William E. Downey

Poor long-term patient and graft survival after primary percutaneous coronary intervention for acute myocardial infarction due to saphenous vein graft occlusion†

Primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) due to saphenous vein graft (SVG) occlusion has been associated with poor procedural results and poor short‐term outcomes, but long‐term graft patency and patient survival have not been evaluated. Consecutive patients (n = 2,240) with STEMI treated with primary PCI from 1984 to 2003 were followed for 6.6 years (median). Follow‐up angiography was obtained in 80% of hospital survivors following primary PCI for SVG occlusion at 2.3 years (median). Patients with primary PCI for SVG occlusion (n = 57) vs. native artery occlusion had more prior MI, advanced Killip class, and three‐vessel coronary disease and lower acute ejection fraction (EF). Patients with SVG occlusion had lower rates of TIMI 3 flow post‐PCI (80.7% vs. 93.6%; P = 0.0001), higher in‐hospital mortality (21.1% vs. 8.0%; P = 0.0004), and lower follow‐up EF (49.3% vs. 54.7%; P = 0.055). Culprit SVGs were patent in 64% of patients at 1 year and 56% at 5 years. Late survival was strikingly worse in patients with primary PCI for SVG occlusion vs. native vessel occlusion (49% vs. 76% at 10 years), and SVG occlusion was the second strongest predictor of late cardiac mortality by multivariate analysis (HR = 2.11; 95% CI = 1.38–3.23; P = 0.0006). Patients with STEMI due to SVG occlusion treated with primary PCI have poor acute procedural results, frequent late reocclusion, and very high late mortality. The introduction of new adjunctive therapies (distal protection, thrombectomy, and drug‐eluting stents) may improve short‐term outcomes, but improved long‐term outcomes may require new and more durable revascularization strategies.