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Published on: November 19, 2019
PCI of Native Coronary Artery vs Saphenous Vein Graft After Prior Bypass Surgery: A Multicenter, Randomized Trial
Ruben W de Winter1, Roel Hoek1, Simon J Walsh2
1Department of Cardiology, Heart Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands.
Insights
Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) showed better clinical outcomes than native vessel PCI in patients with prior coronary artery bypass grafting (CABG). SVG PCI reduced major adverse cardiac events, primarily due to lower PCI-related myocardial infarction.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Current guidelines suggest native vessel PCI over bypass graft PCI for graft failure post-coronary artery bypass grafting (CABG).
- This recommendation is based on limited observational data, necessitating further clinical investigation.
Purpose of the Study:
- To compare clinical outcomes between native vessel PCI and saphenous vein graft (SVG) PCI in post-CABG patients with SVG failure.
- To evaluate the efficacy and safety of different PCI strategies in a complex patient population.
Main Methods:
- The PROCTOR trial was a multicenter, randomized study involving patients with significant SVG stenosis and indication for revascularization.
- Patients were assigned to either native vessel PCI or SVG PCI (1:1 ratio).
- The primary endpoint was major adverse cardiac events at 1 year, including all-cause mortality, nonfatal myocardial infarction (MI), or revascularization.
Main Results:
- A total of 220 patients were randomized; 108 to native vessel PCI and 112 to SVG PCI.
- At 1 year, major adverse cardiac events occurred in 34% of the native vessel PCI group versus 19% in the SVG PCI group (HR: 2.14; P=0.006).
- SVG PCI demonstrated lower rates of PCI-related MI and target coronary territory revascularization compared to native vessel PCI.
Conclusions:
- In the PROCTOR trial, SVG PCI was associated with improved 1-year clinical outcomes compared to native vessel PCI.
- The observed benefit of SVG PCI was primarily driven by reduced rates of PCI-related MI and clinically driven revascularization.
Background:
In patients with prior coronary artery bypass grafting (CABG) presenting with graft failure, current guidelines recommend percutaneous coronary intervention (PCI) of the bypassed native coronary artery over PCI of the bypass graft. However, this recommendation relies solely on observational data.
Objectives:
This study compared clinical outcomes between a strategy of native vessel PCI with saphenous vein graft (SVG) PCI in post-CABG patients presenting with SVG failure.
Methods:
The multicenter, randomized PROCTOR (Percutaneous Coronary Intervention of Native Coronary Artery versus Saphenous Vein Graft in Patients with Prior Coronary Artery Bypass Graft Surgery) trial included patients with significant SVG stenosis and a heart team-defined clinical indication for revascularization. Patients were randomly assigned (1:1) to either a strategy of native vessel PCI or SVG PCI using an interactive web-based randomization platform. The trial was conducted across 14 centers in Europe. We report the occurrence of major adverse cardiac events at 1 year following the index PCI, defined as the composite of all-cause mortality, nonfatal target coronary territory myocardial infarction (MI), or clinically driven target coronary territory revascularization, analyzed on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov (NCT03805048), and long-term follow-up is ongoing.
Results:
Between January 2019 and December 2023, 220 patients (mean age 73 ± 7 years; 84% men [185/220 patients]) were randomized to a strategy of native vessel PCI (n = 108) or SVG PCI (n = 112). At 1 year, major adverse cardiac events occurred in 37 patients (34%) in the native vessel PCI group and 21 patients (19%) in the SVG PCI group (HR: 2.14; 95% CI: 1.25-3.65; P = 0.006). There was no significant difference in all-cause mortality (HR: 1.59; 95% CI: 0.45-5.64; P = 0.472), whereas both nonfatal target coronary territory MI (HR: 2.12; 95% CI: 1.08-4.17; P = 0.029) and clinically driven target coronary territory revascularization (HR: 2.19; 95% CI: 1.02-4.72; P = 0.044) occurred more frequently in patients assigned to native vessel PCI. The incidence of PCI-related MI was 13% in the native vessel PCI group and 1% in the SVG PCI group (HR: 14.85; 95% CI: 1.95-112.96; P = 0.009).
Conclusions:
In the randomized PROCTOR trial, SVG PCI was associated with improved 1-year clinical outcomes compared with native vessel PCI, primarily driven by lower rates of PCI-related MI and clinically driven target coronary territory revascularization.
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