. Distally to the target lesion, vessel should have about 4 cm safe landing segment where the device can be deployed. Severe stenotic lesions (especially aortoostial lesions) make using distal embolic protection technically challenging or impossible. Some operators advocate in such cases with difficulty passing the embolic protection device is to perform direct stenting if it allows. Fibrotic lesions (instent restenosis) with no friable thrombotic material, might not benefit from embolic protection. Direct stenting is another approach to minimize distal embolization and microvascular obstruction when feasible. Aneurysmal changes in SVG are very common which makes stent sizes difficult. Sizing should be based on the nonaneurysmal segment and post dilation can be used when needed. Proximal embolic protection devices are still available but are not used as much as the distal one during PCI on SVGs. The idea of these devices to reduce the thrombi that can

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

No reflow phenomena is common during any coronary or graft intervention. It is more common with thrombotic lesions and thought to be related to microvascular thrombosis and/or dysfunction. In addition to minimize clot burden with embolectomy, angioplasty and stenting to trap clots, administrating of microvascular active

Simple focal restenosis is usually treated with DES. The era of DES changed the approach of instent restenosis treatment. A second and a third layer of stents can be used to treat the lesion especially focal lesions in the body of the stent or edge of stent whether the prior used stent was a BMS or DES. Treatment of instent restenosis can be very challenging due to the variable potential underlying pathophysi-

calcification, neoatherosclerosis, fibrotic tissue or presence of diffuse instent restenosis. Understanding the mechanism of restenosis is the main step to choose the appropriate treatment strategy. Intravascular imaging with IVUS or OCT if possible can be very helpful. However, most of the time these imaging catheters cannot cross

In case of diffuse instent neoatherosclerosis cutting balloons is not a good option especially if the prior stents are well sized and fully apposed. The decision of adding a

Spider RX (ev3) 6Fr 3.2 Fr 3–6 mm 10 mm/39 mm, Only one with wire

6Fr 3.2 Fr 2.5–5.5 mm 15 mm/39 mm

Interceptor 6Fr 2.7 Fr 2.5–5.5 mm Capture Small

3–6 mm

**Vessel size Length of filter/**

**landing zone**

**Notes**

of choice

Particles <50 μm

travel upwards and cause organ ischemia specifically a stroke.

**4.4 Instent restenosis treatment**

**Device Guide**

*Distal embolization protection devices.*

FilterWire (Boston Scientific)

**Table 15.**

**238**

**compatibility**

GaurdWire 6Fr 2.1 and

medications nitroprusside, verapamil and/or adenosine is necessary.

ology of stent restenosis: undersized, under expanded stent, presence of

the restenosis. In these setting, ballooning might be the only option.

**Crossing profile**

2.8 Fr

Percutaneous coronary interventions have always been crucial in medical care. Now more than ever, with rapidly evolving percutaneous interventions and less surgical interventions, coronary percutaneous interventions are priority. Developing required technical skills and mastering basic and complicated intervention techniques have never been as important as they are now. Before proceeding with any intervention, all necessary equipment and medications should be available. Other essential requirements for any successful intervention include planning, having competency in required techniques, early recognition, and being prepared to manage complications.
