Clinical Investigation
Interventional Cardiology
Long-term clinical outcome after fractional flow reserve– versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts

https://doi.org/10.1016/j.ahj.2013.04.007Get rights and content

Background

Fractional flow reserve (FFR)–guided percutaneous revascularization (percutaneous coronary intervention [PCI]) of intermediate stenosis in native coronary artery is safe and associated with better clinical outcomes as compared with an angiography-guided PCI. It is unknown whether this applies to coronary artery bypass grafts (CABGs).

Methods

We included 223 patients with CABG and with stable or unstable angina and an intermediate stenosis involving an arterial or a venous graft. Patients were divided into 2 groups: FFR guided (n = 65, PCI performed in case of FFR ≤0.80) and angio guided (n = 158, PCI performed based on angiographic evaluation). Primary end point was major adverse cardiac and cerebrovascular event, defined as death, myocardial infarction, target vessel failure, and cerebrovascular accident (CVA).

Results

The 2 groups were similar in terms of demographic and clinical characteristics. Percutaneous coronary intervention was performed in 23 patients (35%) of the FFR-guided group and 90 patients (57%) of the angio-guided group (P < .01). In the FFR-guided group, PCI was more often performed in arterial grafts as compared with the angio-guided group (16 [70%] vs 12 [13%], respectively; P < .01). Follow-up was obtained in 96% of patients at a median of 3.8 years (1.6-4.0 years). At multivariate analysis, major adverse cardiac and cerebrovascular event rate was significantly lower in the FFR-guided group as compared with the angio-guided group (18 [28%] vs 77 [51%], hazard ratio 0.33 [0.11-0.96], P = .043]. Procedure costs were overall reduced in the FFR-guided group (€2240 ± €652 vs €2416 ± €522, P = .03).

Conclusions

An FFR-guided PCI of intermediate stenosis in bypass grafts is safe and results in better clinical outcomes as compared with an angio-guided PCI. This clinical benefit is achieved with a significant overall reduction in procedural costs.

Section snippets

Patient population

All patients referred to coronary angiography for stable or unstable angina from January 2000 until June 2011 with at least 1 intermediate stenosis of an arterial or a venous bypass graft measured with FFR were included. Contemporary patients with previous CABG undergoing coronary angiography and with intermediate stenosis of an arterial or a venous bypass graft were used as a reference group. Intermediate stenosis was defined as percent diameter stenosis (%DS) at a visual estimation between

Clinical characteristics of the patients

A total of 223 patients were included: 65 in the FFR-guided group and 158 in the angio-guided group. No significant differences were found between the 2 groups in terms of clinical and demographic characteristics (Table I). In patients with unstable angina, all PCI procedures were performed within 48 hours from symptoms onset, similarly in the FFR-guided and angio-guided groups (27.5 ± 3.5 hours vs 28.1 ± 3.9 hours [P = .65], respectively).

Angiographic and procedural characteristics

Angiographic characteristics are reported in Table II.

Discussion

Our findings demonstrate that FFR-guided PCI of intermediate stenosis in bypass grafts is safe and results in a better clinical outcome as compared with an angio-guided PCI. This clinical benefit was more pronounced in arterial grafts, whereas it was limited to a reduced incidence of PMI in SVGs. In addition, a significant overall reduction in procedural costs has also been observed.

Conclusions

An FFR-guided revascularization strategy in CABGs is safe and results in better clinical outcomes as compared with an angio-guided strategy in arterial grafts. In SVGs, the FFR-guided strategy was associated with a significant reduction in PCI rate and procedural-related MI, with no excess risk up to 4-year clinical follow-up. This clinical benefit is achieved with a significant overall reduction in procedural costs.

Disclosures

None.

References (29)

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