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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 Does it Matter?

None of the authors has any disclosures related to this study


Background l.jpg

Background Does it Matter?

  • 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 l.jpg
Vein Graft Failure Does it Matter?

Pathogenesis of VGF

Intimal injury

Smooth muscle migration

Neointimal hyperplasia

Atherosclerosis

Thrombosis


Background5 l.jpg

Background Does it Matter?

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


Background6 l.jpg

Background Does it Matter?

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


Objectives l.jpg

Objectives Does it Matter?

  • 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


Prevent iv study design follow up l.jpg

Enrolled Patients Does it Matter?

(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 l.jpg

Methods Does it Matter?

  • 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


Methods10 l.jpg

Methods Does it Matter?

  • 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 l.jpg

Statistical Analysis Does it Matter?

  • 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 analysis12 l.jpg

Statistical Analysis Does it Matter?

  • 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 angiogram angiography cohort l.jpg
Time to 1-Year Angiogram Does it Matter?Angiography Cohort

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


Death mi or revascularization l.jpg
Death, MI, or Revascularization Does it Matter?

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 l.jpg
Death or MI Does it Matter?

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 Does it Matter?

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 l.jpg

Results: VGF and Outcomes Does it Matter?

  • 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


Post angiogram events l.jpg

0.3 Does it Matter?

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 l.jpg

Vein Graft Failure and Outcomes Does it Matter?“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 l.jpg

Limitations Does it Matter?

  • 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 l.jpg

Conclusions Does it Matter?

  • 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


Slide22 l.jpg

Thank you Does it Matter?


Slide23 l.jpg

Back up slides Does it Matter?


Mi prior to 1 year angiogram l.jpg
MI Prior to 1-Year Angiogram Does it Matter?

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 l.jpg
Revascularizations Prior to 1-Year Angiogram Does it Matter?

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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