DES reduced mortality vs. BMS in stenosis of saphenous vein grafts

Drug-eluting stents were associated with a 28% reduction in mortality compared with bare-metal stents in a cohort of patients undergoing PCI for stenosis of saphenous vein grafts, according to new data published in the Journal of the American College of Cardiology.

Researchers of the study noted that the efficacy of DES vs. BMS in treating this patient population remains unclear. The current study included 2,471 individuals from the national VA health system undergoing PCI for stenosis of saphenous vein grafts.

Patient accrual occurred between 2008 and 2011.

Procedural complications, MI and all-cause mortality were the clinical outcomes that underwent evaluation.

Clinicians used DES in 1,549 patients, or 63% of the cohort. DES use increased from 50% in 2008 to 69% in 2011.

Procedural complications occurred in 2.3% of patients receiving DES and 2.8% among those receiving BMS (P=.54).

The long-term follow-up duration was more than 2 years. During this period, DES yielded a lower mortality rate than BMS (HR=0.72; 95% CI, 0.57-0.89) in a propensity-matched cohort. However, similar rates of MI were reported for the two stent groups (HR=0.94; 95% CI, 0.71-1.24) in this analysis.

In an accompanying editorial, Christodoulos Stefanadis, MD, of Athens Medical School at Hippokration Hospital in Athens, Greece, suggested that the increasing use of DES may reflect the fact that clinicians are becoming more confident in using this type of stent due to an increasing body of positive evidence.

“As in previous studies, acute safety data from this study demonstrate similar incidence rates of in-hospital complications between BMS and DES,” he wrote. “Additionally, a lower incidence of no-reflow and vessel perforation was observed for DES, attributed mainly to potential procedural confounders.”

Stefanadis added that the mortality rates reported by Aggarwal and colleagues also align with previous findings. “Importantly, in contrast to previous studies performed mainly with first-generation DES, second-generation DES were used in almost two-thirds of the DES-treated population in this study,” he wrote. “This observation supports the safety of second-generation DES in [stenosis of saphenous vein graft]-PCI, consistent with clinical observations that these stents have an enhanced safety profile in native vessel PCI and with imaging observations of a favorable healing response.”

There are, however, still unanswered questions, according to Stefanadis. Data for cardiac mortality are not available for the current cohort, nor are data for DAPT status.

“In the absence of confirmatory randomized data, the lower mortality rate observed with DES should, therefore, be interpreted with caution and regarded as an unproven hypothesis,” he wrote. “Moreover, the lack of angiographic follow-up does not allow the late behavior of DES implanted for treatment of [stenosis of saphenous vein graft] disease to be elucidated. This is an important issue that remains unaddressed, as previous reports revealed the possible presence of a late ‘catch-up’ phenomenon, with no differences in repeat revascularization rates with longer-term follow-up, contradicting other studies that showed a sustained benefit for DES.”

Stefanadis called for adequately powered randomized trials to assess these issues.

“However, the contribution of studies like that of Aggarwal et al. should not be neglected; such real-world registries are important for evaluating whether clinical practice is, indeed, moving on the right track and for providing large-scale observations that corroborate and supplement findings from randomized studies,” he wrote.

For more information:

Aggarwal V. J Am Coll Cardiol. 2014;64:1825-1836.

Stefanadis C. J Am Coll Cardiol. 2014;64:1837-1839.

Disclosure: The researchers report financial disclosures with Abbott Vascular, Asahi, Boston Scientific, Guerbet, Janssen, Medtronic, St. Jude Medical and Terumo. Stefanadis reports no relevant financial disclosures.