Graft failure following surgical revascularization occurs in up to 50% of saphenous vein bypasses at 10 years, with reported graft occlusion rates reaching up to 27% within the first year of follow-up. For patients requiring repeat revascularization, percutaneous coronary intervention (PCI) is the technique of choice, with the native vessel being the recommended target according to current clinical guidelines. However, evidence supporting this recommendation remains limited, as some studies suggest superior outcomes with PCI to native vessels, while others report no significant differences between PCI performed on grafts versus native vessels. Given this uncertainty, this study aimed to clarify an important clinical question: which vessel should be targeted for PCI?
This study analyzed data from all PCIs performed at six centers in Victoria, Australia, between 2005 and 2018, in patients with previous surgical revascularization. In total, data from 2,764 patients were assessed, divided into two groups: 1,928 patients who underwent PCI on a native vessel and 836 patients who received PCI on a graft. The primary outcome of the study was major adverse cardiovascular and cerebrovascular events (MACCEs), including all-cause mortality, myocardial infarction (MI), target vessel revascularization, and stroke. The main secondary outcome was long-term mortality. A comparative analysis was performed on demographic, clinical, and procedural characteristics, in-hospital complications, 30-day MACCEs, and long-term mortality between the two groups.
The group undergoing PCI on grafts had a higher burden of cardiovascular risk factors (older age, male sex, estimated glomerular filtration rate <60 ml/min, and hypertension, all with p < .05) and more cardiovascular comorbidities (previous acute myocardial infarction, prior heart failure, left ventricular ejection fraction <50%, peripheral artery disease, and cerebrovascular disease, all with p < .05) than the group treated with PCI on native vessels. Most patients who presented with out-of-hospital cardiac arrest underwent PCI on a native vessel (p = .01), whereas most patients presenting with acute coronary syndrome received PCI on a graft (p < .05). Angiographically, the graft PCI group had a higher incidence of complex lesions (p < .001), while the native vessel PCI group had a greater prevalence of chronic total occlusions (CTO) (p < .001). Most graft PCI procedures were performed on saphenous vein grafts (84%). This group exhibited higher rates of no-reflow, coronary perforation, and stent thrombosis (p < .05), although the revascularization success rate was also higher (97% vs. 92%; p < .001). MACCE rates and 30-day mortality were similar between the two groups (p > .05). However, long-term mortality (median follow-up: 4.8 years) was higher in the graft PCI group (44% vs. 32%; p < .01). Nonetheless, after multivariable Cox adjustment, graft PCI was not identified as an independent predictor of long-term mortality (age, cerebrovascular disease, left ventricular ejection fraction <35%, chronic kidney disease, and the need for emergent PCI were). The authors concluded that short- and long-term outcomes were comparable between the two groups.
COMMENTARY:
The findings of this study may aid in selecting the most appropriate target vessel for PCI in patients with previous surgical revascularization.
In the short term, no significant differences were observed between PCI on grafts versus native vessels in terms of mortality or major cardiovascular events that would clearly favor one approach over the other. In the long term, although higher mortality was reported in the graft PCI group—potentially explained by the more complex clinical profile of these patients (older age, higher prevalence of chronic kidney disease, previous heart failure, etc.)—this approach was not identified as an independent predictor of mortality. Additionally, the success rate of target vessel revascularization was higher in the graft PCI group, despite a higher prevalence of complex lesions (ACC/AHA B2/C classification).
It is also crucial to consider the ongoing development of new revascularization strategies for complex native vessel lesions, including chronic total occlusions, which may play a key role in the management of patients with challenging anatomies.
Given these findings and awaiting the results of the PROCTOR randomized trial (PCI to native vessels vs. PCI to venous grafts), this study aligns with previous research. A patient-tailored approach, considering anatomical and clinical characteristics—such as age and comorbidities—seems reasonable when selecting the optimal target vessel for revascularization.
REFERENCE:
Cohen NS, Ajani AE, Dinh D, Clark DJ, Brennan A, Tie EN et al. Outcomes After Percutaneous Coronary Intervention in Patients With Previous Coronary Artery Bypass Grafting. Am J Cardiol. 2025 Jan 15;235:67-72. doi: 10.1016/j.amjcard.2024.10.021.
