It is justified to use distal protection filter in venous bridges?

The current guidelines point out a class I recommendation to the use of distal embolic protection devices for angioplasty in venous bridges, in fact, the evidence is controversial to support this recommendation.

The goal of this meta-analysis was to compare mortality from any cause, major cardiovascular events, acute myocardial infarction, and target vessel revascularization of interventions on saphenous venous bridges with or without distal protection systems.

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A total of 8 studies were analyzed with the incredible number of 52893 patients who compared angioplasty in venous bridges with distal protection system (n = 11506) and without embolic protection (n = 41387).

There were no significant differences in mortality from any cause (OR 0.79, TI 95% 0.55 -1.12; p = 0.19), major adverse cardiovascular events (OR 0.73, TI 95% 0.51 -1.05; p = 0.09), revascularization of the target lesion (OR 1.0, TI 95% 0.95 -1.05, p = 0.94), periprocedural myocardial Infarction (OR 1.12, TI 95% 0.65 -1.90, p = 0.69) or infarction at follow-up (OR 0.80, TI 95% CI 0.52 -1.23; p = 0.30) between the two groups.

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A sensitivity analysis excluding the CathPCI registry did not show differences in terms of periprocedural myocardial Infarction or revascularization, but a lower mortality and combined events. The analyzes, including only the observational studies, did not show significant differences in any of the aforementioned points.

Conclusion

This work, which included more than 50,000 patients, suggests that there is no apparent benefit in the routine use of distal embolic protection systems when angioplasty is performed on venous bridges in contemporary real-world interventions. Obviously, randomized studies are necessary to define the topic and, in the meantime, review the current recommendations of the guidelines.

Editorial comment

Surprisingly, when a fixed effect model was used, it was observed that the use of distal embolic protection systems was associated with an increase of 1.5 times the risk of periprocedural myocardial Infarction (p <0.0001). This is exactly the opposite of what was expected, since the main goal of the filters should be to prevent the “no reflow” and the consequent infarction. Here is the reason for all the questions and the reason to continue investigating.

The CathPCI Registry has the largest number of patients and could have biased itself, the results of this meta-analysis. That is why in the sensitivity analysis the mentioned work was excluded, observing a clear homogeneity of all the events.

Original title: Outcomes of Saphenous Vein Graft Intervention With and Without Embolic Protection Device. A Comprehensive Review and Meta-Analysis.

Reference: Timir K. Paul et al. Circ Cardiovasc Interv. 2017 Dec; 10(12).

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