BACKGROUND In patients with prior coronary artery bypass grafting (CABG) presenting with graft failure, current guidelines recommend percutaneous coronary intervention (PCI) of the bypassed native coronary artery over PCI of the bypass graft. However, this recommendation relies solely on observational data.
OBJECTIVES This study compared clinical outcomes between a strategy of native vessel PCI with saphenous vein graft (SVG) PCI in post-CABG patients presenting with SVG failure.
METHODS The multicenter, randomized PROCTOR (Percutaneous Coronary Intervention of Native Coronary Artery versus Saphenous Vein Graft in Patients with Prior Coronary Artery Bypass Graft Surgery) trial included patients with significant SVG stenosis and a heart team–defined clinical indication for revascularization. Patients were randomly assigned (1:1) to either a strategy of native vessel PCI or SVG PCI using an interactive web-based randomization platform. The trial was conducted across 14 centers in Europe. We report the occurrence of major adverse cardiac events at 1 year following the index PCI, defined as the composite of all-cause mortality, nonfatal target coronary territory myocardial infarction (MI), or clinically driven target coronary territory revascularization, analyzed on an intention-totreat basis. The trial is registered with ClinicalTrials.gov (NCT03805048), and long-term follow-up is ongoing. --
RESULTS Between January 2019 and December 2023, 220 patients (mean age 73 ± 7 years; 84% men [185/220 patients]) were randomized to a strategy of native vessel PCI (n = 108) or SVG PCI (n = 112). At 1 year, major adverse cardiac events occurred in 37 patients (34%) in the native vessel PCI group and 21 patients (19%) in the SVG PCI group (HR: 2.14; 95% CI: 1.25-3.65; P = 0.006). There was no significant difference in all-cause mortality (HR: 1.59; 95% CI: 0.45-5.64; P = 0.472), whereas both nonfatal target coronary territory MI (HR: 2.12; 95% CI: 1.08-4.17; P = 0.029) and clinically driven target coronary territory revascularization (HR: 2.19; 95% CI: 1.02-4.72; P = 0.044) occurred more frequently in patients assigned to native vessel PCI. The incidence of PCI-related MI was 13% in the native vessel PCI group and 1% in the SVG PCI group (HR: 14.85; 95% CI: 1.95-112.96; P = 0.009).
CONCLUSIONS In the randomized PROCTOR trial, SVG PCI was associated with improved 1-year clinical outcomes compared with native vessel PCI, primarily driven by lower rates of PCI-related MI and clinically driven target coronary territory revascularization. (JACC. 2026;87:269–282) © 2026 Published by Elsevier on behalf of the American College of Cardiology Foundation.
Editors
Editor-in-Chief
Harlan M. Krumholz, MD, SM, FACC
CME Editor
Ragavendra R. Baliga, MD
Author
Ioannis Dimarakis, MD, PhD
Important Dates
Date of Release: January 27, 2026
Term of Approval/Date of CME/MOC Expiration: January 26, 2027