Courtesy of Dr. Carlos Fava.

The treatment of vein graft lesions has always been difficult in relation to angioplasty, due to their characteristics. While drug-eluting stents (DES) have proven to be superior to bare-metal stents (BMS) for coronary arteries, such superiority is unclear as regards vein grafts. Several studies with first-generation DES (DES1) have even reported worse outcomes for these devices.

This study enrolled 15,003 patients who underwent angioplasty to vein grafts. Of these, 5685 (38%) received BMS, 2265 (24.3%) received DES1, and 7053 (47.1%) received second-generation DES (DES2).

There were significant differences among groups: first, patients treated with DES1 were younger; second, patients treated with DES2 presented higher levels of diabetes, hypertension, and dyslipidemia, and a high rate of acute myocardial infarction (MI), and peripheral vascular disease. Multivessel disease was 27% for DES1, 21% for DES2, and 14% for BMS.

Propensity score matching was applied to make the sample more uniform.

As regards raw data analysis, the BMS group presented higher rates of in-hospital major adverse cardiac events (MACE), and mortality at 30 days and 1 year, when compared with DES.

The rate of in-hospital MACE was significantly lower for the DES2 group (odds ratio [OR]: 0.51; 95% confidence interval [CI]: 0.38-0.68; p > 0.001), but not for those with DES1 (compared to those who received BMS).

The rates of mortality at 30 days and 1 year were lower for those who received DES2 (30 days: OR 0.43; 95% CI: 0.32-0.59; p < 0.001; 1 year: OR 0.60; 95% CI: 0.51-0.70; p < 0.001) when compared to the BMS patient group, but there was no difference regarding the DES1 group.

Conclusion

Patients receiving DES2 for the treatment of vein grafts had lower rates of in-hospital MACE, 30-day mortality, and 1-year mortality, compared with those who received BMS.

Editorial Comment

Performing an angioplasty to a vein graft is evidence of a patient with a higher presence of atherosclerotic disease.

The DELAYED RRIS (CYPHER) had reported worse outcomes for patients with DES1 in this sense. Studies after had shown similar mortality rates, but lower incidence of restenosis and target lesion revascularization.

This analysis shows that a different stent scaffold, another drug, and different polymers can lower the incidence of a hard event such as death for angioplasty to vein grafts.

In any case, this study is inconclusive. Further research is warranted to shed light on this issue.

Courtesy of Dr. Carlos Fava.

Original title: Choice of Stent for Percutaneous Coronary Intervention of Saphenous Vein Graft.

Reference: Javaid Iqbal, et al. Circulation Cardiovasc Intv 2017;10:e004457.

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