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Vein Graft Failure Following Vein Graft Failure Following Coronary Artery Bypass Surgery: Coronary Artery Bypass Surgery:
Does it Matter?Does it Matter?
Renato D. LopesRenato D. Lopes • John H. Alexander • Rajendra H. Mehta • Gail • John H. Alexander • Rajendra H. Mehta • Gail E. Hafley • Michael J. Mack • Keith B. Allen • Eric D. Peterson • E. Hafley • Michael J. Mack • Keith B. Allen • Eric D. Peterson • Robert A Harrington • C. Michael Gibson • Robert M. Califf • Robert A Harrington • C. Michael Gibson • Robert M. Califf • Nicholas T. Kouchoukos • T. Bruce FergusonNicholas T. Kouchoukos • T. Bruce Ferguson
- ACC- Atlanta, 2010 -- ACC- Atlanta, 2010 -
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DisclosuresDisclosuresDisclosuresDisclosures
None of the authors has any disclosures related to this studyNone of the authors has any disclosures related to this study
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BackgroundBackground
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 FailureVein Graft Failure
Pathogenesis of VGFPathogenesis of VGF Intimal injuryIntimal injury Smooth muscle Smooth muscle
migrationmigration Neointimal hyperplasiaNeointimal hyperplasia AtherosclerosisAtherosclerosis ThrombosisThrombosis
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BackgroundBackground
Predictors of Vein Graft Failure:
Location
Diameter
Quality
Number of anastomoses
Time since implantation of the SVG
Cataldo G,Circulation 2003
Shah PJ. J Thorac Cardiovasc Surg 2003
Roth JA, Ann Thorac Surg 1979
native target vessel
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BackgroundBackground
Little is know about the relationship between vein graft failure and subsequent clinical outcomes
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ObjectivesObjectives
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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EDIFOLIGIDE(n=1508)
PLACEBO(n=1506)
Angiography Cohort(n=1197)
5-year Clinical Endpoint (N=1430, 94.8%)
Angiography Cohort(n=1203)
5-year Clinical Endpoint (N=1435, 95.3%)
Non-Angiography(n=311)
1-year Angiographic Endpoint (81%)
1-year Angiographic Endpoint (79%)
Non-Angiography(n=303)
Enrolled PatientsEnrolled Patients
(n=3014)(n=3014)
PREVENT-IVPREVENT-IVStudy Design & Study Design & Follow-UpFollow-Up
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MethodsMethodsMethodsMethods
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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MethodsMethods
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 AnalysisStatistical 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 AnalysisStatistical 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 AngiogramTime to 1-Year AngiogramAngiography CohortAngiography Cohort
Alexander JH. JAMA 2005; 16;294(19):2446-2454
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Death, MI, or RevascularizationDeath, MI, or Revascularization
0.0
0.1
0.2
0.3
0 1 2 3 4 5
Ev
ent
Ra
te
Years
Placebo
Edifoligide
HR 1.03 (95% CI: 0.89-1.18)
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Death or MIDeath or MI
0.0
0.1
0.2
0.3
0 1 2 3 4 5
Ev
ent
Ra
te
Years From Angiogram
Placebo
EdifoligideHR 1.01 (95% CI: 0.83-1.23)
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DeathDeath
0.0
0.1
0.2
0.3
0 1 2 3 4 5
Ev
ent
Ra
te
Years
Placebo
EdifoligideHR 1.10 (95% CI: 0.89-1.36)
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Results: VGF and OutcomesResults: 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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0.0
0.1
0.2
0.3
0 1 2 3 4
Ev
ent
Ra
te
Years From Angiogram
DD D/MID/MI D/MI/RevascD/MI/Revasc
Vein Graft FailureVein Graft Failure
No Vein Graft FailureNo Vein Graft Failure
Post Angiogram EventsPost Angiogram Events
HR 1.79, 95% CI 1.40-2.28; P<0.001
NSNS
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Vein Graft Failure and OutcomesVein Graft Failure and Outcomes““Subgroups”Subgroups”Vein Graft Failure and OutcomesVein Graft Failure and Outcomes““Subgroups”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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LimitationsLimitations
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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ConclusionsConclusions
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 youThank you
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Back up slidesBack up slides
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MI Prior to 1-Year AngiogramMI Prior to 1-Year Angiogram
No Vein Graft Failure
Vein Graft Failure
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0 2 4 6 8 10 12
Ev
ent
Ra
te
Months From Enrollment
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Revascularizations Prior to 1-Year AngiogramRevascularizations Prior to 1-Year Angiogram
No Vein Graft Failure
Vein Graft Failure
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0 2 4 6 8 10 12
Ev
ent
Ra
te
Months From Enrollment