Umut Ata UĞRAŞ, Muhammed Emre GÜLEŞİR
Middle Black Sea Journal of Health Science - 2026;12(2):303-311
Background: Saphenous vein graft (SVG) failure remains one of the major limitations of coronary artery bypass grafting (CABG) despite advances in surgical techniques and secondary prevention strategies. Compared with arterial conduits, SVGs demonstrate lower long-term patency and are more vulnerable to thrombosis, intimal hyperplasia, and accelerated atherosclerotic degeneration. Percutaneous coronary intervention (PCI) for SVG lesions is associated with increased procedural complexity and higher risks of distal embolization, no-reflow phenomenon, periprocedural myocardial infarction, restenosis, and repeat revascularization. Review text: This review summarizes contemporary management strategies for SVG disease with particular emphasis on lesion-specific procedural planning. The pathological characteristics of SVG lesions are presented using the practical "4F" and "2C" frameworks, describing their diffuse, inflamed, foamy, and friable nature, together with the relative absence of heavy calcification and a stabilizing fibrous cap. Based on these features, a simplified "5N" strategy is proposed: Native vessel PCI first, No-reflow preparedness, No routine predilation, No oversizing, and No aggressive postdilation. Current evidence regarding drug-eluting stents, embolic risk reduction techniques, and aggressive secondary prevention is reviewed. In addition, emerging technologies such as mesh-covered and double-layer stent platforms are discussed as potential adjunctive options for highly degenerated graft lesions with substantial embolic burden. Conclusion: SVG PCI represents a distinct and high-risk subset of coronary intervention requiring careful lesion assessment and tailored procedural techniques. Whenever feasible, native coronary revascularization should remain the preferred strategy. When SVG intervention is necessary, structured management algorithms and evolving device technologies may improve procedural safety and long-term clinical outcomes.
