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vein graft failure following coronary artery bypass surgery does it matter

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

Disclosures

None of the authors has any disclosures related to this study

background

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
Vein Graft Failure

Pathogenesis of VGF

Intimal injury

Smooth muscle migration

Neointimal hyperplasia

Atherosclerosis

Thrombosis

background5

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

background6

Background

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

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
prevent iv study design follow up
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

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
methods10

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

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 analysis12

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 angiogram angiography cohort
Time to 1-Year AngiogramAngiography Cohort

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

death mi or revascularization
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
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

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

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
post angiogram events

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

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

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

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
mi prior to 1 year angiogram
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
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