Increased Late Mortality After Sirolimus-Eluting Stents Versus Bare-Metal Stents in Diseased Saphenous Vein Grafts

Effectiveness and safety of drug-eluting stents in vein grafts: a meta-analysis

BACKGROUND

The use of drug-eluting stents (DES) in degenerative vein grafts is currently an off-label indication. Recent studies have had conflicting results regarding the effectiveness and safety of this practice. The objective of this meta-analysis was to compare DES to bare-metal stents for the treatment of vein graft stenosis.

METHODS

PubMed and the Cochrane clinical trials database were systematically searched to identify all randomized controlled trials (RCTs) and observational studies examining DES for vein graft stenosis published in English between 2003 and 2009. Inclusion criteria included follow-up duration > or =6 months. Data were stratified by study design and pooled using random effects models.

RESULTS

Twenty studies were found to meet our inclusion criteria. Eighteen studies were observational and 2 were RCTs. In observational studies, DES were associated with a reduction in major adverse cardiac events (MACE) (odds ratio [OR] 0.50, 95% CI 0.35-0.72), death (OR 0.69, 95% CI 0.53-0.91), target vessel revascularization (TVR) (OR 0.54, 95% CI 0.37-0.79), and target lesion revascularization (TLR) (OR 0.54, 95% CI 0.37-0.78). The incidence of myocardial infarction was similar between groups. In the RCTs, pooled results were inconclusive because of small sample sizes.

CONCLUSIONS

Although data from observational studies suggest that the use of DES for vein graft stenosis has favorable effects on MACE, death, TVR, and TLR, these data should be interpreted with caution due to their observational nature. Corresponding RCT data are inconclusive. There remains a need for large multicenter RCTs to address the effectiveness and safety of DES for vein graft stenosis.

Outcomes with drug-eluting versus bare-metal stents in saphenous vein graft intervention results from the STENT (strategic transcatheter evaluation of new therapies) group

OBJECTIVES

This study compares outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in patients undergoing saphenous vein graft (SVG) intervention.

BACKGROUND

The safety and efficacy of DES in patients undergoing SVG intervention is controversial.

METHODS

The STENT (Strategic Transcatheter Evaluation of New Therapies) registry is a multicenter U.S. registry evaluating outcomes with DES. Our study population includes patients undergoing PCI of SVG lesions with DES (n = 785) or BMS (n = 343) who completed 9-month or 2-year follow-up. Outcomes were adjusted with propensity analyses.

RESULTS

The DES patients had fewer emergent procedures but had smaller vessels and longer lesions. The DES patients had less death or myocardial infarction at 9 months (hazard ratio [HR]: 0.52, 95% confidence interval [CI]: 0.33 to 0.83, p = 0.006) and less death at 2 years (HR: 0.60, 95% CI: 0.36 to 0.98, p = 0.041). Target vessel revascularization (TVR) was less with DES at 9 months (7.2% vs. 10.0%, HR: 0.36, 95% CI: 0.22 to 0.61, p < 0.001) but was no different by 2 years (18.3% vs. 16.9%, p = 0.86), although adjusted TVR rates were lower (HR: 0.60, 95% CI: 0.40 to 0.90, p = 0.014). The DES reduced TVR at 9 months in SVG lesions with diameter <3.5 mm (8.0% vs. 17.2%, p = 0.013) but not >or=3.5 mm (6.0% vs. 6.6%, p = 0.74).

CONCLUSIONS

Treatment of SVG lesions with DES vs. BMS is effective in reducing TVR at 9 months, although most of this advantage is lost at 2 years. The DES seem safe with less death or myocardial infarction, although selection bias might have affected these results. Our data suggest that DES might have short-term advantages over BMS in SVG lesions with diameter <3.5 mm.

Minimally Invasive Direct Coronary Artery Bypass as a Primary Strategy for Reoperative Myocardial Revascularization

Objective

Conventional reoperative coronary artery bypass grafting is associated with risk of sternal re-entry, injury to patent grafts, and embolization from diseased grafts. Sternal sparing minimally invasive direct coronary artery bypass (MIDCAB) avoids such risks in cases where it is technically feasible. We sought to examine in-hospital outcomes of reoperative MIDCAB surgery.

Methods

We recorded prospective standardized data from the New York Cardiac Surgical Reporting System database of 369 reoperative MIDCAB cases from 1996 to 2006 and compared with 822 primary MIDCAB patients in the same time period. We compared the preoperative risk profile and postoperative in-hospital outcomes and length of stay for both groups.

Results

There was a significantly higher risk profile typical of the reoperative patient population (P < 0.001 for stroke, peripheral/cerebrovascular disease, extensive aortic calcification, renal failure, and left ventricular ejection fraction <40%) compared with the primary MIDCAB group. Despite this fact, there was no difference in the in-hospital outcomes and length of hospital stay between the two groups.

Conclusions

Reoperative MIDCAB provides targeted coronary revascularization and avoids hazards of sternal re-entry, graft injury and manipulation, and deleterious effects of cardiopulmonary bypass. This hastens recovery and provides excellent early outcomes equivalent to primary MIDCAB procedures.

Drug-eluting stents in saphenous vein graft interventions: a systematic review

AIMS

A systematic review of the outcomes after drug-eluting stents (DES) implantation in saphenous vein grafts (SVGs) was performed.

METHODS AND RESULTS

The majority of the 33 published studies were retrospective with only two prospective randomised trials. Late loss and binary restenosis was reduced compared to bare metal stents (BMS) in all seven studies with angiographic follow-up. With the exception of one study there was no difference in mortality, myocardial infarction, or stent thrombosis between BMS and DES. The need for repeat target vessel or lesion revascularisation was lower in the DES arm in approximately half the published studies and similar in the remaining studies.

CONCLUSIONS

Until data from large, prospective, randomised-controlled studies become available, DES implantation in SVGs appears to be safe and, although not yet definitively proven, likely to reduce angiographic restenosis and the need for repeat target lesion revascularisation.

Complete fracture of sirolimus-eluting stent in a saphenous vein graft to left anterior descending artery

Coronary stent fractures have been suggested as a potential new mechanism of restenosis. The mechanical properties of stents were designed not only to prevent vessel recoil, but also to resist the mechanical stress of vessel movement over millions of cardiac cycles. We present a case in which mechanical stress may have contributed to the fracture of a stent implanted in a saphenous vein graft (SVG) to the left coronary artery. The patient was admitted due to chest pain 2 years after receiving a coronary artery bypass graft. A coronary angiography revealed the culprit vessel to be the SVG to the left coronary artery. The graft was stenosed and was stented with a sirolimus-eluting stent. A 6-month follow-up coronary angiography revealed 80% in-stent restenosis with stent fracture. We re-intervened by balloon angioplasty. This is the first report of sirolimus-eluting stent fracture combined with restenosis of SVG in Korea.

Comparison of Plaque Sealing With Paclitaxel-Eluting Stents Versus Medical Therapy for the Treatment of Moderate Nonsignificant Saphenous Vein Graft Lesions

Background— The presence of moderate saphenous vein graft (SVG) lesions is a major predictor of cardiac events late after coronary artery bypass grafting. We determined the effects of sealing moderate nonsignificant SVG lesions with paclitaxel-eluting stents (PES) on the prevention of SVG atherosclerosis progression.

Methods and Results— Patients with at least 1 moderate SVG lesion (30% to 60% diameter stenosis) were randomized either to stenting the moderate SVG lesion with a PES (n=30, PES group) or to medical treatment alone (n=27, medical treatment group). Patients had an angiographic and intravascular ultrasound evaluation of the SVG at baseline and at 12-month follow-up. The primary end points were (1) the ultrasound SVG minimal lumen area at follow-up and (2) the changes in ultrasound atheroma volume in an angiographically nondiseased SVG segment. Mean time from coronary artery bypass grafting was 12±6 years, and mean low-density lipoprotein cholesterol level was 73±31 mg/dL. A total of 70 moderate SVG lesions (39±7% diameter stenosis) were evaluated. Significant disease progression occurred in the medical treatment group at the level of the moderate SVG lesion (decrease in minimal lumen area from 6.3±3.0 to 5.6±3.1 mm 2 ; P <0.001), leading to a severe flow-limiting lesion or SVG occlusion in 22% of the patients compared with none in the PES group ( P =0.014). In the PES group, mean minimal lumen area increased ( P <0.001) from 6.1±2.2 to 8.6±2.9 mm 2 at follow-up ( P =0.001 compared with the medical treatment group at 12 months). There were no cases of restenosis or stent thrombosis. No significant atherosclerosis progression occurred at the nonstented SVG segments. At 12-month follow-up, the cumulative incidence of major adverse cardiac events related to the target SVG was 19% in the medical treatment group versus 3% in the PES group ( P =0.091).

Conclusions— Stenting moderate nonsignificant lesions in old SVGs with PES was associated with a lower rate of SVG disease progression and a trend toward a lower incidence of major adverse cardiac events at 1-year follow-up compared with medical treatment alone, despite very low low-density lipoprotein cholesterol values. This pilot study supports further investigation into the role of plaque sealing in SVGs.

Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT002289835.

Drug-eluting versus bare-metal stents for treating saphenous vein grafts

BACKGROUND

Current data show conflicting results regarding safety and efficacy of drug-eluting stents (DES) versus bare-metal stents (BMS) for treating saphenous vein grafts (SVG). Our objective was to compare DES with BMS for SVG intervention.

METHODS

Patients undergoing stenting with DES or BMS to SVG from January 2000 to June 2007 were included. To eliminate any unobserved bias regarding stent selection, the BMS cohort was divided into pre- and post-2003 when DES became available. Adjusted Cox analysis compared DES with pre- and post-2003 BMS patients. The primary end point was a composite of all-cause mortality, myocardial infarction, or target lesion revascularization.

RESULTS

Of the total 566 patients, 217 (38%) received DES, 110 (20%) received BMS post-2003, and 239 (42%) received BMS pre-2003. Median follow-up was 2.9 years (interquartile range 1.4-4.9 years). There was a trend toward lower primary end point with DES compared to post-2003 BMS (91 events, adjusted hazard ratio 0.61, 95% CI 0.35-1.07, P = .08). However, despite 179 events, DES use was not associated with lower primary end point compared with pre-2003 BMS (adjusted hazard ratio 0.61, 95% CI 0.28-1.35, P = .23).

CONCLUSIONS

Although DES showed a trend toward a lower primary end point when compared with BMS post-2003, this association was no longer present when DES was compared to pre-2003 BMS. These results are consistent with the preponderance of available data and indicate that unobserved bias in observational registries may explain the reported benefit of DES over BMS for treating SVG.

Expanded use of the TAXUS Express Stent: two-year safety insights from the 7,500 patient ARRIVE Registry programme

AIMS

We report 2-year outcomes in a large unselected drug-eluting stent population (N=7,492) in the TAXUS Express2 ARRIVE post-market surveillance programme (101 U.S. sites).

METHODS AND RESULTS

No specific inclusion/exclusion criteria were mandated; patients enrolled at procedure initiation. Two-year follow-up was 94%, with independent adjudication of major cardiac events, monitoring of patients with cardiac events and an additional 10-20% sample by site. Most ARRIVE cases (64%, n=4,794) typified expanded use based on patient/lesion characteristics outside the simple use (single vessel/stent) pivotal trial populations. These expanded use patients had higher 2-year rates than simple use patients for mortality (7.8% vs. 4.2%, P<0.001), myocardial infarction (MI, 3.9% vs. 2.2%, P<0.001), target lesion revascularisation (TLR, 9.2% vs. 5.4%, P<0.001), and stent thrombosis (3.3% vs. 1.4%, P<0.001). Among subgroups with renal disease, chronic total occlusion (CTO), lesion >28 mm, reference vessel diameter (RVD) <2.5 mm, multivessel stenting, acute MI, bifurcation, vein graft, or in-stent restenosis, TLR ranged from 3.8% to 8.9% in year one, and from 1.3% to 6.0% during year two.

CONCLUSIONS

Mortality and stent-related events were higher in expanded use than simple use patients in the pivotal trials. ARRIVE provides a detailed estimate of procedural and 2-year outcomes in such real-world patients.

Outcomes and complications with off-label use of drug-eluting stents: results from the STENT (Strategic Transcatheter Evaluation of New Therapies) group

OBJECTIVES

This study evaluates outcomes and complications in patients treated with drug-eluting stents (DES) for "off-label" indications.

BACKGROUND

Drug-eluting stents have been effective in randomized trials, but their safety and efficacy for off-label indications has not been well studied.

METHODS

The STENT (Strategic Transcatheter Evaluation of New Therapies) Registry is the largest multicenter U.S. registry evaluating outcomes of DES. Off-label indications included ostial, left main, long, bifurcation, and in-stent restenotic lesions, saphenous vein grafts, chronic total occlusions, small or large vessels, multilesion or multivessel percutaneous coronary interventions, and ST-segment elevation myocardial infarction. Outcomes were adjusted using Cox proportional hazards regression and propensity analyses.

RESULTS

Drug-eluting stents were used in an off-label manner in 59% of patients. The patients who received off-label treatment were more often male, had a higher incidence of prior infarction and bypass surgery, and lower ejection fractions. Off-label versus "on-label" use of DES was associated with higher rates of death, myocardial infarction, target vessel revascularization, major adverse cardiac events, and stent thrombosis at 9 months and 2 years. Off-label use of DES compared with off-label use of bare-metal stents (BMS) had lower rates of death, myocardial infarction, target vessel revascularization, and major adverse cardiac events at 9 months and 2 years and lower rates of stent thrombosis at 9 months.

CONCLUSIONS

Off-label use of DES is associated with higher event rates compared with on-label use of DES, which is consistent with a higher risk clinical and lesion profile. However, event rates with off-label use of DES are lower compared with off-label use of BMS. Pending results from randomized trials, our data support the use of DES for off-label indications in selected patients.

Outcome of patients treated by a novel thin-strut cobalt-chromium stent in the drug-eluting stent era: Results of the SKICE (Skylor in real world practice) registry

OBJECTIVES

To investigate the outcome of patients undergoing percutaneous coronary interventions (PCI) with implantation of a new thin-strut cobalt-chromium bare-metal-stent (BMS) in the drug-eluting-stent (DES) era.

BACKGROUND

Despite the contemporary penetration of DES in the clinical practice, a relevant percentage of patients are still treated by BMS. Data on clinical outcome of novel BMSs are lacking.

METHODS

This is a single-centre-registry enrolling patients treated by Skylor stent implantation. During the study, the criteria for BMS selection adopted at our institution ("internal" criteria) were as follows: (1) limited compliance to prolonged double antiplatelet therapy, (2) ST-elevation myocardial infarction (STEMI) or saphenous vein grafts (SVG) interventions, and (3) in the absence of these conditions, noncomplex (no bifurcations, no chronic total occlusions) lesions considered at low restenosis risk on the basis of arbitrary angiographic criteria (short lesions, large vessels). Primary and secondary end-points were respectively major adverse cardiovascular events (MACE) and target vessel failure (TVF) up to 9-month.

RESULTS

A total of 150 patients were treated with Skylor stent on 169 lesions. At 9-month follow-up, MACE occurred in 12 patients (8.0%) and TVF in 21 lesions (12.4%). By multivariable analysis, the predictors of MACE were Euroscore>or=9 and ejection fraction < 30% while the predictors of TVF were the absence of the angiographic criteria of low restenosis risk and ejection fraction < 30%.

CONCLUSIONS

In the DES era, the use of a last-generation BMS in patients with limited compliance to double antiplatelet therapy, STEMI or SVG interventions, and noncomplex angiographic lesions may be associated with acceptable clinical outcome.

Comparison of percutaneous coronary intervention in native coronary arteries vs. bypass grafts in patients with prior coronary artery bypass graft surgery

OBJECTIVE

To compare the procedural and clinical outcomes of prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) in native arteries vs. bypass grafts.

METHODS

The medical and catheterization records and the angiograms of 142 consecutive prior CABG patients who underwent 165 PCI of 247 lesions at our institution between January 1, 2003, and December 31, 2006, were retrospectively reviewed.

RESULTS

Mean age was 66+/-10 years and 99% were men: 79 and 63 patients underwent native coronary or bypass graft PCI, respectively. Compared to patients undergoing bypass graft PCI, those undergoing native coronary artery PCI were younger (mean age 64+/-10 vs. 68+/-10 years, P=.008), more likely to present with stable angina (29% vs. 8%, P=<.001), and presented earlier after CABG (after a mean of 9+/-6 vs. 12+/-5 years, P<.01). Compared to bypass graft PCI, native coronary PCI was more likely to be performed with drug-eluting stents (88% vs. 57%, P<.001) and was associated with lower risk of no-reflow (3% vs. 24%, P<.001). After a mean follow-up of 2.5+/-1.1 years, both groups of patients had similar but high incidence of myocardial infarction, repeat PCI, and death.

CONCLUSIONS

Prior CABG patients undergoing native coronary artery PCI have lower procedural risk, but similar postprocedural clinical outcomes compared to patients undergoing bypass graft PCI. If feasible, native coronary arteries may be the preferred PCI target in prior CABG patients.

Paclitaxel-eluting stent long-term outcomes in percutaneous saphenous vein graft interventions (PELOPS) study

This study examined the 1-year clinical and angiographic follow-up results of implantation of paclitaxel-eluting stents (PES) in aortocoronary saphenous vein graft (SVG) lesions. Sixty-eight consecutive patients with 90 nonoccluded SVG lesions were treated with PES (Taxus), size ranging from 2.25 to 4.5 mm. Angiographic follow-up was performed on 63 patients (93%) and 83 lesions (92%) at 12 months; major adverse cardiac event (MACE) was recorded in all patients at 1 year. The mean age of patients was 71+/-8 years with predominance of men (75%); the mean graft age was 13+/-4 years. Glycoprotein IIb/ IIIa inhibitors were given in 21 patients (31%); embolic protection devices were used in 54 lesions (60%). On average, patients received 1.4 stents per lesion with a stent size of 3.4+/-0.6 mm and a length of 35.8+/-27.0 mm. Angiographic follow-up revealed a late loss of 0.36+/-0.66 mm with an in-segment binary restenosis rate of 7%. The in-hospital MACE was 7%, which was solely contributed by 5 patients with postprocedure non-Q myocardial infarction; the 1-year MACE was 15%, accounted by 1 noncardiac death and 9 patients with target vessel revascularization. Peripheral vascular disease and the use of glycoprotein IIb/ IIIa inhibitors were the independent predictors of MACE at 1 year. In conclusion, implantation of PES to treat degenerative aortocoronary SVG lesions is safe and associated with low late loss, angiographic restenosis, and MACE at 1-year follow-up.

Off-label use of stents: bare-metal versus drug-eluting stents

Drug-eluting stents (DES) became the default strategy for percutaneous revascularization due to their improved intermediate-term outcomes when compared with bare-metal stents (BMS) in the pivotal randomized, controlled trials. The excellent results of DES in on-label or US FDA-approved indications led to extrapolation of the results to more complex situations that were excluded from initial pivotal trials; such as off-label indications. Safety concerns began to grow after reports of increased late thrombosis and possibly associated increased death and myocardial infarction with DES, especially in the off-label situations. Recently, however, several important published registries have calmed some of those uncertainties and reassured the cardiology community of the safety and efficacy of DES compared with BMS. There is an overall poorer outcome with off-label use of any stent (BMS or DES) compared with standard or on-label use. This difference in outcome is most likely related to patient or specific coronary lesion characteristics or comorbidities that predispose an individual to adverse outcomes regardless of the stent type used. It is accepted now that DES use does result in a small increased risk of late thrombosis, but that risk is offset by a significant reduction in restenosis. Overall, the current data suggest that the use of DES in most lesion subsets is at least as safe as and clearly more efficacious than use of BMS in similar situations.

Drug-eluting stents versus bare metal stents for narrowing in saphenous vein grafts

Conflicting data exist regarding an advantage of drug-eluting stents (DES) over bare metal stents (BMS) in catheter-based treatment of saphenous vein graft (SVG) stenoses. This study was undertaken to compare the efficacy of these modalities in that lesion subset. The DES group consisted of 138 cases with 183 lesions (sirolimus-eluting stents, n = 117; paclitaxel-eluting stents, n = 66) and the BMS group consisted of 344 cases with 478 lesions that were followed to 1 year. We examined a composite end point that comprised death, Q-wave myocardial infarction, and target lesion revascularization. More BMS were deployed per patient (p <0.001) and the diameters of BMS deployed was significantly greater (p <0.001). Peak postprocedure values of creatine kinase-MB (p = 0.003) and troponin I (p = 0.05) were higher in BMS. At 1 year there was no significant superiority of DES over BMS with regard to hard end points (death and Q-wave myocardial infarction). In conclusion, this study indicates that both DES and BMS for SVG disease provide acceptably safe and efficacious results, but unlike the case in native coronary arteries, DES use does not reduce the frequency of the need for repeat revascularization.

Coronary artery stents: Part I. Evolution of percutaneous coronary intervention

The subspecialty of interventional cardiology has made significant progress in the management of coronary artery disease over the past three decades with the development of percutaneous coronary transluminal angioplasty, atherectomy, and bare-metal and drug-eluting stents (DES). Bare-metal stents (BMS) maintain vessel lumen diameter by acting as a scaffold and prevent collapse incurred by angioplasty. However, these devices cause neointimal hyperplasia leading to in-stent restenosis and requiring reintervention in more than 20% of patients by 6 mo. DES (sirolimus and paclitaxel) prevent restenosis by inhibiting neointimal hyperplasia. However, DESs also delay endothelialization, causing the stents to remain thrombogenic for an extended, yet unknown, period of time. Late stent thrombosis is associated with a 45% mortality rate. Premature discontinuation of antiplatelet therapy, particularly clopidogrel, is the strongest predictor of stent thrombosis. Sixty percent of patients receive stents for off-label (unapproved) indications, which also increases the frequency of stent thrombosis. Clopidogrel and aspirin are the cornerstone of therapy in the prevention of stent thrombosis in both BMS and DES. Recommendations pertaining to the optimal duration of dual-antiplatelet therapy have been debated. Both the Food and Drug Administration and the American Heart Association/American College of Cardiologists, in association with other major societies, have made recommendations to extend the duration of dual-antiplatelet therapy in patients with DES to 1 yr. The 6-wk duration of dual-antiplatelet therapy in patients with BMS remains unchanged. All patients with coronary stents must remain on life-long aspirin monotherapy. Since the introduction of percutaneous transluminal coronary angioplasty for the treatment of coronary atherosclerosis, the practice of percutaneous coronary intervention has undergone a dramatic transformation from simple balloon dilation catheters to sophisticated mechanical endoprostheses. These advancements have impacted the practice of perioperative medicine. In this series of two articles, in Part I we will review the evolution of percutaneous coronary intervention and discuss the issues associated with percutaneous transluminal coronary angioplasty and coronary stenting; in Part II we will discuss perioperative issues and management strategies of coronary stents during noncardiac surgery.

Correlates of late and very late thrombosis of drug eluting stents

BACKGROUND

Late and very late thrombosis of coronary drug-eluting stents (DES) has received much attention but essentially remains unpredictable. We sought to identify correlates of stent thrombosis (ST) developing >30 days after DES implantation.

METHODS

We analyzed data from our single-center registry on 5,342 consecutive patients, who underwent a first DES implant between May 2003 and December 2006. The Academic Research Consortium definitions were applied to classify definite, probable, and possible ST. Cox regression analysis was performed to identify predictors of ST.

RESULTS

Follow-up information was obtained at 6 months and at 1, 2, and 3 years after DES implantation in 97.2%, 95.2%, 92.4%, and 89.8% of patients, respectively. We identified 34 patients who developed definite and 5 with probable ST >30 days after the index stent procedure. The 3-year cumulative incidence of definite and definite + probable ST >30 days was 1.33% and 1.50%, respectively. By Cox multiple variable regression, predictors of definite + probable ST were age (hazard ratio [HR] 0.95, 95% CI 0.92-0.98, P < .001), current smoking (HR 2.55, 95% CI 1.29-5.07, P = .007), prior percutaneous coronary intervention (HR 2.68, 95% CI 1.42-5.05, P = .002), "off-label" DES indication (HR 3.10, 95% CI 1.10-8.75, P = .032), bifurcation stenting (HR 2.37, 95% CI 1.40-3.99, P = .001), and stenting an occluded vessel (HR 3.02, 95% CI 1.59-5.74, P < .001).

CONCLUSIONS

We identified several baseline characteristics, which, when combined, may identify patients at risk for late-occurring ST, particularly after off-label DES placement.

Fourteen month follow-up angioscopic findings of a sirolimus-eluting stent implanted in a 15-year-old saphenous vein graft

Saphenous vein grafts (SVGs) are common, as is their degeneration and early failure after coronary artery bypass graft surgery (CABG). Percutaneous SVG intervention with drug-eluting stents (DES) was associated with superior short-term clinical outcomes. However, SVG intervention compared with coronary intervention often results in distal embolisation and periprocedural myocardial infarction. In this case, we discuss 9 and 14 month follow-up neointimal coverage of a DES implanted in a 15 year-old SVG and other morphological changes using angioscopy.

Long-term outcomes with drug-eluting stents versus bare metal stents in the treatment of saphenous vein graft disease (results from the REgistro Regionale AngiopLastiche Emilia-Romagna registry)

Percutaneous revascularization of saphenous vein grafts (SVGs) remains a challenging task. Drug-eluting stents (DESs) have been shown to decrease the incidence of restenosis in de novo native coronary artery lesions. However, their clinical value in SVGs remains to be established. We compared long-term clinical outcomes of percutaneous coronary intervention with DESs and bare metal stents (BMSs) for de novo lesions in SVGs. In a large prospective, multicenter registry, 360 patients underwent stenting of a de novo lesion in SVGs using BMSs (288 patients) or DESs (72 patients). Incidence of major adverse cardiac events (MACEs), including all-cause mortality, reinfarction, and target vessel revascularization, was recorded at a 12-month follow-up. Compared with the DES group, patients receiving BMSs were more likely to be men, to have chronic renal insufficiency or higher Charlson scores, but less likely to have undergone previous percutaneous coronary intervention. Incidence of MACEs at 12-month follow-up was similar in the 2 groups (17.8% in DES group vs 20.3% in BMS group, respectively, p = 0.460). Cox regression analysis identified age, chronic renal failure, cardiogenic shock at presentation, and ostial location of stenosis as independent predictors of long-term MACEs. In conclusion, our data suggest that rates of 12-month MACEs associated with the use of DESs and BMSs are similar in patients undergoing treatment of de novo lesions in SVGs.