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

Single-Centre Registry Analysis of Patients Who Underwent Percutaneous Coronary Intervention on Their Coronary Bypass Grafts

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Shaping the Future of Cardiovascular Disease by 3D Printing Applications in Stent Technology and its Clinical Outcomes

Cardiovascular disease (CVD) is a leading cause of death worldwide. In recent years, 3D printing technology has ushered in a new era of innovation in cardiovascular medicine. 3D printing in CVD management encompasses various aspects, from patient-specific models and preoperative planning to customized medical devices and novel therapeutic approaches. In-stent technology, 3D printing has revolutionized the design and fabrication of intravascular stents, offering tailored solutions for complex anatomies and individualized patient needs. The advantages of 3D-printed stents, such as improved biocompatibility, enhanced mechanical properties, and reduced risk of in-stent restenosis. Moreover, the clinical trials and case studies that shed light on the potential of 3D printing technology to improve patient outcomes and revolutionize the field has been comprehensively discussed. Furthermore, regulatory considerations, and challenges in implementing 3D-printed stents in clinical practice are also addressed, underscoring the need for standardization and quality assurance to ensure patient safety and device reliability. This review highlights a comprehensive resource for clinicians, researchers, and policymakers seeking to harness the full potential of 3D printing technology in the fight against CVD.

Short-term outcomes of drug-coated balloon versus drug-eluting stent for de novo saphenous vein graft lesions in coronary heart disease

Background

As a device for percutaneous coronary intervention, drug-coated balloon (DCB) is widely used to treat in-stent restenosis. However, data regarding the use of DCB in treating de novo saphenous vein graft (SVG) lesions are limited. This study aimed to explore the outcomes of using the DCB in the treatment of de novo SVG lesions of coronary heart disease (CHD).

Methods

This retrospective and observational study analyzed CHD patients with de novo SVG lesions treated with DCB or the new-generation drug-eluting stent (DES) between January 2018 and December 2020. Restenosis was the primary endpoint, whereas target lesion revascularization (TLR), major adverse cardiac events, restenosis, cardiac death, target vessel revascularization, and myocardial infarction were the secondary outcomes.

Results

We enrolled 31 and 23 patients treated with DCB and DES, respectively. The baseline clinical data, lesion characteristics, and procedural characteristics were similar between the two groups. Twenty-eight (90.3%) patients in the DCB group and 21 (91.3%) in the DES group completed follow-up angiography after 1 year. The quantitative coronary angiography measurements at angiographic follow-up showing late lumen loss were -0.07 ± 0.95 mm for the DCB group and 0.86 ± 0.71 mm for the DES group (P = 0.039), and the rates of restenosis were 13.3% and 21.7% for the DCB and DES groups, respectively (P = 0.470). No significant differences were observed in the rates of MACE (16.7% vs. 26.1%, P = 0.402) and TLR (13.3% vs. 4.3%, P = 0.374) during clinical follow-up.

Conclusion

Our findings suggest that when pre-dilatation was successful, DCB might be safe and effective in treating de novo SVG lesions.

Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization

Patients who have undergone coronary artery bypass graft (CABG) surgery are susceptible to bypass graft failure and progression of native coronary artery disease. Although the saphenous vein graft (SVG) was traditionally the most-used conduit, arterial grafts (including the left and right internal thoracic arteries and the radial artery) have improved patency rates. However, the need for secondary revascularization remains common, and percutaneous coronary intervention (PCI) has become the most common modality of secondary revascularization after CABG surgery. Procedural characteristics and clinical outcomes differ considerably from those associated with PCI in patients without previous CABG surgery, owing to altered coronary anatomy and differences in conduit pathophysiology. In particular, SVG PCI carries an increased risk of complications, and operators are shifting their focus towards embolic protection strategies and complex native-vessel interventions, increasingly using SVGs as conduits to facilitate native-vessel PCI rather than pursuing SVG PCI. In this Review, we discuss the differences in conduit pathophysiology, changes in CABG surgery techniques, and the latest evidence in terms of PCI in patients with previous CABG surgery, with a particular emphasis on safety and long-term efficacy. We explore the subject of contemporary CABG surgery and subsequent percutaneous revascularization in this complex patient population.

In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial)

Saphenous vein grafts (SVGs) have high rates of in-stent restenosis (ISR). We compared the baseline clinical and angiographic characteristics of patients and lesions that did develop ISR with those who did not develop ISR during a median follow-up of 2.7 years in the DIVA study (NCT01121224). We also examined the ISR types using the Mehran classification. ISR developed in 119 out of the 575 DIVA patients (21%), with similar incidence among patients with drug-eluting stents and bare-metal stents (BMS) (21% vs 21%, p = 0.957). Patients in the ISR group were younger (67 ± 7 vs 69 ± 8 years, p = 0.04) and less likely to have heart failure (27% vs 38%, p = 0.03) and SVG lesions with Thrombolysis In Myocardial Infarction 3 flow before the intervention (77% vs 83%, p <0.01), but had a higher number of target SVG lesions (1.33 ± 0.64 vs 1.16 ± 0.42, p <0.01), more stents implanted in the target SVG lesions (1.52 ± 0.80 vs 1.31 ± 0.66, p <0.01), and longer total stent length (31.37 ± 22.11 vs 25.64 ± 17.42 mm, p = 0.01). The incidence of diffuse ISR was similar in patients who received drug-eluting-stents and BMS (57% vs 54%, p = 0.94), but BMS patients were more likely to develop occlusive restenosis (17% vs 33%, p = 0.05).

Impact of target vessel choice on outcomes following percutaneous coronary intervention in patients with a prior coronary artery bypass graft

OBJECTIVES

To evaluate and compare characteristics and clinical outcomes of percutaneous coronary intervention (PCI) among target vessel types in patients with a prior coronary artery bypass graft (CABG) surgery.

BACKGROUND

Patients with a prior CABG often require repeat revascularization with PCI. Graft PCI has been associated with worse outcomes compared to native vessel PCI, yet the optimal PCI strategy in prior CABG patients remains unknown.

METHODS

We stratified prior CABG patients who underwent PCI at a tertiary-care center between 2009 and 2017 by target vessel type: native vessel, venous graft, and arterial graft. The primary outcome of major adverse cardiac events (MACE) was a composite of all-cause death, myocardial infarction, stent thrombosis, or target vessel revascularization up to 1 year post-PCI.

RESULTS

Prior CABG patients (n = 3983) represented 19.5% of all PCI interventions during the study period. PCI was most frequently performed on native vessels (n = 2928, 73.5%) followed by venous (n = 883, 22.2%) and arterial grafts (n = 172, 4.3%). Procedural success and complications were similar among the groups; however, slow- and no-reflow phenomenon was more common in venous graft PCI compared to native vessel PCI (OR 4.78; 95% CI 2.56-8.95; p < 0.001). At 1 year, there were no significant differences in MACE or in its individual components.

CONCLUSIONS

Target vessel choice did not appear to affect MACE at 1 year in a large cohort of patients with prior CABG undergoing PCI. Whether PCI of surgical grafts versus native arteries truly results in similar outcomes warrants further investigation in randomized controlled trials.

Mechanisms, Prevention and Treatment of Saphenous Vein Graft Disease

Saphenous vein grafts are imperfect yet indispensable conduits commonly used for coronary artery bypass grafting. Their degeneration ultimately leading to occlusion results from the pathological response of the vein to altered blood rheology and several types of vascular injury. Surgical techniques minimizing vessel damage, and prolonged antiplatelet and lipid-lowering treatment are established methods of mitigating the degeneration process hence preventing graft occlusions. Percutaneous interventions in degenerated vein grafts carry high risk of embolization, periprocedural myocardial infarction and restenosis. Thus, native vessel should be the preferred treatment target in case of graft failure whenever technically feasible.

Long-term outcomes of percutaneous coronary interventions within coronary artery bypass grafts

INTRODUCTION

The long-term outcomes of percutaneous coronary interventions (PCIs) within coronary artery bypasses are still poor as compared to those within native coronary arteries. Thus, we aimed to assess predictors of long-term clinical outcomes after PCIs of coronary bypasses.

MATERIAL AND METHODS

We enrolled 194 patients after PCIs of coronary artery bypasses at the mean age of 69.5 ±8.3 years (73.2% male). The primary study endpoint was a combination of target-vessel revascularization (TVR), target-lesion revascularization (TLR), myocardial infarction (MI), stroke, coronary artery bypass grafting (CABG) and death. The mean follow-up was 964 ±799.1 days and was completed among 156 patients. Multivariate analysis was used to assess determinants of study endpoints during follow-up. Moreover, we compared survival curves according to the type of PCI and presence of anti-embolic protection.

RESULTS

The primary endpoint of the study occurred in 59.7% of patients after the mean time of 669.6 ±598.7 days. The TVR occurred in 37.9% of individuals, TLR in 24.2%, MI in 26.3%, stroke in 4.2%, CABG in 2.1% and death in 30.5% of patients. In Cox multivariate analysis, PCI of two or more bypasses (p < 0.01), post-dilatation (p < 0.05) and no-reflow (p < 0.05) were the independent determinants of the primary study endpoint. No significant impact of anti-embolic protection devices on long-term outcomes was observed.

CONCLUSIONS

Percutaneous coronary interventions of two or more bypasses, post-dilatation and no-reflow are predictors of worse outcome in patients undergoing PCI within coronary artery bypass grafts.

Long-Term Results After Drug-Eluting Versus Bare-Metal Stent Implantation in Saphenous Vein Grafts: Randomized Controlled Trial

Background Efficacy data on drug-eluting stents (DES) versus bare-metal stents (BMS) in saphenous vein grafts are controversial. We aimed to compare DES with BMS among patients undergoing saphenous vein grafts intervention regarding long-term outcome. Methods and Results In this multinational trial, patients were randomized to paclitaxel-eluting or BMS. The primary end point was major adverse cardiac events (cardiac death, nonfatal myocardial infarction, and target-vessel revascularization at 1 year. Secondary end points included major adverse cardiac events and its individual components at 5-year follow-up. One hundred seventy-three patients were included in the trial (89 DES versus 84 BMS). One-year major adverse cardiac event rates were lower in DES compared with BMS (2.2% versus 16.0%, hazard ratio, 0.14; 95% CI, 0.03-0.64, P=0.01), which was mainly driven by a reduction of subsequent myocardial infarctions and need for target-vessel revascularization. Five-year major adverse cardiac event rates remained lower in the DES compared with the BMS arm (35.5% versus 56.1%, hazard ratio, 0.40; 95% CI, 0.23-0.68, P<0.001). A landmark-analysis from 1 to 5 years revealed a persistent benefit of DES over BMS (hazard ratio, 0.33; 95% CI, 0.13-0.74, P=0.007) in terms of target-vessel revascularization. More patients in the BMS group underwent multiple target-vessel revascularization procedures throughout the study period compared with the DES group (DES 1.1% [n=1] versus BMS 9.5% [n=8], P=0.013). Enrollment was stopped before the target sample size of 240 patients was reached. Conclusions In this randomized controlled trial with prospective long-term follow-up of up to 5 years, DES showed a better efficacy than BMS with sustained benefits over time. DES may be the preferred strategy in this patient population. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT00595647.

Rapamycin-Loaded Biomimetic Nanoparticles Reverse Vascular Inflammation

Rationale:

Through localized delivery of rapamycin via a biomimetic drug delivery system, it is possible to reduce vascular inflammation and thus the progression of vascular disease.

Objective:

Use biomimetic nanoparticles to deliver rapamycin to the vessel wall to reduce inflammation in an in vivo model of atherosclerosis after a short dosing schedule.

Methods and Results:

Biomimetic nanoparticles (leukosomes) were synthesized using membrane proteins purified from activated J774 macrophages. Rapamycin-loaded nanoparticles were characterized using dynamic light scattering and were found to have a diameter of 108±2.3 nm, a surface charge of −15.4±14.4 mV, and a polydispersity index of 0.11 +/ 0.2. For in vivo studies, ApoE −/− mice were fed a high-fat diet for 12 weeks. Mice were injected with either PBS, free rapamycin (5 mg/kg), or rapamycin-loaded leukosomes (Leuko-Rapa; 5 mg/kg) once daily for 7 days. In mice treated with Leuko-Rapa, flow cytometry of disaggregated aortic tissue revealed fewer proliferating macrophages in the aorta (15.6±9.79 %) compared with untreated mice (30.2±13.34 %) and rapamycin alone (26.8±9.87 %). Decreased macrophage proliferation correlated with decreased levels of MCP (monocyte chemoattractant protein)-1 and IL (interleukin)-b1 in mice treated with Leuko-Rapa. Furthermore, Leuko-Rapa–treated mice also displayed significantly decreased MMP (matrix metalloproteinases) activity in the aorta (mean difference 2554±363.9, P =9.95122×10 −6 ). No significant changes in metabolic or inflammation markers observed in liver metabolic assays. Histological analysis showed improvements in lung morphology, with no alterations in heart, spleen, lung, or liver in Leuko-Rapa–treated mice.

Conclusions:

We showed that our biomimetic nanoparticles showed a decrease in proliferating macrophage population that was accompanied by the reduction of key proinflammatory cytokines and changes in plaque morphology. This proof-of-concept showed that our platform was capable of suppressing macrophage proliferation within the aorta after a short dosing schedule (7 days) and with a favorable toxicity profile. This treatment could be a promising intervention for the acute stabilization of late-stage plaques.

Drug-eluting versus bare-metal stents for saphenous vein graft lesions

A best evidence topic was written addressing the question 'in patients with saphenous vein graft lesions requiring percutaneous coronary intervention, do long-term clinical outcomes differ between drug-eluting and bare-metal stents?' Altogether 1466 papers were found, of which seven represented the best evidence. Although one major recent randomised trial was neutral, the weight of earlier evidence supports drug-eluting stents as standard of care. Bare-metal stents may represent a reasonable, efficacious, and less expensive alternative to drug-eluting stents in well selected patient groups.

Care of the Post-CABG Patient

An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the "no-reflow phenomenon," which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.

Drug-Eluting Stents Versus Bare-Metal Stents in Saphenous Vein Graft Intervention

Background Percutaneous coronary intervention with drug-eluting stents (DES) has been increasingly used for revascularization of saphenous vein graft stenosis without strong clinical evidence favoring their use. Randomized controlled trials comparing DES versus bare-metal stents (BMS) in saphenous vein graft-percutaneous coronary intervention have been inconclusive. Methods and Results We performed a comprehensive literature search through May 15, 2018, for all eligible studies comparing DES versus BMS in patients with saphenous vein graft stenosis in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Clinical outcomes included all-cause mortality, cardiovascular mortality, major adverse cardiovascular events, myocardial infarction, stent thrombosis, and target vessel revascularization. Six randomized controlled trials were eligible and included 1582 patients, of whom 797 received DES and 785 received BMS. The follow-up period ranged from 18 months to 60 months. There was no statistically significant difference between DES and BMS for all-cause mortality (risk ratio [RR],1.11; 95% CI, 0.0.77-1.62; P=0.57), cardiovascular mortality (RR, 1.00; 95% CI, 0.64-1.57; P=0.99), major adverse cardiovascular events (RR, 0.83; 95% CI, 0.63-1.10; P=20), target vessel revascularization (RR, 0.73; 95% CI, 0.48-1.11; P=0.14), myocardial infarction (RR, 0.74; 95% CI, 0.48-1.16; P=0.19), or stent thrombosis (RR, 1.06; 95% CI, 0.42-2.65; P=0.90). Conclusions In patients undergoing percutaneous coronary intervention for saphenous vein graft lesions, our results showed that there was no significant difference between DES and BMS for mortality, major adverse cardiovascular events, target vessel revascularization, myocardial infarction, or stent thrombosis.

Repeat Coronary Bypass Surgery or Percutaneous Coronary Intervention After Previous Surgical Revascularization

OBJECTIVE

To assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG.

METHODS

From January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used.

RESULTS

In multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65).

CONCLUSION

RCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.

Efficacy Over Time With Drug-Eluting Stents in Saphenous Vein Graft Lesions

BACKGROUND

In the ISAR-CABG (Is Drug-Eluting-Stenting Associated with Improved Results in Coronary Artery Bypass Grafts?) trial, clinical outcomes at 1 year in patients undergoing treatment of saphenous vein graft lesions were superior with drug-eluting stents (DES) versus bare-metal stents.

OBJECTIVES

The authors compared outcomes between treatment groups at 5 years.

METHODS

Patients were randomized (1:1:1:3) to receive DES (either permanent-polymer paclitaxel-eluting stents, permanent-polymer sirolimus-eluting stents, or biodegradable-polymer sirolimus-eluting stents) or bare-metal stents. The primary endpoint was the combined incidence of death, myocardial infarction (MI), or target lesion revascularization (TLR). Secondary endpoints were the composite of death or MI and TLR.

RESULTS

A total of 610 patients were allocated to treatment with DES (n = 303) or bare-metal stents (n = 307). At 5 years, the primary endpoint occurred in 159 (55.5%) versus 157 (53.6%) patients in the DES and bare-metal stent groups, respectively (hazard ratio [HR]: 0.98; 95% confidence interval [CI]: 0.79 to 1.23; p = 0.89). There was interaction between treatment effect and time (p_interaction = 0.005), with a lower event rate in the DES group at 1 year (HR: 0.64; 95% CI: 0.44 to 0.94; p = 0.02) but a numerically higher rate between 1 and 5 years (HR: 1.24; 95% CI: 0.94 to 1.63; p = 0.13). Death or MI occurred in 93 (32.8%) versus 108 (36.6%) patients, respectively (HR: 0.85; 95% CI: 0.64 to 1.12; p = 0.24), without significant interaction between treatment effect and time (p_interaction = 0.57). TLR occurred in 84 (33.1%) versus 69 (25.5%) patients in the DES and bare-metal stent groups, respectively (HR: 1.20; 95% CI: 0.87 to 1.64; p = 0.27). There was interaction between treatment effect and time (p_interaction <0.001): TLR was significantly lower in the DES group at 1 year (HR: 0.49; 95% CI: 0.28 to 0.86; p = 0.01) but significantly higher thereafter (HR: 2.02; 95% CI: 1.32 to 3.08; p = 0.001).

CONCLUSIONS

In patients undergoing treatment of saphenous vein graft lesions, the advantage of DES over bare-metal stents demonstrated at 1 year was lost at 5 years due to higher attrition of efficacy in the DES group. (Efficacy Study of Drug-Eluting and Bare Metal Stents in Bypass Graft Lesions [ISAR-CABG]; NCT00611910).

Long-term safety of bioresorbable scaffolds: insights from a network meta-analysis including 91 trials

AIMS

The aim of this study was to investigate the long-term safety and efficacy of biodegradable scaffolds and metallic stents.

METHODS AND RESULTS

We analysed a total of 91 randomised controlled trials with a mean follow-up of 3.7 years in 105,842 patients which compared two or more coronary metallic stents or biodegradable scaffolds and reported the long-term clinical outcomes (≥2 years). Network meta-analysis showed that patients treated with the Absorb bioresorbable vascular scaffold (BVS) had a significantly higher risk of definite or probable scaffold thrombosis (ScT) compared to those treated with metallic DES. The risk of very late ScT was highest with the Absorb BVS among comparators. Pairwise conventional meta-analysis demonstrated that the elevated risk of ScT with Absorb BVS compared to cobalt-chromium everolimus-eluting stents was consistent across the time points of ≤30 days (early), 31 days - 1 year (late) and >1 year (very late) ScT. In addition, target lesion failure rates were significantly higher in the Absorb BVS cohort, driven by both increased risk of target vessel myocardial infarction and ischaemia-driven target lesion revascularisation.

CONCLUSIONS

Absorb BVS implantation was associated with increased risk of long-term and very late ScT compared to current-generation metallic DES. The risk of ScT occurred with a rising trend beyond one year.

Drug-eluting Stents Versus Bare-metal Stents for Saphenous Vein Graft Interventions: A Systematic Review and Meta-analysis of Studies With Longer Follow-up

Randomized controlled trials comparing drug eluting stents (DES) with bare-metal stents (BMS) for saphenous vein graft (SVG) interventions have shown conflicting results. We conducted this meta-analysis to evaluate the cumulative evidence for long-term efficacy and safety of DES vs BMS in SVG lesions. A systematic search was conducted of Randomized controlled trials comparing DES vs BMS in patients undergoing percutaneous interventions for SVG lesions. End-points of interest were all-cause death, cardiac death, myocardial infarction, target lesion revascularization and target vessel revascularization at longest available follow-up. Random effects meta-analysis was conducted to estimate risk ratio with 95% confidence intervals for individual end-points. Seven studies with 1639 patients were included in the final analysis. Mean follow-up period was 32 months. Compared with BMS, DES was associated with similar risks of all-cause death (risk ratio 1.06; 95% confidence intervals 0.76-1.48) and cardiac death (0.95; 0.59-1.54). Similarly, there were no differences between DES and BMS in terms of myocardial infarction (0.81; 0.50-1.29), target vessel revascularization (0.73; 0.48-1.110 or target lesion revascularization (1.05; 0.76-1.43). Current analysis suggests no strong evidence for routine DES use in patients undergoing SVG intervention. Future studies should evaluate if SVG lesion characteristics could influence these results.

Drug-Eluting Versus Bare Metal Stents in Saphenous Vein Graft Intervention: An Updated Comprehensive Meta-Analysis of Randomized Trials

BACKGROUND

Drug eluting stents (DES) are preferred over bare metal stents (BMS) for native coronary artery revascularization unless contraindicated. However, the preferred stent choice for saphenous venous graft (SVG) percutaneous coronary interventions (PCI) is unclear due to conflicting results.

METHODS

PubMed, Clinical trials registry and the Cochrane Center Register of Controlled Trials were searched through June 2018. Seven studies (n = 1639) comparing DES versus BMS in SVG-PCI were included. Endpoints were major adverse cardiac events (MACE), cardiovascular mortality, all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), in-stent thrombosis, binary in-stent restenosis, and late lumen loss (LLL).

RESULTS

Overall, during a mean follow up of 32.1 months, there was no significant difference in the risk of MACE, cardiovascular mortality, all-cause mortality, MI, stent thrombosis, TVR and TLR between DES and BMS. However, short-term follow up (mean 11 months) showed lower rate of MACE (OR 0.66 [0.51, 0.85]; p = 0.002), TVR (OR 0.47 [0.23, 0.97]; p = 0.04) and binary in-stent restenosis (OR 0.14 [0.06, 0.37]; p < 0.0001) in DES as compared with BMS. This benefit was lost on long-term follow up with a mean follow up 35.5 months.

CONCLUSION

In this meta-analysis of SVG-PCI, DES use was associated with similar MACE, cardiovascular mortality, all-cause mortality, MI, in-stent thrombosis, TVR and TLR compared with BMS during long-term follow up. There was high incidence of MACE noted in both DES and BMS suggesting a need for exploring novel strategies to treat SVG disease to improve clinical outcomes.

A comprehensive meta-analysis of randomized controlled trials comparing drug-eluting stents with bare-metal stents in saphenous vein graft interventions

BACKGROUND

Several large randomized controlled trials (RCTs) have proven the superiority of drug-eluting stents (DESs) over bare-metal stents (BMSs) for native coronary stenosis. However, RCTs comparing DESs with BMSs for SVG lesions have predominantly been small in size and have yielded conflicting results. Therefore, we conducted an updated comprehensive meta-analysis of RCTs comparing DESs versus BMSs for SVG interventions using the largest sample size to date.

METHODS

Scientific databases and websites were searched to find RCTs. Data from six RCTs involving 1,582 patients were included. Pooled risk ratios (RRs) were calculated using random-effects models. The primary outcome of this meta-analysis was target vessel revascularization (TVR). The secondary outcomes were major adverse cardiac events (MACEs), myocardial infarction (MI), stent thrombosis, all-cause mortality, and cardiac mortality.

RESULTS

Data from six RCTs involving 1,582 patients were included. Saphenous vein graft interventions with DESs reduced TVR (RR, 0.52; 95% CI, 0.30-0.88; P = 0.017) and MACE rate (RR, 0.60; 95% CI, 0.42-0.87; P = 0.007) compared to BMSs. No difference between the stents were found in rates of MI (RR, 0.69; 95% CI, 0.43-1.10; P = 0.123), stent thrombosis (RR, 0.61; 95% CI, 0.27-1.41; P = 0.255), all-cause mortality (RR, 1.13; 95% CI, 0.74-1.71; P = 0.554), or cardiac mortality.

CONCLUSION

For SVG intervention, the MACE rate was lower for DESs compared to BMSs, driven primarily by decreased non-MI-related TVR. Rates of MI, all-cause mortality, cardiac mortality, and stent thrombosis were not different between the stents.

Drug-eluting stents are associated with improved outcomes for the treatment of infrainguinal bypass graft stenoses

BACKGROUND

Existing endovascular therapies for failing infrainguinal bypass grafts are associated with modest patency rates. The use of everolimus drug-eluting stents (eDESs) for endovascular bypass graft revision has not yet been reported. The objective of this study was to describe and to compare clinical outcomes of eDESs vs percutaneous cutting balloons (PCBs) vs percutaneous transluminal angioplasty (PTA) for the treatment of infrainguinal bypass graft stenoses.

METHODS

A multicenter, single-institution retrospective analysis of patients with infrainguinal bypass graft stenoses treated by endovascular intervention (August 2010-December 2017) was conducted. The primary study outcome was primary patency of the treated lesion. The secondary outcome was limb salvage. Outcomes are described overall and stratified by endovascular treatment modality using Kaplan-Meier curves and log-rank tests.

RESULTS

During the 7-year study period, 43 patients with 78 infrainguinal bypass stenoses were treated by endovascular intervention (eDES, 15; PCB, 23; PTA, 40). Mean age was 63.3 ± 1.7 years, 53.5% were male, and 55.8% were black. The majority of patients were diabetic (60.5%) with a history of smoking (74.4%), and nearly all (83.7%) had two or more comorbidities. Half (48.7%) of bypasses treated were femoral-popliteal bypasses, followed by popliteal-distal (25.6%) and femoral-tibial (25.6%) configurations. The location of revision was the proximal anastomosis in 37.2%, midbypass in 25.6%, and distal anastomosis in 37.2%. There were no significant differences in baseline characteristics, bypass configuration, or revision location between treatment groups (P ≥ .19). Technical success for endovascular bypass intervention was 100%. At 2 years after intervention, primary patency was significantly better for patients treated with eDES (81.8%) compared with PCB (54.7%) or PTA (33.2%; log-rank, P = .03). Limb salvage was achieved in 93.6% of patients, including 86.7%, 91.3%, and 97.5% for eDES, PCB, and PTA, respectively (P = .30).

CONCLUSIONS

This is the first study reporting the results of eDESs for the treatment of infrainguinal bypass graft stenoses. Use of eDESs for endovascular bypass graft revision not only is feasible but may have better primary patency than other endovascular therapies. These data suggest that eDESs may be considered a safe and efficacious endovascular technique in the armamentarium for treatment of infrainguinal bypass graft stenoses.

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial

BACKGROUND

Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions.

METHODS

Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50-99% stenosis of a 2·25-4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with ClinicalTrials.gov, number NCT01121224.

FINDINGS

Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63-1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached.

INTERPRETATION

In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy.

FUNDING

US Department of Veterans Affairs Cooperative Studies Program.

The short- and long-term outcomes of percutaneous intervention with drug-eluting stent vs bare-metal stent in saphenous vein graft disease: An updated meta-analysis of all randomized clinical trials

The use of drug-eluting stents (DES) vs bare-metal stents (BMS) in saphenous vein graft (SVG) lesions remains controversial. We conducted a meta-analysis of all randomized clinical trials comparing the outcomes of DES with BMS in SVG percutaneous coronary interventions. A search of PubMed, Embase, the Cochrane Register of Controlled Trials, and Clinicaltrials.gov was performed for all randomized clinical trials. We evaluated the short- and long-term clinical outcomes of the following: all-cause mortality, major adverse cardiovascular events (MACE), definite/probable stent thrombosis, target lesion revascularization (TLR), and target-vessel revascularization (TVR). From a total of 1582 patients in 6 randomized clinical trials, 797 had DES and 785 had BMS. Patients with DES had lower short-term MACE, TLR, and TVR in comparison with BMS (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.35-0.91, P = 0.02; OR: 0.43, 95% CI: 0.19-0.99, P = 0.05; and OR: 0.45, 95% CI: 0.22-0.95, P = 0.04, respectively). However, there were no different outcomes for all-cause mortality (P = 0.63) or stent thrombosis (P = 0.21). With long-term follow-up, there were no significant reductions of MACE (P = 0.20), TLR (P = 0.57), TVR (P = 0.07), all-cause mortality (P = 0.29), and stent thrombosis (P = 0.76). The use of DES in SVG lesions was associated with lower short-term MACE, TLR, and TVR in comparison with BMS. However, there were no significant differences with long-term follow-up.

Comparison between the STENTYS self-apposing bare metal and paclitaxel-eluting coronary stents for the treatment of saphenous vein grafts (ADEPT trial)

AIMS

To describe the safety and performance of STENTYS self-expandable bare metal stents (BMS) versus paclitaxel-eluting stents (PES) in saphenous vein grafts (SVGs).

METHODS AND RESULTS

A randomised controlled trial was performed in four hospitals in three European countries between December 2011 and December 2013. Patients with de novo lesions (>50% stenosis) in an SVG with a diameter between 2.5-6 mm were included. Primary endpoint was late lumen loss at 6 months. Secondary endpoints included procedural success and the occurrence of major adverse cardiac events (MACE) at 12 months. A total of 57 patients were randomised to STENTYS self-apposing BMS (n = 27) or PES (n = 30). Procedural success was obtained in 89.5%. No significant differences in late lumen loss were found between BMS and PES at 6 months (0.53 mm vs 0.47; p = 0.86). MACE rates at 12 months were comparable in both groups (BMS 22.2% vs. PES 26.7%; p = 0.70).

CONCLUSIONS

Treatment of SVGs with STENTYS self-expandable stents is safe and effective. No significant differences were found in late lumen loss and MACE between BMS and PES.

Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory?

The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.

Current State of the Art in Approaches to Saphenous Vein Graft Interventions

Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.

Rationale and design of the Drug-Eluting Stents vs Bare-Metal Stents in Saphenous Vein Graft Angioplasty (DIVA) Trial

VA Cooperative Studies Program #571 (DIVA) was designed to evaluate the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure when compared with bare-metal stents (BMS) in participants undergoing stenting of de novo SVG lesions. Participants undergoing clinically indicated stenting of de novo SVG lesions were randomized in a 1:1 ratio to DES or BMS. Randomization was stratified by presence/absence of diabetes mellitus and the number of target SVG lesions (1 vs ≥2) within each participating site. At sites that did not routinely administer 12-months of dual antiplatelet therapy after SVG stenting participants without acute coronary syndromes received 1 month of open-label clopidogrel, followed by 11 months of clopidogrel for those assigned to DES and 11 months of placebo for those assigned to BMS. The primary endpoint was the 12-month incidence of target-vessel failure (defined as the composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization). Secondary endpoints included the incidence of other clinical endpoints and the incremental cost-effectiveness of DES relative to BMS. Due to lower-than-anticipated target-vessel failure rates, target enrollment was increased from 519 to 762. The study had randomized 599 participants when recruitment ended in December 2015. The DIVA trial will provide clarity on the appropriate stent type for de novo SVG lesions.

Choice of Stent for Percutaneous Coronary Intervention of Saphenous Vein Grafts

Background—

There are limited data on comparison of contemporary drug-eluting stent (DES) platforms, previous generation DES, and bare-metal stents (BMS) for percutaneous coronary intervention in saphenous vein grafts (SVG). We aimed to assess clinical outcomes following percutaneous coronary intervention to SVG in patients receiving bare-metal stents (BMS), first-generation DES, and newer generation DES in a large unselected national data set from the BCIS (British Cardiovascular Intervention Society).

Methods and Results—

Patients undergoing percutaneous coronary intervention to SVG in the United Kingdom from January 2006 to December 2013 were divided into 3 groups according to stent use: BMS, first-generation DES, and newer generation DES group. Study outcomes included in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality. Patients (n=15 003) underwent percutaneous coronary intervention to SVG in England and Wales during the study period. Of these, 38% received BMS, 15% received first-generation DES, and 47% received second-generation DES. The rates of in-hospital major adverse cardiovascular events were significantly lower in patients treated with second-generation DES (odds ratio, 0.51; 95% confidence interval, 0.38–0.68; P <0.001), but not with first-generation DES, compared with BMS-treated patients. Similarly, 30-day mortality (odds ratio, 0.43; 95% confidence interval, 0.32–0.59; P <0.001) and 1-year mortality (odds ratio, 0.60; 95% confidence interval, 0.51–0.71; P <0.001) were lower in patients treated with second-generation DES, but not with first-generation DES, compared with the patients treated with BMS.

Conclusions—

Patients receiving second-generation DES for the treatment SVG disease have lower rates of in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality, compared with those receiving BMS.

Sealing Intermediate Nonobstructive Coronary Saphenous Vein Graft Lesions With Drug-Eluting Stents as a New Approach to Reducing Cardiac Events

Background—

The objective of this study was to assess the efficacy of sealing intermediate nonobstructive coronary saphenous vein graft (SVG) lesions with drug-eluting stents (DES; paclitaxel- or everolimus-eluting stents) for reducing major adverse cardiac events (MACE).

Methods and Results—

This was a randomized controlled multicenter clinical trial that enrolled patients with a previous coronary artery bypass graft who had developed at least 1 intermediate nonobstructive SVG lesion (30%–60% diameter stenosis by visual estimation). Patients were randomized (1:1) to DES implantation (SVG-DES) or medical treatment (SVG-MT) of the target SVG lesion. The primary efficacy outcome was the first occurrence of MACE defined as the composite of cardiac death, myocardial infarction, or coronary revascularization related to the target SVG during the duration of follow-up (minimum of 2 years). Secondary efficacy outcomes included MACE related to the target SVG lesion and overall MACE. A total of 125 patients (mean age 70±9 years, 87% men) were included, with a mean time from coronary artery bypass graft of 12±5 years. Sixty and 65 patients were allocated to the SVG-DES and SVG-MT groups, respectively. There were no events related to the target SVG at 30 days. After a median follow-up of 3.4 (interquartile range: 2.8–3.9) years, the MACE rate related to the target SVG was not significantly different in the 2 groups (SVG-DES: 15.0%, SVG-MT: 20.0%; hazard ratio, 0.65; 95% confidence interval, 0.23–1.53; P =0.33). There were no significant differences between groups in MACE related to the target SVG lesion (SVG-DES: 10.0%, SVG-MT: 16.9%; hazard ratio, 0.53; 95% confidence interval, 0.20–1.43; P =0.21) or global MACE (SVG-DES: 36.7%, SVG-MT: 44.6%; hazard ratio, 0.73; 95% confidence interval, 0.42–1.27; P =0.26).

Conclusions—

Sealing intermediate nonobstructive SVG lesions with DES was safe but was not associated with a significant reduction of cardiac events at 3-year follow-up.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01223443.

Drug deposition in coronary arteries with overlapping drug-eluting stents

Drug-eluting stents are accepted as mainstream endovascular therapy, yet concerns for their safety may be under-appreciated. While failure from restenosis has dropped to below 5%, the risk of stent thrombosis and associated mortality remain relatively high. Further optimization of drug release is required to minimize thrombosis risk while maintaining therapeutic dose. The complex three-dimensional geometry of deployed stents together with the combination of diffusive and advective drug transport render an intuitive understanding of the situation exceedingly difficult. In situations such as this, computational modeling has proven essential, helping define the limits of efficacy, determine the mode and mechanism of drug release, and identify alternatives to avoid toxicity. A particularly challenging conformation is encountered in coronary arteries with overlapping stents. To study hemodynamics and drug deposition in such vessels we combined high-resolution, multi-scale ex vivo computed tomography with a flow and mass transfer computational model. This approach ensures high geometric fidelity and precise, simultaneous calculation of blood flow velocity, shear stress and drug distribution. Our calculations show that drug uptake by the arterial tissue is dependent both on the patterns of flow disruption near the wall, as well as on the relative positioning of drug-eluting struts. Overlapping stent struts lead to localized peaks of drug concentration that may increase the risk of thrombosis. Such peaks could be avoided by anisotropic stent structure or asymmetric drug release designed to yield homogeneous drug distribution along the coronary artery and, at the least, suggest that these issues need to remain in the forefront of consideration in clinical practice.

Drug-eluting versus bare metal stent in treatment of patients with saphenous vein graft disease: A meta-analysis of randomized controlled trials

Drug-eluting stent (DES) and bare metal stent (BMS) are effective treatments for preventing vascular disease, but whether using DES is associated with positive clinical outcomes compared with BMS in patients with saphenous vein graft disease (SVGD) has not been established. Three electronic databases including PubMed, EmBase, and the Cochrane Central Register of Controlled Trials were searched to identify potentially includible studies. We did a random-effects meta-analysis of randomized controlled trials (RCTs) to obtain summary effect estimates for the clinical outcomes with the use of relative risk calculated from the raw data of individual trial. Among 812 patients from 4 RCTs, DES was associated with lower risk of short-term major cardiovascular events (MACEs) when compared with BMS, whereas no significant effect on the risk of long-term MACEs. Furthermore, there was no significant difference between DES and BMS for short-term myocardial infarction (MI) and long-term MI. Similarly, DES was not associated with risk of short- and long-term mortality risk as compared with BMS. In addition, DES has no significant effect on the risk of cardiac death and stent thrombosis. Finally, DES therapy significantly reduced the risk of TLR, TVF, and TVR. SVGD patients received DES can minimize the risk of short-term MACEs, TLR, TVF, and TVR when compared with BMS. However, it does not effect on the incidence of long-term MACEs, MI, mortality, cardiac death, and stent thrombosis.

Percutaneous Coronary Intervention in Native Coronary Arteries Versus Bypass Grafts in Patients With Prior Coronary Artery Bypass Graft Surgery: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

OBJECTIVES

The aim of this study was to examine 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.

BACKGROUND

Patients with prior CABG surgery often undergo PCI, but the association between PCI target vessel and short- and long-term outcomes has received limited study.

METHODS

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).

RESULTS

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: 1.18 to 1.42), myocardial infarction (adjusted HR: 1.61; 95% confidence interval: 1.43 to 1.82), and repeat revascularization (adjusted HR: 1.60; 95% confidence interval: 1.50 to 1.71).

CONCLUSIONS

In a national cohort of veterans, almost three-quarters of PCIs performed in patients with prior CABG involved native coronary artery lesions. Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of short- and long-term major adverse events, including more than double the rate of in-hospital mortality.

Saphenous Vein Graft Interventions

Saphenous vein graft interventions compose a small but important subset of percutaneous coronary revascularization. Because of their unique biology, percutaneous angioplasty and stenting require tailored patient and lesion selection and modification of intervention technique to optimize outcomes. The use of embolic protection and appropriate adjunctive pharmacology can help minimize periprocedural complications, such as the no-reflow phenomenon. Recommendations for best practice in saphenous vein graft interventions continue to evolve with emerging research and therapy.