Native Coronary Artery Versus Saphenous Vein Graft Percutaneous Coronary Intervention After Coronary Artery Bypass...

Patients with prior coronary artery bypass grafting frequently require repeat revascularization because of progressive native coronary artery disease and saphenous vein graft degeneration. Observational studies have consistently reported worse procedural and long-term outcomes with saphenous vein graft percutaneous coronary intervention (PCI) compared with native-vessel PCI. This has shaped guideline recommendations that favor native-vessel revascularization when feasible. However, these comparisons are inherently confounded, as vein graft intervention is often selected when the native vessel is not technically amenable to PCI. PROCTOR is the first randomized trial to compare native vessel versus saphenous vein graft PCI after bypass surgery, enrolling patients only after heart-team confirmation that both targets were clinically appropriate and technically feasible. The trial was terminated early after enrollment of 220 of 584 planned patients and reported only 1-year outcomes. Consequently, PROCTOR provides randomized evidence in a highly selected population characterized by favorable graft anatomy and complex native coronary disease, including a high prevalence of chronic total occlusions. In this review, we integrate the PROCTOR findings with contemporary registry data and mechanistic studies, highlighting how graft morphology and native lesion complexity modulate early procedural risk and long-term durability. We further propose an anatomy-driven framework for target-vessel selection following bypass surgery. In conclusion, PROCTOR should be interpreted as hypothesis-generating randomized evidence that refines-rather than supplants-the native-first paradigm by identifying clinical and anatomic scenarios in which carefully selected saphenous vein graft intervention may confer lower early hazard, while longer-term durability remains uncertain.