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Published on: November 19, 2019
Percutaneous Coronary Intervention of Saphenous Vein Graft
Björn Redfors1, Philippe Généreux2, Bernhard Witzenbichler1
1From the Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., P.G., T.M., X.H., A.M., G.W., R.M., A.J.K., G.W.S.); Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center (J.D., A.M., G.W., A.J.K., G.W.S.); Gagnon Cardiovascular Institute, Morristown Medical Center, NJ (P.G.); Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Quebec, Canada (P.G.); Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany (B.W.); Els & Charles Bendheim Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel (G.W.); and The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.).
Insights
Percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs) significantly increases the risk of adverse ischemic events. High platelet reactivity (HPR) poses a similar risk in SVG PCI and native PCI, suggesting enhanced antiplatelet therapy may be beneficial.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) historically carries high ischemic event risks.
- Contemporary data on second-generation drug-eluting stents in SVGs and the role of high platelet reactivity (HPR) are limited.
- The comparative importance of HPR in SVG PCI versus native lesion PCI remains unclear.
Purpose of the Study:
- To evaluate ischemic and bleeding events following SVG PCI.
- To determine the association of HPR with these events in SVG PCI.
- To compare outcomes between SVG PCI and non-SVG PCI.
Main Methods:
- Prospective, multicenter ADAPT-DES study including 8582 subjects.
- Stratification of subjects into SVG PCI and non-SVG lesion PCI groups.
- Analysis of 2-year outcomes using Cox proportional hazards models, defining HPR and major adverse cardiac events.
Main Results:
- 405 subjects (4.7%) underwent SVG PCI.
- SVG PCI was independently linked to increased 2-year risks of major adverse cardiac events (aHR 2.34), ischemia-driven target vessel revascularization (aHR 1.82), and stent thrombosis (aHR 2.26).
- No significant association was found between SVG PCI and bleeding events (aHR 0.99), and no interaction between HPR and SVG PCI regarding major adverse cardiac events was observed.
Conclusions:
- SVG PCI is associated with a substantially higher risk of 2-year adverse ischemic events.
- HPR confers a similar risk in both SVG PCI and non-SVG PCI.
- Consideration of more potent and longer antiplatelet therapy is warranted for patients undergoing SVG PCI.
Background:
Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) has historically been associated with a high risk of adverse ischemic events, but there is a paucity of contemporary data on the second-generation drug-eluting stent use within SVG, and the relative importance of high platelet reactivity (HPR) in SVG PCI versus native lesion PCI is unknown. We studied ischemic and bleeding events after SVG PCI and their association with HPR.
Methods And Results:
Subjects in the prospective, multicenter ADAPT-DES study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) were stratified according to whether they had PCI of an SVG or a non-SVG lesion. Two-year outcomes were compared between groups using univariate and multivariable Cox proportional hazards models. HPR was defined as on-clopidogrel P2Y12 platelet reaction units >208 as measured by the VerifyNow assay; major adverse cardiac events were defined as the composite of cardiac death, myocardial infarction, or stent thrombosis. Among 8582 subjects in ADAPT-DES, 405 (4.7%) had SVG PCI. SVG PCI was independently associated with a higher 2-year risk of major adverse cardiac events (adjusted hazard ratio, 2.34; 95% confidence interval, 1.69-3.23; P<0.0001), ischemia-driven target vessel revascularization (adjusted hazard ratio, 1.82; 95% confidence interval, 1.37-2.42; P<0.0001), and stent thrombosis (adjusted hazard ratio, 2.26; 95% confidence interval, 1.42-3.59; P=0.0006), but not of bleeding (adjusted hazard ratio, 0.99; 95% confidence interval, 0.68-1.46; P=0.97). There was no statistical interaction between HPR and SVG PCI in regard to major adverse cardiac events (adjusted Pinteraction=0.99).
Conclusions:
SVG PCI is associated with a considerably higher risk of 2-year adverse ischemic events, with HPR conferring similar risk in SVG and non-SVG PCI. More potent and longer antiplatelet therapy may be beneficial for patients undergoing SVG PCI.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.
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