Do angiographic results from symptom-directed studies reflect true graft patency?

Coronary artery graft patency results have been obtained from repeat angiograms in patients who presented with evidence of ischemia. The purpose of this study is to compare protocol-directed angiographic results from a randomized clinical trial with symptom-directed angiography in nontrial patients.

Repeat angiography after primary isolated coronary artery bypass grafting was performed in 337 of 2,259 patients between July 1996 and September 2004. Patients were divided into two groups: 596 graft angiograms in 192 trial patients were compared with 389 graft angiograms in 142 nontrial patients. The mean interval from surgery was 1,306 +/- 800 days versus 1,119 +/- 777 days, respectively. Grafting techniques were similar in both groups except that the right internal thoracic artery was used almost exclusively as a free graft in the trial patients. Angiographic outcomes were defined as patent (stenosis <80%) or failure (stenosis > or =80%, occlusion, or the string sign). Comparisons of trial versus nontrial grafts were made using a generalized linear mixed model. Five-year estimates of graft patency were made using survival analyses accounting for interval censoring.

The odds ratio for graft failure for nontrial compared with trial patient grafts was 2.6 (95% confidence interval, 1.6 to 4.3; p < 0.001). Cumulative patency estimates for all grafts at 5 years were trial 91% versus nontrial 83%, p = 0.004. Five-year estimates for individual conduits were left internal thoracic artery, 99% versus 92%, p = 0.002; right internal thoracic artery, 86% versus 87%, p = 0.8; radial artery, 87% versus 86%, p = 0.6; and saphenous vein, 86% versus 56%, p = 0.003.

Graft patency rates were superior in the trial compared with nontrial patients. Symptom-directed graft failure rates were approximately double those of trial patients.