Urokinase recanalization of chronically occluded aortocoronary vein grafts.

The problem of aortocoronary vein graft occlusion remains a major clinical challenge. The approach described above offers one method of preserving the life of some occluded vein grafts. Adherence to the protocol, particularly the inclusion and exclusion criteria, is the primary determinant of acute success and lower complications. The following summarizes the experience to date: (1) This procedure is safe and effective when applied to the patients outlined and when the protocol is strictly adhered to. (2) Acute recanalization is improved if TIMI grade 2 or 3 flow is achieved by lysis alone. (3) Acute recanalization is not influenced by (i) age of graft, (ii) duration of occlusion up to 6 months, (iii) size of distal native vessel, (iv) site of stenosis (intragraft versus anastomosis). (4) Six-month patency is greater when (i) TIMI grade 3 flow was achieved by lysis alone, (ii) the site of offending lesion is intragraft versus anastomosis. (5) Six-month patency may be influenced by (i) a size of distal native vessel greater than 2 mm, (ii) graft flow at initial operation greater than 200 ml/min. These studies were performed before the release of the coronary stent. As shown by Tierstein [32], long-term patency can be greatly enhanced by the use of stents. This procedure will presumably permit more patients to become candidates for this new technology and thereby improve the long-term patency and reduce the need for repeat operations.