PCI of Native Coronary Artery versus Saphenous Vein Graft After Prior Bypass Surgery: A Multicenter, Randomized Trial (PROCTOR) (JACC January 2026-2)-PCI of Native Coronary Artery versus Saphenous Vein Graft After Prior Article: Bypass Surgery: A Multicenter, Randomized Trial (PROCTOR)

PCI of Native Coronary Artery versus Saphenous Vein Graft After Prior Article: Bypass Surgery: A Multicenter, Randomized Trial (PROCTOR)

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The PROCTOR trial is the first multicenter, randomized study comparing clinical outcomes of percutaneous coronary intervention (PCI) on native coronary arteries versus saphenous vein grafts (SVGs) in patients with prior coronary artery bypass grafting (CABG) presenting with SVG failure. Current guidelines favor native vessel PCI over SVG PCI based on observational evidence, yet randomized data were lacking.<br /><br />The trial enrolled 220 patients (mean age 73, 84% male) across 14 European centers between 2019 and 2023. Eligible patients had significant SVG stenosis and a heart team–defined indication for revascularization, with both native vessel and SVG deemed technically feasible for PCI. Patients were randomized 1:1 to native vessel PCI or SVG PCI. The primary endpoint was major adverse cardiac events (MACE) at 1 year, defined as the composite of all-cause mortality, nonfatal target coronary territory myocardial infarction (MI), or clinically driven target coronary territory revascularization.<br /><br />The native vessel PCI group had a higher prevalence of chronic total occlusions (CTOs) (83%) compared with SVG PCI. Native vessel PCI involved longer stent length, more stents, longer fluoroscopy time, and higher contrast volume. At 1 year, the SVG PCI group showed significantly better outcomes, with MACE rates of 19% versus 34% in native vessel PCI (hazard ratio [HR] 2.14; P=0.006). This was primarily driven by higher rates of PCI-related MI (13% vs 1%; HR 14.85; P=0.009) and target territory revascularization (18% vs 9%; HR 2.19; P=0.044) in the native vessel group. All-cause mortality rates were not significantly different (6% vs 4%).<br /><br />These findings challenge previous observational studies that favored native vessel PCI, potentially due to selection bias and lower CTO prevalence in those datasets. The complexity and procedural risk of native vessel PCI, especially with CTO lesions, likely contributed to more periprocedural MI and repeat interventions. The study emphasizes that when both strategies are technically feasible, SVG PCI may offer superior 1-year clinical outcomes.<br /><br />Limitations include early termination with a smaller sample size than planned, exclusion of high-risk SVG lesions, open-label design, and limited power to detect mortality differences. Longer-term follow-up at 3 and 5 years is ongoing to assess durability given SVG disease’s progressive nature.<br /><br />In conclusion, for post-CABG patients with significant SVG disease and feasible PCI options, the PROCTOR trial supports an SVG PCI strategy over native vessel PCI at 1 year, with lower major adverse cardiac events and fewer periprocedural complications. These results may influence guideline recommendations and clinical decision-making but require confirmation with longer follow-up.

Keywords

PROCTOR trial

percutaneous coronary intervention

PCI

native coronary arteries

saphenous vein grafts

SVG failure

coronary artery bypass grafting

CABG

major adverse cardiac events

randomized clinical trial