PCI in Native Coronary vs. Bypass Grafts in Prior CABG Patients
What are the frequency, associations, and outcomes of native coronary artery versus bypass graft percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (CABG) in the Veterans Affairs (VA) integrated health care system?
A national cohort of 11,118 veterans with prior CABG who underwent PCI between October 2005 and September 2013 at 67 VA hospitals was examined, and the outcomes of patients who underwent native coronary versus bypass graft PCI were compared. Logistic regression with generalized estimating equations was used to adjust for correlation between patients within hospitals. Cox regressions were modeled for each outcome to determine the variables with significant hazard ratios (HRs).
During the study period, patients with prior CABG represented 18.5% of all patients undergoing PCI (11,118 of 60,171). The PCI target vessel was a native coronary artery in 73.4% and a bypass graft in 26.6%: 25.0% in a saphenous vein graft and 1.5% in an arterial graft. Compared with patients undergoing native coronary artery PCI, those undergoing bypass graft PCI had higher risk characteristics and more procedure-related complications. During a median follow-up period of 3.11 years, bypass graft PCI was associated with significantly higher mortality (adjusted HR, 1.30; 95% confidence interval [CI], 1.18-1.42), myocardial infarction (adjusted HR, 1.61; 95% CI, 1.43-1.82), and repeat revascularization (adjusted HR, 1.60; 95% CI, 1.50-1.71).
The authors concluded that compared with native coronary PCI, bypass graft PCI was associated with a higher incidence of short- and long-term major adverse events, including more than double the rate of in-hospital mortality.
This study reports that bypass graft PCI was significantly less frequent than native coronary artery PCI, was performed in patients who had more comorbidities, and was independently associated with worse acute and long-term outcomes. Given these and other available data, native coronary arteries remain the target vessel of choice, when they are amenable to PCI. Clinicians need to make efforts to overcome barriers to native coronary artery recanalization in patients with prior CABG, including in selected patient treatment of chronic total occlusions.
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