Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) resulted in lower one-year rates of major adverse cardiovascular events (MACE) compared with PCI of native coronary arteries in patients with prior coronary artery bypass grafting (CABG), according to results from the PROCTOR trial presented by Dr. Ruben W. de Winter of Amsterdam University Medical Centers at TCT 2025 and simultaneously published in JACC.
The PROCTOR trial is the first randomized study to directly compare outcomes between native vessel and SVG PCI in patients requiring repeat revascularization after CABG. Conducted across 14 European centers, the investigator-initiated, open-label trial randomized 220 patients with significant SVG stenosis, where both SVG and native vessel interventions were technically feasible. Participants were assigned 1:1 to SVG PCI (n=112) or native vessel PCI (n=108) and followed for one year.
Patients were elderly (mean age 73 years), predominantly male (84%), and had high rates of hypertension (79%), diabetes (45%), and chronic kidney disease (34%). The median time since CABG was 17 years. Chronic total occlusions were common, affecting over 80% of target native vessels.
The primary endpoint—MACE at one year, defined as all-cause mortality, non-fatal target territory myocardial infarction (MI), or clinically driven target territory revascularization—occurred in 18.7% of the SVG PCI group versus 34.3% of the native vessel PCI group (HR 2.14; 95% CI 1.25–3.65; p=0.004). Both non-fatal target territory MI (11.7% vs. 22.6%; HR 2.12; p=0.024) and repeat revascularization (9.1% vs. 18.4%; HR 2.19; p=0.039) were significantly lower with SVG PCI. Mortality was numerically higher in the native vessel PCI arm (5.6% vs. 3.6%) but not statistically significant (p=0.47).
Procedural success rates were high and comparable (≈93%) between groups, but native vessel PCI required significantly more stents (mean 2.7 vs. 1.3; p<0.001), longer stent length, and greater fluoroscopy time (55 vs. 11 minutes; p<0.001). These findings reflect the higher technical complexity and lesion burden typically encountered in chronically diseased native vessels post-CABG.
Investigators noted that the PROCTOR trial challenges current guideline recommendations, which suggest favoring native vessel PCI when feasible. The one-year results indicate that, in selected patients, SVG PCI may provide superior short-term outcomes with fewer periprocedural complications and lower MACE rates.
The authors acknowledged limitations, including early study termination and the exclusion of high-risk SVGs (with heavy thrombus or aneurysmal degeneration). Longer-term follow-up will clarify whether the early advantage with SVG PCI persists over time.
The PROCTOR trial provides important new evidence to refine revascularization strategies in the growing population of patients with prior CABG undergoing repeat PCI.
Reference: Ruben W. de Winter, PCI of Native Coronary Artery versus Saphenous Vein Graft in Patients with Prior CABG (PROCTOR) a Multicenter, Open-label, Randomized Trial, TCT Conference 2025, San Francisco.
https://www.tctconference.com/
About the Study Presenter: Dr. Ruben W. de Winter is affiliated with Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands.
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