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Clinical Presentation and Angiographic Characteristics of Saphenous Vein Graft Failure After Stenting

Insights From the SOS (Stenting Of Saphenous Vein Grafts) Trial

Christopher Lichtenwalter, MD^_*,, James A. de Lemos, MD^_*,, Michele Roesle, RN^_*, Owen Obel, MD^_*,, Elizabeth M. Holper, MD, Donald Haagen, RCIS^_*, Bilal Saeed, MD, Jose Miguel Iturbe, MD, BA^_*,, Kendrick Shunk, MD, PhD, Joseph K. Bissett, MD^||, Rajesh Sachdeva, MD^||, Vassilios V. Voudris, MD, PhD^¶, Panagiotis Karyofillis, MD^¶, Biswajit Kar, MD^#, James Rossen, MD^_**, Panayotis Fasseas, MD, Peter Berger, MD, Subhash Banerjee, MD^_*,, Emmanouil S. Brilakis, MD, PhD^_*,,_*

^_* Veteran Affairs North Texas Healthcare System, Dallas, Texas
University of Texas Southwestern Medical Center, Dallas, Texas
Department of Internal Medicine, University of Toledo, Toledo, Ohio
San Francisco VA Medical Center, University of California, San Francisco School of Medicine, San Francisco, California
^|| Central Arkansas Veterans Healthcare System and University of Arkansas for Medical Sciences, Little Rock, Arkansas
^¶ Onassis Cardiac Surgery Center, Athens, Greece
^# Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas
^_** Iowa City Veteran Affairs Medical Center, Iowa City, Iowa
Medical College of Wisconsin, Milwaukee, Wisconsin
Geisinger Clinic, Danville, Pennsylvania

^_* Reprint requests and correspondence: Dr. Emmanouil S. Brilakis, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, Texas 75216 (Email: esbrilakis{at}yahoo.com).

Objectives: We sought to compare the clinical presentation and angiographic patterns of saphenous vein graft (SVG) failure after stenting with a paclitaxel-eluting stent (PES) versus a similar bare-metal stent (BMS).

Background: The mode of SVG failure after stenting has been poorly characterized.

Methods: The SOS (Stenting Of Saphenous Vein Grafts) trial enrolled 80 patients with 112 lesions in 88 SVGs who were randomized to a BMS or PES. Angiographic follow-up at 12 months was available in 83% of the patients.

Results: Binary angiographic restenosis occurred in 51% (24 of 47) of BMS-treated lesions versus 9% (4 of 43) of PES-treated lesions (p < 0.0001). Graft occlusion occurred in 9 of the 21 SVGs (43%) that failed in the BMS group and in 2 of 4 SVGs (50%) that failed in the PES group. SVG failure after stenting presented as an acute coronary syndrome in 10 of the 24 patients (42%) (7 of those 10 patients presented with non–ST-segment elevation acute myocardial infarction), stable angina in 9 (37%) patients, and without symptoms in 5 (21%) patients. Of the 19 patients (with 20 grafts) who developed symptomatic graft failure, repeat SVG revascularization was successfully performed in all 13 (100%) subtotally obstructed SVGs but was attempted (and successful) in only 1 of 7 (14%) occluded SVGs. Revascularization of a native coronary artery was performed in an additional 4 of 7 (57%) symptomatic patients with an occluded SVG.

Conclusions: SVG failure after stenting often presents as acute myocardial infarction and with SVG occlusion. Compared with BMS, PES reduce SVG failure.

Key Words: bare-metal stents • coronary artery bypass graft surgery • drug-eluting stents • outcomes • percutaneous coronary intervention • saphenous vein grafts

Abbreviations and Acronyms   ACS = acute coronary syndrome   ARC = Academic Research Consortium   BMS = bare-metal stent(s)   CABG = coronary artery bypass grafting   DES = drug-eluting stent(s)   MI = myocardial infarction   NSTEMI = non–ST-segment elevation acute myocardial infarction   PCI = percutaneous coronary intervention   PDA = posterior descending artery   PES = paclitaxel-eluting stent(s)   SVG = saphenous vein graft

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