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Vein Graft Failure Following Coronary Artery Bypass Surgery: Does it Matter?

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Vein Graft Failure Following Coronary Artery Bypass Surgery: Does it Matter?

Renato D. Lopes • John H. Alexander • Rajendra H. Mehta • Gail E. Hafley • Michael J. Mack • Keith B. Allen • Eric D. Peterson • Robert A Harrington • C. Michael Gibson • Robert M. Califf • Nicholas T. Kouchoukos • T. Bruce Ferguson

- ACC- Atlanta, 2010 -


Disclosures

None of the authors has any disclosures related to this study


Background

  • Saphenous vein grafts (SVG) are the most common conduit used in coronary artery bypass graft (CABG) surgery

  • Per patient rates of vein graft failure (VGF): 25-45%

  • Depends on:

    • Population

    • When measured

    • How defined

Alexander JH. JAMA 2005; 16;294(19):2446-2454

Widimsky P. Circulation 2004 30;110(22):3418-3423


Vein Graft Failure

Pathogenesis of VGF

Intimal injury

Smooth muscle migration

Neointimal hyperplasia

Atherosclerosis

Thrombosis


Background

Cataldo G,Circulation 2003

Roth JA, Ann Thorac Surg 1979

Shah PJ. J Thorac Cardiovasc Surg 2003

  • Predictors of Vein Graft Failure:

    • Location

    • Diameter

    • Quality

    • Number of anastomoses

    • Time since implantation of the SVG

native target vessel


Background

  • Little is know about the relationship between vein graft failure and subsequent clinical outcomes


Objectives

  • To assess long-term (5 years) clinical outcomes of patients enrolled in the PREVENT-IV trial

  • To assess the relationship between vein graft failure assessed by coronary angiography 12-18 months post-CABG and 5-year clinical outcomes


Enrolled Patients

(n=3014)

PREVENT-IVStudy Design & Follow-Up

EDIFOLIGIDE

(n=1508)

PLACEBO

(n=1506)

Angiography Cohort

(n=1197)

Non-Angiography

(n=311)

Angiography Cohort

(n=1203)

Non-Angiography

(n=303)

1-year Angiographic Endpoint (81%)

1-year Angiographic Endpoint (79%)

5-year Clinical Endpoint (N=1430, 94.8%)

5-year Clinical Endpoint (N=1435, 95.3%)


Methods

  • We assessed the long-term clinical outcomes of patients enrolled in the PREVENT-IV trial

  • Follow-up was performed by mail or telephone survey

  • Clinical outcomes included death, MI, and repeat revascularization through 5 years

  • All events were confirmed by review of medical records


Methods

  • Vein graft failure was assessed by quantitative coronary angiography and defined as a ≥75% stenosis anywhere in the vein graft

  • Vein graft failure was classified both per patient and per graft

  • Patients who had clinical events or died before angiographic follow-up were excluded from these analyses


Statistical Analysis

  • Cumulative event rates for clinical outcomes were calculated using the Kaplan-Meier method

  • Covariate adjusted analyses of outcomes were assessed using the Cox proportional hazards model

  • Logistic regression was used to assess per patient graft failure outcomes


Statistical Analysis

  • Individual graft failure rates were adjusted for intrapatient correlation using general estimating equation techniques

  • The Cox proportional hazards model (with covariates for the number of grafts implanted and the proportion failed) was used to assess the relationship between graft failure and clinical outcomes


Time to 1-Year AngiogramAngiography Cohort

Alexander JH. JAMA 2005; 16;294(19):2446-2454


Death, MI, or Revascularization

0.3

0.2

Event Rate

0.1

0.0

0

1

2

3

4

5

Years

Edifoligide

HR 1.03 (95% CI: 0.89-1.18)

Placebo


Death or MI

0.3

0.2

Event Rate

0.1

0.0

0

1

2

3

4

5

Years From Angiogram

Edifoligide

HR 1.01 (95% CI: 0.83-1.23)

Placebo


0.3

0.2

Event Rate

0.1

0.0

0

1

2

3

4

5

Years

Death

Edifoligide

HR 1.10 (95% CI: 0.89-1.36)

Placebo


Results: VGF and Outcomes

  • The composite of death, MI, or revascularization occurred more frequently among patients who had vein graft failure compared with those who had did not

    Adjusted HR 1.79, 95% CI 1.40-2.28; P<0.001

  • There was no relationship between vein graft failure and death / MI or death in either per patient or per graft analyses


0.3

0.2

Event Rate

0.1

0.0

0

1

2

3

4

Years From Angiogram

Post Angiogram Events

HR 1.79, 95% CI 1.40-2.28; P<0.001

NS


Vein Graft Failure and Outcomes“Subgroups”

There was no impact on the relationship between vein graft failure and 5-year clinical outcomes based on:

  • Graft Target (LAD vs other)

  • Target Artery Quality (Good vs other)

  • Graft Quality (Good vs other)

  • IMA Failure (Yes vs no)


Limitations

  • A causal relationship between vein graft failure and clinical outcomes cannot be proven. We assessed only associations

  • Angiographic follow-up was protocol driven and may have influence revascularization rates


Conclusions

  • Vein graft failure 1 year after CABG is strongly associated with an increased risk of death, MI, or revascularization at 5 years

  • This association is driven by early revascularization with no association between vein graft failure and death or MI

  • Further investigation of the appropriate management of patients with angiographic VGF post-CABG is needed


Thank you


Back up slides


MI Prior to 1-Year Angiogram

0.06

0.05

0.04

Event Rate

0.03

0.02

0.01

0.00

0

2

4

6

8

10

12

Months From Enrollment

Vein Graft Failure

No Vein Graft Failure


Revascularizations Prior to 1-Year Angiogram

0.06

0.05

0.04

Event Rate

0.03

0.02

0.01

0.00

0

2

4

6

8

10

12

Months From Enrollment

Vein Graft Failure

No Vein Graft Failure


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