Patients who received bypass graft percutaneous coronary intervention (PCI) who had also previously undergone coronary artery bypass grafting (CABG) surgery had higher incidences of short- and long-term major adverse events compared with native coronary PCI.
Researchers noted while native coronary arteries are the “preferred target of PCI” in patients who have had CABG, there are limited data to support this. Therefore, they set out to determine the outcomes of native coronary artery PCI vs bypass graft PCI in patients who had previously undergone CABG. The study results were published in JACC: Cardiovascular Interventions.
A total of 60 171 patients from the VA Clinical Assessment, Reporting, and Tracking (CART) program were included in the study. These patients underwent PCI between October 2015 and September 2013 at 67 VA hospitals. Of the total population (median age: 65.5; 99% male), 11 118 (18.5%) patients had previous CABG procedures. In those patients, 16 440 lesions were treated: native coronary artery (n=12 073; 73.4%), saphenous vein graft (n=4114; 25.0%), and arterial graft (n=253; 1.5%).
Four outcomes were assessed: procedure-related in-laboratory complications, myocardial infarction (MI), all-cause mortality, and repeat revascularization. In terms of complications, researchers included incidence of death, periprocedural MI, no-reflow, dissection, perforation, and acute target vessel closure. Revascularization was defined by repeat PCI or CABG in data following the index PCI.
Patients who underwent bypass graft PCI were older, more likely to have diabetes and chronic kidney disease, and more likely to have depression and sleep apnea, compared with native coronary artery PCI patients. In addition, stable angina was more common in patients who received native coronary artery PCI, but acute coronary syndromes were less prevalent.
In-hospital mortality was higher in patients undergoing bypass graft PCI (1.79% vs 0.83%; adjusted odds ratio [OR]: 6.6; 95% confidence interval [CI]: 0.6-7.0) as well as higher risk of no reflow (3.37% vs 0.40%; adjusted OR: 7.0; 95% CI: 4.8-10.3), periprocedural MI (1.00% 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: 0.6-7.0). However, they also had a lower risk of coronary dissection (0.94% vs 2.08%; adjusted OR: 0.4; 95% CI: 0.3-0.7).
Death, MI, and revascularization occurred in less than 50% of patients during follow-up (median time: 3.11 years). Overall incidence of death was 6.7%, MI was 4.3%, and coronary revascularization was 22.8% during the first year after PCI. At 3 years, these incidences increased to 14.4%, 8.6%, and 31.3% and at 5 years, 19.4%, 10.2%, and 33.7%, respectively.
Patients who underwent bypass graft PCI had a significantly higher incidence of post hospital discharge death on Cox regression analysis (adjusted hazard ratio [HR]: 1.30; 95% CI: 1.18-1.42) as well as MI (adjusted HR: 1.61; 95% CI: 1.43-1.82) and repeat revascularization (adjusted HR: 1.60; CI: 1.50-1.71).
“Bypass graft PCI was significantly less frequent than native coronary artery PCI in prior CABG patients, was performed in patients who had more comorbidities, and was associated with 30% higher mortality, 61% higher risk for MI, and 60% higher risk for repeat revascularization during long-term follow-up,” researchers wrote.
“At present, given the better outcomes achieved with PCI of native coronary arteries,” they added, “every effort should be undertaken to overcome obstacles to native coronary artery recanalization in prior CABG patients, such as treatment of chronic total occlusions.”
Brilakis ES, O’Donnell C, Penny W, et al. Percutaneous coronary intervention in native coronary arteries vs bypass grafts in patients with prior coronary artery bypass graft surgery: insights from the Veterans Affairs CART program. JACC Cardiovasc Interv. 2016. doi:10.1016/j.jcin.2016.01.034.