DES, BMS Both Suitable for Treating Patients With SVG Lesions

For older patients with failing saphenous vein grafts (SVGs), DES are as protective as BMS against MI and urgent revascularization at 3 years and offer lower long-term mortality, according to an observational study published online July 8, 2015, ahead of print in Catheterization and Cardiovascular Interventions. 

As such, “DES use appears to be safe for SVG PCI,” J. Matthew Brennan, MD, MPH, of Duke University Medical Center (Durham, NC), and colleagues say.

The researchers combined Medicare records with data from the National Cardiovascular Data Registry CathPCI Registry to create longitudinal records for 49,325 patients at least 65 years old who underwent stenting with BMS (n = 17,922) or DES (n = 31,403) for SVG failure at 1,001 sites from 2005 through 2009.

Procedural success was similar regardless of stent type, but periprocedural complications—including in-hospital death, MI, cardiogenic shock, and new heart failure symptoms—occurred more often in patients who received BMS than DES (5.9% vs 4.2%; P < .001).

By 3 years, DES patients required more urgent revascularization but were less likely to die than those treated with BMS, and MI rates were equivalent between the 2 groups. Yet propensity-matched analysis demonstrated that the need for repeat treatment did not differ by device type. 

All findings were independent of ACS clinical presentation, treatment history, and graft segment.

To account for possible treatment selection bias, sensitivity analysis was conducted for centers that showed a preference for BMS or DES use (≥ 75% use of either). Compared with patients treated at centers with a BMS preference (57 centers; n = 579), those treated at DES-preference centers (275 centers; n= 13,207) had a lower burden of most baseline characteristics but similar adjusted rates of death, MI, and urgent revascularization.

Conflicting Literature on SVG PCI

Though 3 trials—DELAYED RRISC, SOS, and ISAR-CABG—have compared DES and BMS in SVG lesions, according to the authors, this study represents the “largest-ever reported long-term experience following SVG PCI.”

Results have not been consistent across the trials. For example, patients who received DES in DELAYED RRISC had similar TVR rates compared with those who received BMS but much higher mortality. Yet in the SOS trial, DES patients had not only a similar likelihood of death compared with BMS patients but also reduced TVR and MI. Finally, in ISAR-CABG, BMS- and DES-treated patients experienced similar 1-year mortality and MI rates, with the DES group undergoing less TVR.

In an email to TCTMD, Emmanouil S. Brilakis, MD, PhD, of the Dallas VA Medical Center (Dallas, TX), expressed some surprise that urgent revascularization rates were similar for both stent types in the present study, though he suggested that this could “reflect incomplete data capture in the Medicare database.”

Even so, he said, a reduction in repeat treatment is the “main expected benefit of DES, as shown in the SOS and ISAR-CABG patients, although it was not seen in DELAYED RRISC.”

Debate over the potential for DES in failing SVGs continues, Dr. Brilakis reported, “because all 3 RCTs done to date include routine angiographic follow-up, which can potentially exacerbate a potential benefit of DES.”

Reassurance on Safety

Both Dr. Brilakis and Sheldon Goldberg, MD, of Penn Medicine (Philadelphia, PA), told TCTMD that the results are reassuring about the safety of DES in SVG lesions. Because DES were used almost twice as often as BMS in the registry, it seems that DES are “well accepted in clinical practice,” Dr. Goldberg pointed out in an email.

Among the current study’s limitations, the authors acknowledge, is the lack of details on dual antiplatelet therapy duration and compliance. The former could be especially important, according to Dr. Brilakis, as a 2012 study “showed increased risk for adverse cardiac events immediately after clopidogrel discontinuation.”

The stent choice alone will not make or break the success of SVG intervention, said Dr. Goldberg. “The long-term results, no matter what we do, are dismal. We have realized that the use of arterial conduits and consideration of hybrid procedures combining arterial revascularization with stenting of native vessels deserve careful consideration,” he observed.

Stenting a native artery will result in better outcomes “than placing a vein graft to that vessel,” Dr. Goldberg concluded. “As I've said for years, the best way to keep a saphenous vein patent is to leave it in the leg.”