Myocardial infarction in saphenous percutaneous intervention: Are we really doing our best?

We have read with interest the article written by Bonello et al1 related with the influence of the new definition of myocardial infarction in saphenous interventions. Saphenous percutaneous intervention carries a significant risk of myocardial infarction due to distal embolization of atherothrombotic debris. As IIb/IIIa inhibitors have not demonstrated benefits in this scenario,2 the 2 only approaches to diminish this complication are direct stenting3 and embolic protection devices.4 Direct stenting is widely used in saphenous interventions. However, despite that embolic protection devices are a class IB recommendation in the American College of Cardiology/American Heart Association and European Society of Cardiology guidelines, their use is far bellow the desired rates. In an analysis of 19 546 saphenous vein graft percutaneous coronary intervention procedures in the American College of Cardiology–National Cardiovascular Data Registry from January 2004 to March 2006, these devices were only used in 22%5 and 29% in the Bonello et al cohort. Rates are not better in other series. In a recent published study performed by our group in 5 centers in Spain, they were used in only 18% of the cases performed after 20056 and in the Spanish Registry of 2007 only in 17%.7 Although the Bonello et al series the new definition of acute myocardial infarction had no influence in the long-term follow-up, the inhospital outcome showed 3% of death in the group with type 4a myocardial infarction versus 0.5% in the group without infarction, as well as important differences in inhospital major cardiac events. In our opinion, saphenous grafts remain as one of the most challenging lesions in percutaneous intervention, and special effort should be made to reduce complications, including the use of embolic protection devices in a much higher percentage than the current one.