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Published on: March 27, 2018
Clinical outcome after surgical or percutaneous revascularization in coronary bypass graft failure
Ralf E Harskamp1, Marcel A Beijk, Peter Damman
1Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Insights
Outcomes after surgical or percutaneous coronary intervention for graft failure are similarly poor. Repeat revascularization is more frequent with percutaneous coronary intervention, especially using bare-metal stents.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Graft failure after coronary artery bypass grafting (CABG) necessitates revascularization.
- Long-term outcomes comparing surgical (redo CABG) and percutaneous coronary intervention (PCI) for graft failure are not well-defined.
Purpose of the Study:
- To compare the long-term outcomes of surgical versus percutaneous revascularization in patients experiencing graft failure.
Main Methods:
- A cohort of 287 patients with graft failure were analyzed, with 243 undergoing PCI and 44 undergoing redo CABG.
- The primary endpoint was a composite of death, myocardial infarction (MI), or target vessel revascularization (TVR) over a 5-year follow-up.
- Multivariable Cox proportional hazard models identified independent predictors of outcomes.
Main Results:
- Five-year rates for death, MI, or TVR were similar between PCI (57.6%) and redo CABG (51%) (P=0.51).
- Repeat revascularization (TVR/TLR) was significantly higher after PCI (30.7%/21.3%) compared to redo CABG (8.0%/3.2%) (P=0.009).
- Bare-metal stents (BMS) in PCI were associated with higher TVR and target lesion revascularization (TLR) rates compared to drug-eluting stents (DES).
Conclusions:
- Clinical outcomes are comparably poor for both surgical and percutaneous interventions in graft failure patients.
- PCI leads to more frequent repeat revascularization, particularly when using BMS.
Aims:
To describe long-term outcome following surgical and percutaneous revascularization in graft failure.
Methods:
We analyzed consecutive patients with graft failure after heart-team assignment to percutaneous coronary intervention (PCI) or redo coronary artery bypass grafting (CABG) between 2003 and 2008. The primary endpoint was the composite of death, myocardial infarction (MI) or target vessel revascularization (TVR). Kaplan-Meier event rate estimates were calculated up to a 5-year follow-up. Independent predictors for outcomes were identified by backward selection in a multivariable Cox proportional hazard model.
Results:
We identified 287 patients treated for graft failure: 243 with PCI and 44 with redo CABG. Patients undergoing PCI more frequently presented with ST-elevated myocardial infarction (STEMI) (P < 0.001), multivessel disease (P < 0.001), vein graft failure (P = 0.04), a history of MI (P < 0.001) and shorter time-to-graft failure (P = 0.001). Bare-metal stents (BMS) were used in 81.3% of the PCI-treated lesions and drug-eluting stents (DES) in 18.7%. The median follow-up was 3.9 years. Five-year rate of composite all-cause death, MI or TVR was 57.6% after PCI and 51% after CABG (P = 0.51). Repeat revascularization [TVR and target lesion revascularization (TLR)] was 30.7 and 21.3% after PCI, and 8.0 and 3.2% following CABG (P = 0.009; P = 0.008). In the PCI group, BMS was associated with higher rates of TVR (35.1 vs. 12.6%; P = 0.04) and TLR (24.8 vs. 7.6%; P = 0.04), but similar rate of death or MI compared with DES. Independent predictors for the primary outcome were creatinine [hazard ratio 1.008 per μmol/l, 95% confidence interval (CI) 1.005-1.011, P < 0.001] and peak creatine kinase MB (hazard ratio 1.001 per U/l, 95% CI 1.000-1.002, P = 0.027).
Conclusion:
Clinical outcomes are similarly poor after heart-team triage for surgical or percutaneous intervention in patients with graft failure. Repeat revascularization occurred more frequent after PCI, particularly following BMS implantation.
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