In patients with prior CABG presenting with graft failure, PCI of saphenous vein grafts (SVG) was associated with better one-year clinical outcomes compared to PCI of native vessels, based on findings from the PROCTOR trial presented at TCT 2025 and simultaneously published in JACC. In presenting the findings, Ruben W. de Winter, MD, noted these results were primarily driven by lower rates of PCI-related myocardial infarction (MI) and clinically driven target coronary territory revascularization.

The trial, which was conducted across 14 centers in Europe, randomized 220 patients with significant SVG stenosis and a Heart Team-defined clinical indication for revascularization to receive either native vessel PCI (n=108) or SVG PCI (n=112). The primary endpoint was major adverse cardiac events at one year, including all-cause mortality, nonfatal target coronary territory MI or clinically driven target coronary territory revascularization. The average age of participants was 73 years and 85% were male.

At one year, the primary endpoint occurred in 34% of patients in the native vessel PCI group (n=37 patients) compared with 19% of patients in the SVG PCI group (n=21). Broken down by event, researchers observed no significant difference in all-cause mortality between the two groups. However, patients assigned to native vessel PCI experienced both non-fatal target coronary territory MI and clinically driven target coronary territory revascularization more frequently, they said. The incidence of PCI-related MI was 1% in the SVG PCI group vs. 13% in the native vessel PCI group.

"Patients with prior CABG represent a clinically challenging population characterized by older age, multiple comorbidities, and complex coronary anatomy complicating repeat revascularization strategies," says de Winter and colleagues. "Observational cohort studies have reported better outcomes with native vessel PCI compared with SVG PCI, informing current guideline recommendations to favor the bypassed native coronary artery when technically feasible. […] The findings of the PROCTOR trial appear to challenge the conclusions drawn from observational data."

In a related editorial comment, Yousif Ahmad, MD, PhD, FACC; Rohin K. Reddy, MBBS, and Robert W. Yeh, MD, MSc, FACC, call the PROCTOR trial "illuminating," noting that it "advances the field by demonstrating native vessel PCI should not be considered the default approach, particularly if the native intervention is likely to be exceptionally complicated and higher risk, even if feasible." Additionally, they applaud the study for more broadly revealing "the competition between evidence and dogma in the interventional community." They write: "We must stop relying on expert consensus and flawed observational data to guide our practice."

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Transcatheter Cardiovascular Therapeutics, TCT25, Angiography, Cardiac Surgical Procedures, Acute Coronary Syndrome