Meta-analysis Comparing Outcomes of Percutaneous Coronary Intervention of Native Artery Versus Bypass Graft in Patients With Prior Coronary Artery Bypass Grafting

doi:10.1016/j.amjcard.2020.10.062

The American Journal of Cardiology

Volume 140, 1 February 2021, Pages 47-54

https://doi.org/10.1016/j.amjcard.2020.10.062 Get rights and content

Percutaneous coronary intervention (PCI) is common in patients with prior coronary artery bypass graft surgery (CABG), however the data on the association between the PCI target-vessel and clinical outcomes are not clear. We aimed to investigate long-term clinical outcomes of patients with prior CABG who underwent PCI of either bypass graft or native artery. We performed a systematic review and meta-analysis of observational studies comparing PCI of either bypass graft or native artery in patients with prior CABG. Twenty-two studies comprising 40,984 patients were included. The median follow-up duration was 2 (1 to 3) years. Compared with bypass graft PCI, native artery PCI was frequent (61% vs 39%) and was associated with lower major adverse cardiac events (MACE) (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.45 to 0.57, p <0.001), lower all-cause death (OR 0.65, 95% CI 0.49 to 0.87, p = 0.004), lower myocardial infarction (OR 0.56, 95% CI 0.45 to 0.69, p <0.001), and lower target vessel revascularization (TVR) (OR 0.62, 95% CI 0.51to 0.76, p <0.001). There was no significant difference in the early incidence of major bleeding or stroke between the 2 cohorts. In 6 studies involving 2,919 patients with ST-elevation myocardial infarction, there was no significant differences between the 2 cohorts. The increase in TVR risk with bypass graft PCI was associated with MACE. In conclusion, in observational studies involving patients with prior CABG, native artery PCI was associated with lower MACE, all-cause death, myocardial infarction, and TVR compared with bypass graft PCI at a median follow-up of 2 years. Native artery PCI might be considered the preferred treatment for bypass graft failure.

Section snippets

Methods

We performed a systematic review and meta-analysis of studies reporting long-term clinical outcomes after PCI of either bypass graft or native coronary artery lesions in patients with prior CABG. The study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement and Cochrane methodology. Our study also complies with the recommendations in the consensus statement outlined by the MOOSE (Meta‐Analysis of Observational Studies in Epidemiology)

Results

Twenty-two observational studies were identified, including 40,984 patients with prior CABG and reporting long-term clinical outcomes after PCI of either bypass graft or native coronary artery (Table 1). The bypass graft was a SVG in all studies apart from 6 studies,4, 5, 6, 7, 8, 9 which also included a few arterial grafts. The study-quality was assessed using the modified Risk of Bias in Nonrandomized Studies of Interventions tool and is shown in Supplementary Table 2. The comparison groups

Discussion

The major findings of our study are that in patients with prior CABG and as compared with bypass graft PCI, native coronary artery PCI is performed more frequently and is associated with lower incidence of MACE, all-cause death, MI and TVR at a median follow-up of 2 years (Figure 6). There was no significant difference in the early incidence of major bleeding or stroke between the 2 study cohorts. The effect of bypass graft PCI on TVR was associated with MACE and did not depend on the patient's

Authors’ Contributions

Mohamed Farag: Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – Original draft & Review, Project administration; Ying X Gue: Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – Original draft; Emmanouil S Brilakis: Methodology, Investigation, Visualization, Supervision, Writing – Review; Mohaned Egred: Conceptualization, Methodology, Investigation, Visualization, Supervision, Writing –

Disclosures

The authors have no conflicts of interest to declare.

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Cited by (9)

Single-Centre Registry Analysis of Patients Who Underwent Percutaneous Coronary Intervention on Their Coronary Bypass Grafts
2024, CJC Open
The study assessed the outcomes of patients undergoing percutaneous coronary intervention (PCI) to bypass grafts, focusing on all-cause mortality and target vessel failure (TVF) rates.
A single-centre registry analysis included 364 patients who underwent PCI on coronary bypass grafts between 2008 and 2019. The study analyzed all-cause mortality and TVF, which encompassed target lesion revascularization, target vessel revascularization, and medically treated occluded target graft post-PCI.
The median age of the patients was 71 years (interquartile range: [IQR] 65-78), with 82.1% being male. Most patients (94.8%) received PCI on saphenous vein grafts, and the median graft age was 13.0 years (IQR: 8.4-17.6). Drug-eluting stents were used more frequently (54.4%) than bare-metal stents (45.6%), with a median stent diameter of 3.5 mm (IQR: 3-4) and length of 19 mm (IQR: 18-28). Outcome differences were not significant for PCI sites (aorto-ostial, graft body, anastomosis), use of drug-eluting stents, or use of protection devices. The 1-year mortality rate was 3.3%, whereas the combined rate of TVF or death was 20.3%. After 5 years, the mortality rate increased to 14.9%, and the combined TVF or death rate rose to 40.3%. Multivariable analyses revealed that chronic kidney disease was independently associated with mortality (hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.16-2.61, P = 0.007), whereas hypertension (HR 2.42, 95% CI 1.32-4.42, P = 0.004) and increased stent length (HR 1.01, 95% CI 1.00-1.02, P = 0.007) were independently associated with the TVF-or-mortality outcome.
Patients undergoing PCI to bypass grafts experience considerable adverse outcomes over a 5-year period, highlighting the need for further strategies in managing this high-risk population.
L’étude visait à évaluer l’issue des patients ayant subi une intervention coronarienne percutanée (ICP) sur un greffon coronarien, en mettant l’accent sur le taux de mortalité toutes causes confondues et le taux d’échecs de revascularisation du vaisseau cible (EVC).
Une analyse du registre d’un seul établissement a porté sur 364 patients ayant subi une ICP sur un greffon coronarien de 2008 à 2019. L’étude a analysé la mortalité toutes causes confondues et les EVC, qui comprenaient la revascularisation de la lésion cible, la revascularisation du vaisseau cible et le traitement médical de l’occlusion du greffon coronarien cible après l’ICP.
L’âge médian des patients était de 71 ans (intervalle interquartile [IIQ] de 65 à 78) et 82,1 % d’entre eux étaient de sexe masculin. La plupart des patients (94,8 %) avaient subi une ICP sur un greffon de veine saphène; l’âge médian des greffons était de 13,0 ans (IIQ de 8,4 à 17,6). Les endoprothèses médicamentées avaient été utilisées plus fréquemment (54,4 %) que les endoprothèses non médicamentées (45,6 %), le diamètre médian de l’endoprothèse étant de 3,5 mm (IIQ de 3 à 4) et sa longueur, de 19 mm (IIQ de 18 à 28). Les différences pour ce qui est de l’issue clinique n’étaient pas significatives à l’égard des sites d’ICP (aorto-ostial, corps du greffon, anastomose), de l’utilisation d’une endoprothèse médicamentée, ou encore de l’utilisation de dispositifs de protection. Le taux de mortalité à 1 an était de 3,3 %, alors que le taux combiné d’EVC ou de décès était de 20,3 %. Après 5 ans, le taux de mortalité avait augmenté à 14,9 %, alors que le taux combiné d’EVC ou de décès s’élevait à 40,3 %. Les analyses multivariables ont révélé que la néphropathie chronique était indépendamment associée au décès (rapport des risques instantanés [RRI] de 1,74, intervalle de confiance [IC] à 95 % de 1,16 à 2,61, p = 0,007), alors que l’hypertension (RRI de 2,42, IC à 95 % de 1,32 à 4,42, p = 0,004) et une longueur accrue de l’endoprothèse (RRI de 1,01, IC à 95 % de 1,00 à 1,02, p = 0,007) étaient indépendamment associées à une issue d’EVC ou de décès.
Les patients qui ont subi une ICP sur un greffon coronarien présentent des complications considérables sur une période de 5 ans, ce qui souligne le besoin de mettre en place davantage de stratégies de prise en charge pour cette population à risque élevé.
Native coronary artery or bypass graft percutaneous coronary intervention in patients after previous coronary artery bypass surgery: A large nationwide analysis from the Netherlands Heart Registration
2024, International Journal of Cardiology
Patients with previous coronary artery bypass surgery (CABG) who require repeat revascularization frequently undergo percutaneous coronary intervention (PCI). We sought to identify factors associated with the decision to intervene on the native vessel versus a bypass graft and investigate their outcomes in a large nationwide prospective registry.
We identified patients who underwent PCI with a history of prior CABG from the Netherlands Heart Registration between 2017 and 2021 and stratified them by isolated native vessel PCI versus PCI including at least one venous- or arterial graft. The primary endpoint of major adverse cardiac events (MACE) was a composite of all-cause death and target vessel revascularization (TVR) at one-year post PCI. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), and TVR at 30 days.
Out of 154,146 patients who underwent PCI, 12,822 (8.3%) had a prior CABG. Isolated native vessel PCI was most frequently performed (75.2%), while an acute coronary syndrome (ACS) presentation was most strongly associated with graft interventions. The primary outcome of MACE at one-year post PCI occurred more frequently in interventions including grafts compared with native vessels alone (19.7% vs. 14.3%; adjOR 1.267; 95% CI 1.101–1.457); p < 0.001) driven by TVR. There was however no difference in mortality or the key secondary endpoint between the two groups.
In this nationwide prospective registry, ACS presentation was strongly associated with bypass graft PCI. At one year after PCI, interventions including bypass grafts had a higher composite of MACE compared with isolated native vessel interventions.
Postcardiac surgery myocardial ischemia: Why, when, and how to intervene
2023, Journal of Thoracic and Cardiovascular Surgery
Believe in Your CABG ACS PCI Skills, but Never Stop Improving
2022, Cardiovascular Revascularization Medicine
Comparison of percutaneous coronary intervention of native coronary artery versus bypass graft in patients with prior coronary artery bypass grafting
2023, Journal of Thoracic Disease
Manual of Chronic Total Occlusion Percutaneous Coronary Interventions: A Step-by-Step Approach, Thrid Edition
2023, Manual of Chronic Total Occlusion Percutaneous Coronary Interventions: A Step-by-Step Approach, Thrid Edition

View all citing articles on Scopus

: Funding: None.

: Ethics approval: All included studies in this meta-analysis obtained ethics approval.

: Patient and public involvement: Not involved.

: PROSPERO ID: CRD42020179499.

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Meta-analysis Comparing Outcomes of Percutaneous Coronary Intervention of Native Artery Versus Bypass Graft in Patients With Prior Coronary Artery Bypass Grafting

Section snippets

Methods

Results

Discussion

Authors’ Contributions

Disclosures

Ann Thorac Surg

Cardiovasc Revasc Med

Can J Cardiol

Cardiovasc Revasc Med

JACC Cardiovasc Interv

Rev Port Cardiol

Am J Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Int J Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

Saphenous vein graft interventions

Curr Treat Options Cardiovasc Med

Outcomes following primary percutaneous coronary intervention in patients with previous coronary artery bypass surgery

Circ Cardiovasc Interv

Percutaneous coronary intervention of saphenous vein graft

Circ Cardiovasc Interv