Challenges and Advances in Saphenous Vein Graft Perforation During Percutaneous Coronary Intervention: Incidence, Risk Factors, Management and Prophylactic Strategies

Saphenous vein grafts (SVGs) remain the most commonly used conduits in coronary artery bypass grafting, but their high failure rates necessitate repeated revascularization in many cases. SVG perforation, although rare, is a severe complication that can result in cardiac tamponade, myocardial infarction, or death if not promptly managed. Three main stages describe SVG failure pathophysiology, starting with thrombosis, followed by intimal hyperplasia, and progressing to atherosclerosis later in the process. The development of SVG perforation results from patient-related characteristics, including advanced age, male gender, and hypertension, as well as graft-related elements such as degenerate or older grafts and procedural aspects, including stent oversizing in chronic total occlusion interventions. Perforations categorized by the Ellis scale exist in 3 types, but type III represents the most serious condition, which leads to high mortality rates. The priorities for immediate SVG perforation treatment include balloon inflation, anticoagulation reversal, and placing stents into the affected area. Larger perforations need treatment with either covered stents or coil embolization methods. Surgical intervention is the only option available for perforations that cannot be treated through catheter interventions or when all other endovascular approaches have failed. After an SVG perforation occurs, the medical prognosis becomes unfavorable because patients have considerably elevated mortality rates during hospitalization and beyond it. The prognosis of SVG perforation appears to improve through prevention methods combining undersized vein grafts and new-generation procedures like intravascular lithotripsy. This review underlines the need to discover SVG perforations early for effective treatment and preventive strategies that enhance patient survival.