Original title: Long-term clinical outcome after fractional flow reserve– versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts. Reference: Luigi Di Serafino et al. Am Heart J 2013;166:110-8.
Bypass coronary angioplasty is often preferred strategy versus re-operation , however it is associated with a greater number of events, both short and long term, compared to native vessels angioplasty. The procedure is usually more difficult given the high amount of patient comorbidities and complexity of lesions so it is crucial to counterbalance the cost / benefit, especially in intermediate lesions .
The fractional flow reserve ( FFR ) has been shown to improve outcomes in native arteries but, so far there is no evidence to use it in coronary bypass. Intermediate lesions were considered those with a stenosis degree between 40% and 70% by visual estimation. We excluded patients with bypass tandem lesions, distal to the anastomosis native artery lesions and sequential bypass .
FFR branch guided patients received angioplasty only if FFR was ≤ 0.8. In total 223 patients were registered, of which 65 received FFR and 158 were guided by angiography. The injury rate in the FFR group has been more frequent in arterial bypasses and severity of intermediate lesions was higher in the angiography guided group.
In the FFR group , 23 patients ( 35 % ) received angioplasty (FFR 0.68 ± 0.09 ) and the rest, optimal medical treatment (FFR 0.92 ± 0.05, p = 0.01 versus those receiving angioplasty). In the angiography guided group , 90 patients ( 57 % ) underwent angioplasty ( % stenosis by quantitative angiography 56.8 ± 13.7 ) and the rest, medical treatment ( % stenosis by quantitative angiography 41.7 ± 9, p = 0.01 versus those receiving angioplasty). The FFR group received significantly fewer stents than the group guided by angiography. At follow-up at 3.8 years, FFR -guided group showed a lower rate of combined events (death, MI , stroke , revascularization ) than the angiographic group ( 28 versus 51% , HR 0.46, CI 0.28 – 0.77, P = 0.003 ) . This difference remained after making an adjustment using propensity score. The advantage of the FFR was primarily in the arterial bypass since the only saphenous vein bypass was considered, no differences were observed between groups.
Conclusion:
The FFR – guided revascularization in patients with prior CABG and arterial bypasses intermediate lesions resulted in better clinical outcomes compared to angiography guided . For intermediate vein graft lesions the results were similar between the two strategies .
Editorial Comment:
In the group guided by angiography venous grafts were significantly treated and these consecutively had lesions (whereas entering the intermediate definition ) with a greater percentage of stenosis to the group guided by FFR . This point could only explain the difference in events.
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