Ticagrelor to Improve Venous Graft Patency

Saphenous vein graft patency is one of CABG’s “Achilles heals”, especially after the ARTS trial came out showing bilateral internal mammary artery grafting was not superior to simple internal mammary artery grafting. 

THEMIS: eventos isquémicos y hemorrágicos en difícil equilibrio para el ticagrelor crónico

Antiaggregation more potent than aspirin might prolong venous graft patency in cases when the available techniques will fail to improve poor outcomes.   

Previous studies tend to confirm the idea that a more potent antiaggregation therapy could prolong patency. However, reality seems to have debunked this attractive hypothesis. 

This double-blind placebo-controlled randomized study showed that adding ticagrelor does not reduce graft occlusion rate at one-year followup. These outcomes contradict prior study outcomes. 

There is no conclusive evidence to support routine indication of ticagrelor in patients undergoing CABG. 


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Ticagrelor does have antithrombotic effect and probably pleiotropic in patients undergoing CABG in the context of acute coronary syndrome, but this benefit is associated to the clinical syndrome, rather than graft patency.  

Guidelines still recommend administering ticagrelor after acute coronary syndrome with revascularization, regardless the technique. 

499 patients mean age 67.9±8.3 with myocardial revascularization indication were randomized. One third of the cohort received revascularization in the context of acute coronary syndrome. 


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Occlusion rate of venous graft with ticagrelor was 10.5% vs 9.1% in the placebo arm (both arms received low doses of aspirin). 

This difference was not significative.

Conclusion

In this randomized placebo-controlled study, adding ticagrelor to aspirin did not improve saphenous vein graft patency vs. standard aspirin monotherapy.

Título original: The Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG): A Randomized, Double-Blind, Placebo-Controlled Trial.

Referencia: Willemsen LM et al. Circulation. 2020 Aug 31. Online ahead of print. doi: 10.1161/CIRCULATIONAHA.120.050749.


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