What is the role of distal embolic protection devices in percutaneous coronary intervention (PCI)?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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PCI in a saphenous vein graft (SVG) is considered a high-risk procedure, given the increased incidence of distal embolization and no-reflow phenomenon. The SAFER (Saphenous Vein Graft Angioplasty Free of Emboli Randomized) trial initially proved the benefit of embolic protection devices (EPDs) in reducing the 30-day incidence of MACE (9.6% vs 16.5%), MI (8.6% vs 14.7%), and no-reflow (3% vs 9%). [59]

Although the ACC/AHA guidelines gave EPDs in SVGs a class I recommendation, EPD use remains low, for a variety of reasons (eg, anatomic challenges, cumbersome devices, increased complications, and emergence of alternate techniques such as direct stenting, mesh stents, undersizing stents with higher stent-to-lesion length ratio) and laser atherectomy.

Observational data from the NCDR Cath Registry on 49,325 patients who underwent SVG intervention reported low EPD use (~21%) and no reduction in adverse events after 3 years of follow-up. In fact, in the EPD group, there were higher procedural complications of no-reflow, dissection, perforation, and periprocedural MI. 

One of the conclusions that can be inferred from the available data is that not all SVG interventions are the same. The decision to use EPDs should be based on thrombus/plaque burden, risk of embolization, anatomic complexity, and operator familiarity with the devices. [75]

There is no indication for EPD use in native coronary arteries. A 15-month follow-up of the DEDICATION (Drug Elution and Distal Protection in ST Elevation Myocardial Infarction) trial found that in primary PCI for STEMI, routine use of distal protection increased the incidence of stent thrombosis and clinically driven target lesion/vessel revascularization. [76]

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