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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 l.jpg

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 l.jpg

Disclosures

None of the authors has any disclosures related to this study


Background l.jpg

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


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Vein Graft Failure

Pathogenesis of VGF

Intimal injury

Smooth muscle migration

Neointimal hyperplasia

Atherosclerosis

Thrombosis


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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


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Background

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


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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


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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%)


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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


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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


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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


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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


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Time to 1-Year AngiogramAngiography Cohort

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


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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


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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


Death l.jpg

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


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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


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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


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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)


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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


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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


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Thank you


Slide23 l.jpg

Back up slides


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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


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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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