title: Frequency and Predictors of Internal Mammary Artery Graft Failure and Subsequent Clinical Outcomes: Insights From the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV Trial.
abstract: BACKGROUND
  The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking.
  
  
  RESULTS
  The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (≥75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis <75% (odds ratio, 1.76; 95% confidence interval, 1.19-2.59), additional bypass graft to diagonal branch (odds ratio, 1.92; 95% confidence interval, 1.33-2.76), and not having diabetes mellitus (odds ratio, 1.82; 95% confidence interval, 1.20-2.78). LAD stenosis and additional diagonal graft remained predictive of IMA failure in an alternative model that included angiographic failure or death before angiography as the outcome. IMA failure was associated with a significantly higher incidence of subsequent acute (<14 days of angiography) clinical events, mostly as a result of a higher rate of repeat revascularization.
  
  
  CONCLUSIONS
  IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia.
  
  
  BACKGROUND
  URL: http:/www.clinicaltrials.gov. Unique identifier: NCT00042081.
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Ralf E
authors.initials: RE
authors.lastname: Harskamp
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: T Bruce
authors.initials: TB
authors.lastname: Ferguson
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hager
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mack
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Brian
authors.initials: B
authors.lastname: Englum
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Daniel
authors.initials: D
authors.lastname: Wojdyla
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Schulte
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Nicholas T
authors.initials: NT
authors.lastname: Kouchoukos
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Winter
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: C Michael
authors.initials: CM
authors.lastname: Gibson
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.).
authors.forename: Peter K
authors.initials: PK
authors.lastname: Smith
authors.affiliation: From Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (R.E.H., J.H.A., B.E., D.W., P.J.S., E.D.P., P.K.S., R.D.L.); Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands (R.E.H., R.J.d.W.); East Carolina University, Greenville, NC (T.B.F.); North Carolina State University, Raleigh (R.H.); Cardiopulmonary Research Science and Technology Institute, Dallas, TX (M.J.M.); Missouri Baptist Medical Center, St Louis (N.T.K.); PERFUSE Angiographic Laboratory, Boston, MA (C.M.G.); and Department of Medicine, Stanford University, Stanford, CA (R.A.H.). renato.lopes@duke.edu.
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
mesh_terms: D000368:Aged; D006328:Cardiac Catheterization; D002317:Cardiovascular Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D015897:Comorbidity; D017023:Coronary Angiography; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery; D023903:Coronary Restenosis / Q000000981:diagnostic imaging / Q000453:epidemiology; D048909:Diabetes Complications / Q000453:epidemiology / Q000601:surgery; D004311:Double-Blind Method; D005260:Female; D006083:Graft Occlusion, Vascular / Q000453:epidemiology; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000009:adverse effects / Q000706:statistics & numerical data*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000453:epidemiology; D011183:Postoperative Complications / Q000401:mortality; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D017211:Treatment Failure
chemical_list: D002317:Cardiovascular Agents
keywords: coronary artery bypass; mammary arteries