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Bypass graft PCI tied to worse outcomes than native coronary artery PCI in patients with prior CABG
Among patients who previously underwent CABG surgery, bypass graft PCI was associated with increased risk for short- and long-term major adverse events compared with native coronary artery PCI.
Emmanouil S. Brilakis, MD, PhD, and colleagues reviewed the Veterans Affairs Clinical Assessment, Reporting and Tracking (VA-CART) registry to identify a national cohort of 11,118 veterans and previous CABG patients who underwent PCI at 67 participating VA hospitals from 2005 to 2013. The researchers compared the outcomes of patients who underwent native coronary vs. bypass graft PCI. The groups were compared based on the following outcomes of interest: procedure-related in-laboratory complications, MI, all-cause mortality and repeat revascularization. The primary exposure variable was PCI target vessel during index PCI.
Emmanouil S. Brilakis
Overall, 18.5% of all patients who underwent PCI during the specified time period had a history of CABG. In 73.4% of patients, the target vessel for PCI was a native coronary artery, whereas 26.6% had a bypass graft as the target vessel (25% had a saphenous vein graft as the target vessel while 1.5% targeted an arterial graft).
In-hospital mortality was higher among patients who underwent bypass graft PCI vs. those who underwent native coronary artery PCI (1.79% vs. 0.83%; adjusted OR = 6.6; 95% CI, 0.6-7). Patients whose PCI targeted a bypass graft also had a higher risk for no reflow (3.37% vs. 0.4%; adjusted OR = 7; 95% CI, 4.8-10.3) periprocedural MI (1% vs. 0.43%; adjusted OR = 2.3; 95% CI, 1.1-4.7) and cardiogenic shock (0.36% vs. 0.13%; adjusted OR = 2.1; 95% CI, 0.6-7). However, bypass graft PCI patients had a lower risk for coronary dissection (0.94% vs. 2.08%; adjusted OR = 0.4; 95% CI, 0.3-0.7).
Compared with patients who underwent PCI for a native coronary artery, those who underwent bypass graft PCI had significantly higher follow-up rates of mortality (adjusted HR = 1.3; 95% CI, 1.18-1.42), MI (adjusted HR = 1.61; 95% CI, 1.43-1.82) and repeat revascularization (adjusted HR = 1.6; 95% CI, 1.5-1.71).
At baseline, patients who underwent bypass graft PCI were older and more likely to have diabetes, chronic kidney disease, depression and obstructive sleep apnea compared with those who underwent native coronary artery PCI.
“In the future, prospective randomized controlled trials are needed to confirm that native coronary arteries are the target vessels of choice in prior CABG patients,” Brilakis, director of the cardiac catheterization laboratory at the VA North Texas Healthcare System, professor of medicine at University of Texas Southwestern Medical Center in Dallas and Cardiology Today’s Intervention Editorial Board member, and colleagues wrote. “At present, given the better outcomes achieved with PCI of native coronary arteries, every effort should be undertaken to overcome obstacles to native coronary artery recanalization in prior CABG patients, such as treatment of chronic total occlusions.” – by Jennifer Byrne
Disclosure: Brilakis reports receiving honoraria/consultant fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Janssen Pharmaceuticals, Sanofi, Somahlution, St. Jude Medical and Terumo; research support from Boston Scientific and Infraredx; and his spouse is an employee of Medtronic. Please see the full study for a list of the other researchers’ relevant financial disclosures.