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Thrombosis of coronary artery bypass graft — Clinical Guidelines

Overview

Thrombosis of coronary artery bypass grafts (CABG) involves the formation of a blood clot within the bypass graft, potentially compromising graft patency and patient outcomes. This condition can occur at various time points post-surgery and requires prompt intervention to restore blood flow and prevent complications.

Diagnosis

Clinical Presentation: Symptoms may include acute limb ischemia, chest pain, or signs of systemic embolization.

Diagnostic Imaging: Angiography is crucial for visualizing graft patency and identifying thrombi.

Doppler Ultrasound: Useful for detecting flow abnormalities in peripheral grafts.

Laboratory Tests: Elevated D-dimer levels may indicate thrombotic events, though not specific to graft thrombosis.

Management

First-Line Treatments:

- Percutaneous Aspiration Thrombectomy: Effective for chronic thrombi, as demonstrated in aortobifemoral grafts 1. - Percutaneous Thrombolysis: Use of tissue plasminogen activator (tPA) or urokinase for lyse and wait (L&W) techniques 3.

Adjunctive Treatments:

- Balloon Angioplasty and Stenting: Often required post-thrombectomy to address underlying stenoses 1. - Selective Embolectomy: Techniques like Fogarty catheter for specific graft types (e.g., pancreas grafts) 2.

Special Populations

Elderly Patients: Considerations for procedural risks and comorbidities are essential, though specific guidelines are not detailed in the abstracts.

Comorbidities: Patients with diabetes (as seen in pancreas graft cases) may require tailored approaches to manage thrombosis effectively 2.

Key Recommendations

Consider Percutaneous Aspiration Thrombectomy for Chronic Thrombi in Aortobifemoral Grafts: This method shows efficacy even in chronic cases 1 (Evidence: Moderate).

Use Lyse and Wait (L&W) Technique with tPA for Dialysis Grafts: Effective for declotting with acceptable procedural times 3 (Evidence: Moderate).

Evaluate Cost-Effectiveness Between Thrombolysis and Surgical Thrombectomy: Thrombolysis may offer comparable patency with potentially lower costs for dialysis grafts 4 (Evidence: Weak).

Incorporate Imaging Techniques (Angiography, Doppler Ultrasound) for Diagnosis: Essential for accurate identification and management planning 1 3 (Evidence: Expert opinion).

References

1 Önder H, Oğuzkurt L, Tekbaş G, Gür S, Gedikoğlu M. Successful treatment of delayed aortobifemoral graft thrombosis with manual aspiration thrombectomy. Diagnostic and interventional radiology (Ankara, Turkey) 2012. link 2 Izaki K, Yamaguchi M, Matsumoto I, Shinzeki M, Ku Y, Sugimura K et al.. Percutaneous selective embolectomy using a Fogarty Thru-Lumen Catheter for pancreas graft thrombosis: a case report. Cardiovascular and interventional radiology 2011. link 3 Vogel PM, Bansal V, Marshall MW. Thrombosed hemodialysis grafts: lyse and wait with tissue plasminogen activator or urokinase compared to mechanical thrombolysis with the Arrow-Trerotola Percutaneous Thrombolytic Device. Journal of vascular and interventional radiology : JVIR 2001. link61672-8) 4 Vesely TM, Idso MC, Audrain J, Windus DW, Lowell JA. Thrombolysis versus surgical thrombectomy for the treatment of dialysis graft thrombosis: pilot study comparing costs. Journal of vascular and interventional radiology : JVIR 1996. link70791-1) 5 Babatasi G, Bara L, Galateau F, Agostini D, Massetti M, Gerard JL et al.. An animal model for the evaluation of graft thrombosis in the acute phase on carbon-lined PTFE prosthesis. The International journal of artificial organs 1994. link 6 Dascombe WH, Hong C, Garrett KO, White JG, Lyle VA, Miller JL et al.. Artificial microvascular graft thrombosis: the consequences of platelet membrane glycoprotein Ib inhibition and thrombin inhibition. Blood 1993. link 7 Flanigan DP, Goodreau JJ, Burnham SJ. Technique for thrombectomy of reversed saphenous vein arterial bypass grafts. American journal of surgery 1979. link90400-8)

Thrombosis of coronary artery bypass graft