Lack of Benefit From Intravenous Platelet Glycoprotein IIb/IIIa Receptor Inhibition as Adjunctive Treatment for Percutaneous Interventions of Aortocoronary Bypass Grafts

Abstract

Background-Despite widespread use of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors for percutaneous coronary interventions (PCI) of bypass grafts, data supporting this strategy are lacking. Methods and Results-A pooled analysis of 5 randomized intravenous GP IIb/IIIa inhibitor trials (EPIC, EPILOG, EPISTENT, IMPACT II, and PURSUIT) was performed, and outcomes of graft interventions were assessed at 30 days and 6 months. Compared with PCI of native circulation (nϭ13 158), graft interventions (nϭ627) were associated with worse outcomes and in particular with a doubling of mortality at 30 days (2.1% versus 1.0%, Pϭ0.006) and 6 months (4.7% versus 2.0%, PϽ0.001). Revascularization of a graft was identified as an independent predictor of death, myocardial infarction, or revascularization at 6 months (hazard ratio, 1.42; 95% CI, 1.24 to 1.63; PϽ0.001). Among patients undergoing graft PCI, the incidence of the triple end point at 30 days was 16.5% in the platelet GP IIb/IIIa inhibitor group and 12.6% in the placebo group (odds ratio, 1.38; 95% CI, 0.85 to 2.24; Pϭ0.18). At 6 months, 39.4% of patients randomized to GP IIb/IIIa inhibitors and 32.7% of patients allocated to placebo had an ischemic event (hazard ratio, 1.29; 95% CI, 0.97 to 1.72; Pϭ0.07). Conclusions-Intravenous platelet GP IIb/IIIa receptor inhibition does not improve outcomes after PCI of bypass grafts.In the absence of mechanical emboli protection, this procedure is associated with high incidence of death and nonfatal ischemic events. (Circulation. 2002;106:3063-3067.)

Guidelines on myocardial revascularization

“…PCI of de novo SVG stenosis is considered a high-risk intervention because SVG atheroma is friable and more prone to distal embolization. A pooled analysis of five RCTs shows that GPIIb IIIa inhibitors are less effective for SVG PCI than for PCI of native vessels [212]. Many different approaches have been evaluated to prevent distal embolization of particulate debris, including distal blocking/aspirating, proximal blocking, suction, filtering, or mesh-based devices [171].…”

The Effect of Tirofiban and Clopidogrel Pretreatment on Outcome of Old Saphenous Vein Graft Stenting in Patients with Acute Coronary Syndromes

“…Although initial experience with GPIIb/IIIa antagonists in PCI of vein grafts was encouraging, a meta-analysis revealed that adjunctive GPIIb/ IIIa antagonist therapy including abciximab or eptifibatide have failed to improve the outcome of percutaneous bypass graft interventions. Besides, it was also associated with higher incidence of major bleedings (6.8% vs 1.4% in placebo) and minor bleedings (14.9% vs 8.1% in placebo) (Roffi et al 2002). In our study, the PCI was performed after two days of tirofiban administration; however in the aforementioned meta-analysis, abciximab or eptifibatide were used during the PCI procedure.…”

Embolic Protection Devices

“…In addition, the routine use of glycoprotein IIb/IIIa receptor blockers during PCI of SVG has not been shown to be beneficial at reducing major adverse cardiac events. 21,22 Intracoronary calcium channel blockers, adenosine, and nitroprusside are commonly used to treat the no-reflow phenomenon caused by distal embolization but have not been shown to prevent embolization per se.…”