Native Coronary Artery Research Articles

Interventions in Left Internal Mammary Artery

Left internal mammary artery (LIMA) grafts are the preferred arterial grafts as they are more durable. LIMA grafts can develop stenosis most commonly at the distal anastomotic site and less frequently involve the ostium or body of LIMA. They may occur in the immediate post-operative period due to technical faults or occur several years later. LIMA graft interventions are more challenging because of its long and tortuous course and frequently tend to develop spasm and dissection. It might be the only method of revascularization in some patients and needs to be undertaken on and off. LIMA grafts have been used for retrograde revascularization of chronic total occlusion of native coronary arteries.

For patients with prior coronary artery bypass grafting and recurrent myocardial ischemia, percutaneous coronary intervention on bypass graft or native coronary artery?-A 5-year follow-up cohort study.

Real-world data on target vessel of percutaneous coronary intervention (PCI) for patients with prior coronary artery bypass grafting (CABG) was still limited. A prospective cohort was examined to determine the frequency and outcomes of native coronary artery PCI versus bypass graft PCI in patients with prior CABG. A large-sample observational study enrolled a total of 10 724 patients with coronary artery disease (CAD) underwent PCI in 2013. Two- and five-year clinical outcomes were compared between graft PCI group and native artery PCI group in patients with prior CABG. A total of 438 cases had CABG history in the total cohort. Graft PCI group and native artery PCI group accounted for 13.7% and 86.3%, respectively. The rates of 2- and 5-year all-cause death and major adverse cardiovascular and cerebral events (MACCE) showed no significant difference between the two groups (p > .05). Two-year revascularization risk was lower in graft PCI group than native artery PCI group (3.3% and 12.4%, p < .05), but 5-year myocardial infarction (MI) risk was higher (13.3% and 5.0%, p < .05). In multivariate COX regression models, graft PCI group was independently associated with lower 2-year revascularization risk (hazard ratio [HR]: 0.21; 95% confidence interval [CI]: 0.05-0.88; p = .033), but higher 5-year MI risk than native artery PCI group (HR: 2.61; 95% CI: 1.03-6.57; p = .042). Five-year all-cause death and MACCE risk showed no difference between the two groups in model. In patients with prior CABG underwent PCI, patients in graft PCI group had higher 5-year MI risk than patients received native artery PCI. But, 5-year mortality and MACCE was not significantly different between graft PCI group and native artery PCI group.

TCTAP C-012 Using Distal Protection Device in Native Coronary Artery for Treatment of ACS With Heavy Burden of Thrombi

TCTAP C-012 Using Distal Protection Device in Native Coronary Artery for Treatment of ACS With Heavy Burden of Thrombi

Diffuse refractory coronary artery spasm after off-pump coronary artery bypass grafting: a case series

BackgroundDiffuse coronary artery spasm after coronary artery bypass grafting may cause disastrous circulatory collapse and death if not detected and managed promptly.Case presentationFour out of 387 patients who underwent uneventful off-pump coronary artery bypass grafting between January 2019 and December 2021 at our centre developed unexplained arrhythmias and hypotension within 2 to 6 h of the postoperative period. Coronary angiogram showed diffuse coronary vasospasm involving both grafted and ungrafted native coronary arteries. Vasospasm was refractory to intracoronary vasodilators in all these cases. All of the patients recovered completely with the use of intravenous verapamil infusion and intraaortic balloon pump support.ConclusionsCoronary artery spasm should remain in the differential diagnosis in patients developing unexplained arrhythmias and haemodynamic instability following coronary artery bypass grafting. Prompt diagnosis with coronary angiogram and proper management strategy using calcium channel blockers and intraaortic balloon pump can revert this deadly complication. Surgical intervention may delay precious time needed for therapeutic intervention.

Therapeutic angiogenesis as an advanced direction for potentiating the angiogenic effect of coronary artery bypass grafting

Highlights. This review systematizes the results of experimental and clinical studies on the impact of coronary artery bypass grafting on angiogenesis and potential use of pyrimidine derivatives for therapeutic angiogenesis.Abstract. Coronary artery bypass grafting is the preferred treatment modality for multivessel coronary artery disease. However, the clinical efficacy of the procedure decreases over time due to the progression of atherosclerosis in the bypass grafts and native coronary arteries. In this regard, it is of great scientific and practical interest to disclose the mechanisms affecting the development of the microvasculature during myocardial surgical revascularization, as well as the search for pharmacological substances capable of stimulating the process of angiogenesis during these surgeries to improve short and long-term outcomes. The article presents a review of experimental and clinical studies on the effect of coronary artery bypass surgery on angiogenesis and highlights the place of pyrimidine derivatives in therapeutic angiogenesis in coronary artery disease.

Medical Therapy After CABG: the Known Knowns, the Known Unknowns, and the Unknown Unknowns.

Medical therapies play a central role in secondary prevention after surgical revascularization. While coronary artery bypass grafting is the most definitive treatment for ischemic heart disease, progression of atherosclerotic disease in native coronary arteries and bypass grafts result in recurrent adverse ischemic events. The aim of this review is to summarize the recent evidence regarding current therapies in secondary prevention of adverse cardiovascular outcomes after CABG and review the existing recommendations as they pertain to the CABG subpopulations. There are many pharmacologic interventions recommended for secondary prevention in patients after coronary artery bypass grafting. Most of these recommendations are based on secondary outcomes from trials which include but did not focus on surgical patients as a cohort. Even those designed with CABG in mind lack the technical and demographic scope to provide universal recommendations for all CABG patients. Recommendations for medical therapy after surgical revascularization are chiefly based on large-scale randomized controlled trials and meta-analyses. Much of what is known about medical management after surgical revascularization results from trials comparing surgical to non-surgical approaches and important characteristics of the operative patients are omitted. These omissions create a group of patients who are relatively heterogenous making solid recommendations elusive. While advances in pharmacologic therapies are clearly adding to the armamentarium of options for secondary prevention, knowing what patients benefit most from each therapeutic option remains challenging and a personalized approach is still required.

Stent expansion evaluated by optical coherence tomography and subsequent outcomes

Regarding stent expansion indices, previous optical coherence tomography (OCT) studies have shown minimal stent area (MSA) to be most predictive of adverse events. We sought to evaluate the impact of various stent expansion and apposition indices by post-stent OCT on clinical outcomes and find OCT-defined optimal stent implantation criteria. A total of 1071 patients with 1123 native coronary artery lesions treated with new-generation drug-eluting stents with OCT guidance and final post-stent OCT analysis were included. Several stent expansion indices (MSA, MSA/average reference lumen area, MSA/distal reference lumen area, mean stent expansion, and stent expansion by linear model [stent volume/adaptive reference lumen volume]) were evaluated for their association with device-oriented clinical endpoints (DoCE) including cardiac death, target vessel-related myocardial infarction (MI) or stent thrombosis, and target lesion revascularization. MSA was negatively correlated with the risk of DoCE (hazard ratio [HR] 0.80 [0.68‒0.94]). However, stent expansion by linear model representing the overall volumetric stent expansion was associated with greater risk of DoCE (HR 1.02 [1.00‒1.04]). As categorical criteria, MSA < 5.0 mm2 (HR 3.90 [1.99‒7.65]), MSA/distal reference lumen area < 90% (HR 2.16 [1.12‒4.19]), and stent expansion by linear model ≥ 65.0% (HR 1.95 [1.03‒3.89]) were independently associated with DoCE. This OCT study highlights the importance of sufficient stent expansion to achieve adequate, absolute, and relative MSA criteria for improving clinical outcome. It also emphasises that overall volumetric excessive stent expansion may have detrimental effects.

Patient-specific computational simulation of coronary artery bypass grafting.

Coronary artery bypass graft surgery (CABG) is an intervention in patients with extensive obstructive coronary artery disease diagnosed with invasive coronary angiography. Here we present and test a novel application of non-invasive computational assessment of coronary hemodynamics before and after bypass grafting. We tested the computational CABG platform in n = 2 post-CABG patients. The computationally calculated fractional flow reserve showed high agreement with the angiography-based fractional flow reserve. Furthermore, we performed multiscale computational fluid dynamics simulations of pre- and post-CABG under simulated resting and hyperemic conditions in n = 2 patient-specific anatomies 3D reconstructed from coronary computed tomography angiography. We computationally created different degrees of stenosis in the left anterior descending artery, and we showed that increasing severity of native artery stenosis resulted in augmented flow through the graft and improvement of resting and hyperemic flow in the distal part of the grafted native artery. We presented a comprehensive patient-specific computational platform that can simulate the hemodynamic conditions before and after CABG and faithfully reproduce the hemodynamic effects of bypass grafting on the native coronary artery flow. Further clinical studies are warranted to validate this preliminary data.

Serial quantitative angiographic study of target lumen enlargement after drug-coated balloon angioplasty for native coronary artery disease.

Target lumen enlargement (TLE) or "late lumen enlargement" is often encountered after percutaneous coronary intervention (PCI) with drug-coated balloons (DCB). To date, the prognosis of coronary arterial lesions with or without TLE has not been clearly elucidated. This study aimed to assess the long-term prognosis of coronary arterial lesions with or without TLE observed within 1 year (early TLE) after DCB angioplasty using serial quantitative angiographic follow-up. One hundred and ninety-three consecutive patients (de novo coronary arterial lesions, 251) who underwent follow-up angiography within 1 year after DCB angioplasty (early follow-up, median: 6 months) were retrospectively evaluated. Of these, 97 patients (125 lesions) also underwent angiography more than 1 year after DCB angioplasty (late follow-up, median: 37 months). TLE was defined as an increase in minimal lumen diameter (MLD) after PCI at each follow-up. Early TLE was detected in 142 lesions (56.6%). Of these, 76 lesions were also evaluated at late follow-up. TLE persisted even at late follow-up in 67 of the 76 lesions (88.2%). An increase in MLD in early TLE (+) lesions was observed in the period between post-PCI and early follow-up (1.84 ± 0.06 vs. 2.12 ± 0.07 mm, p < 0.001) but not between early and late follow-up (2.12 ± 0.07 vs. 2.16 ± 0.07 mm, p = 0.74). In contrast, 49 of 109 lesions without early TLE were evaluated at late follow-up, of which 28 lesions (57.1%) showed TLE at late follow-up. The MLD of early TLE (-) lesions (n = 49) significantly increased from early (1.63 ± 0.061 mm) to late follow-up (1.84 ± 0.06 mm) (p < 0.001). No aneurysms were found in any of these cases. Early TLE was observed in more than half of the lesions, with the majority remaining at late follow-up. Alternatively, half of the lesions without early TLE showed late TLE, occurring biphasically after DCB angioplasty.

Outcomes After Early Postoperative Myocardial Infarction Due to Graft Failure in Patients Undergoing Coronary Artery Bypass Grafting.

Early graft failure (EGF) after coronary artery bypass grafting (CABG) occurs in up to 12% of grafts, but is often clinically unapparent. EGF may result in perioperative myocardial infarction with consequently increased mortality. The aim of the present study was to analyze the incidence of clinically apparent EGF in patients undergoing CABG and the influence on mortality. We analyzed outcomes of consecutive patients undergoing CABG from January 2015 to December 2018 with respect to postoperative emergency coronary angiography (CAG) due to suspected EGF and 30-day mortality. Patients with CAG-documented EGF were matched to patients without EGF to examine predictors of mortality. The analysis included 5638 patients undergoing CABG. Eighty-six patients (1.5%) underwent emergency CAG due to suspected EGF. Clinically apparent EGF was observed in 61 of these patients (70.9%), whereas 14 (16.3%) had a culprit lesion in a native coronary artery. The majority of patients (n = 45; 52.3%) were treated with percutaneous coronary intervention and 31 (36%) underwent re-do CABG. The remaining patients were treated conservatively. The 30-day mortality rate of suspected EGF patients undergoing CAG was 22.4% (n = 19), which was higher than the mortality rate of 2.8% overall (P<.001); this remained higher after matching the EGF patients with the control group (11 [20.4%] vs 2 [4.0%]; P=.02). Emergency CAG after CABG is rare and is primarily carried out in patients with EGF. The 30-day mortality rate of these patients is high, and EGF is an independent predictor of mortality. Perioperative CAG with subsequent treatment is mandatory in these patients.

Left internal thoracic artery bypass graft.

A 77-year-old man presented with chest discomfort on exertion for several weeks. Thirty-one years prior, he had performed on-pump coronary artery bypass grafting (CABG) using the pedicled left internal thoracic artery (LITA) to left anterior descending artery (LAD) and saphenous vein grafts (SVGs). The SVGs to the left circumflex artery had already occluded and to the right coronary artery (RCA) had previously required percutaneous coronary intervention (PCI). Although an electrocardiogram showed no remarkable change and echocardiography showed findings of known old posterior myocardial infarction, single-photon emission computed tomography demonstrated new inferior myocardial ischemia. Coronary angiography showed occlusion of all native coronary artery and severe stenosis of the residual SVG to RCA. On the other hand, the 31-year-old LITA graft revealed excellent patency (Panel and Supplementary material online, Video). Since the 1980s, the LITA for LAD grafting has been a cornerstone of CABG surgery.1 The European Society of Cardiology guideline recommends grafting with internal thoracic artery to the LAD as Class I.2 Furthermore, LITA graft had better patency than SVG for 20 years post-operatively.3 This case showed the over 30 years patency of LITA graft, although the use of a pump or the harvesting method might affect patency. This case indicated that it is precisely in patients less than 50 years of age scheduled for CABG that LITA to the LAD should be utilized.

Clinical Safety and Efficacy of New-Generation Single-Layer Polytetrafluorethylene Covered Coronary Stents

BackgroundEarly-generation “sandwich-design” polytetrafluorethylene (PTFE) covered coronary stents (CS) are associated with a high frequency of adverse events. New-generation single layer PTFE-CS offers the potential to enhanced procedural efficacy and improves clinical safety. Data from a dedicated study, concerning outcomes after treatment with single-layer PTFE-CS in patients undergoing percutaneous coronary intervention are scant. MethodsThis is a retrospective multicenter registry including 30 patients undergoing implantation of 39 single-layer PTFE-CS (BeGraft-coronary Stent Graft System, Bentley InnoMed GmbH, Hechingen, Germany) in native coronary arteries or saphenous bypass grafts, in 3 centers in Europe, between May 2013 and May 2019. Endpoints of interest were procedural success (placement of covered stent), binary-angiographic restenosis (BAR), percent diameter stenosis (% DS) and late-lumen loss at 6–8 months follow-up angiography, rates of target lesion revascularization (TLR), myocardial infarction (MI), stent thrombosis (ST) and mortality at 12 months. Results28 patients underwent implantation of 37 CS due to coronary artery perforation 2 patients due to coronary artery aneurysm. Technical success was achieved in all patients (100 %). More than one stent was implanted in 7 patients (25 %) all in the perforation group. Follow-up angiography was available in 23 patients (77 %) showing favorable results: BAR = 21.8 %, %DS = 30.3 ± 27.5; LLL = 0.16 ± 0.81 mm. At 12 months all patients were alive, rates of TLR were low (3 patients, 10.0 %), there was one case of late stent thrombosis (3.3 %) and one MI (3.3 %). ConclusionsIn this dedicated study, implantation of a new single layer PTFE-CS for the treatment of native coronary arteries or saphenous vein grafts after perforation or due to aneurysm showed high technical success rates and favorable angiographic and clinical efficacy. Clinical safety outcomes are encouraging, but larger prospective studies are needed to determine long-term safety of this device.

Personalized surgical planning for coronary bypass graft configurations using patient-specific computational modeling to avoid flow competition in arterial grafts.

Flow competition between coronary artery bypass grafts (CABG) and native coronary arteries is a significant problem affecting arterial graft patency. The objectives of this study were to compare the predictive hemodynamic flow resulting from various total arterial grafting configurations and to evaluate whether the use of computational fluid dynamics (CFD) models capable of predicting flow can assist surgeons to make better decisions for individual patients by avoiding poorly functioning grafts. Sixteen cardiac surgeons declared their preferred CABG configuration using bilateral internal mammary and radial arteries for each of 5 patients who had differing degrees of severe triple vessel coronary disease. Surgeons selected both a preferred 'aortic' strategy, with at least one graft arising from the ascending aorta, and a preferred "anaortic" strategy which could be performed as a "no-aortic touch" operation. CT coronary angiograms of the 5 patients were coupled to CFD models using a novel flow solver "COMCAB." Twelve different CABG configurations were compared for each patient of which 4 were "aortic" and 8 were "anaortic." Surgeons then selected their preferred grafting configurations after being shown predictive hemodynamic metrics including functional assessment of stenoses (instantaneous wave-free ratio; fractional flow reserve), transit time flowmetry graft parameters (mean graft flow; pulsatility index) and myocardial perfusion. A total of 87.5% (7/8) of "anaortic" configurations compared to 25% (1/4) of "aortic" configurations led to unsatisfactory grafts in at least 1 of the 5 patients (P = 0.038). The use of the computational models led to a significant decrease in the selection of unsatisfactory grafting configurations when surgeons employed "anaortic" (21.25% (17/80) vs. 1.25% (1/80), P < 0.001) but not "aortic" techniques (5% (4/80) vs. 0% (0/80), P = 0.64). Similarly, there was an increase in the selection of ideal configurations for "anaortic" (6.25% (5/80) vs. 28.75% (23/80), P < 0.001) but not "aortic" techniques (65% (52/80) vs. 61.25% (49/80), P = 0.74). Furthermore, surgeons who planned to use more than one unique "anaortic" configuration across all 5 patients increased (12.5% (2/16) vs. 87.5% (14/16), P<0.001). "COMCAB" is a promising tool to improve personalized surgical planning particularly for CABG configurations involving composite or sequential grafts which are used more frequently in anaortic operations.

Optical coherence tomography as a method for assessing the conduit-anastomosis-artery system in patients after coronary artery bypass grafting

Background. Coronary artery bypass grafting (CABG) remains the most common cardiac surgery in the world. In the long-term follow-up period after surgery, graft failure occurs in a substantial proportion of CABG conduits and is a complex pathomorphological process. Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality that allows to assess in-vivo endothelial integrity.Aim. To substantiate the efficacy and safety of OCT assessment of the conduitanastomosis-artery system in CABG patients.Methods. The prospective observational cohort study included 21 patients with chronic coronary artery disease who underwent CABG. 3–5 days after CABG, patients underwent OCT and angiography of arterial and vein grafts, including distal anastomosis and nearby segment of the target coronary artery. At 12-month follow-up, all patients underwent repeated OCT and angiography of the conduitanastomosis-artery system to assess the changes. The primary endpoint of the study was graft failure; secondary endpoints of the study included unplanned repeat myocardial revascularization, cardiac death, and myocardial infarction due to graft failure.Results. At 12-month follow-up, 14.3% of graft failure and 9.5% of cases of unplanned repeated myocardial revascularization were registered. In most cases of graft failure, primary OCT revealed pronounced changes in the conduit and the native coronary artery (conduit/artery diameter ratio was more than 2 mm), whereas the diameter of the coronary artery anastomosis was less than 2.5 mm. Myocardial infarctions and death within 12 months were not registered.Conclusion. Thus, OCT is an effective and safe intravascular imaging technique for assessing coronary arteries and the conduit-anastomosis-artery system. OCT makes it possible to identify morphological changes in coronary bypass grafts, which can predict their early failure. The conduit/artery diameter ratio greater than 2 and target coronary artery diameter less than 2.5 mm was associated with graft failure within 12 months after CABG.

Coronary Sparing Aneurysmectomy

AbstractRepairing left ventricular aneurysms that form after myocardial infarction may be challenging, especially if located close to the important native coronary arteries. Here, we describe a rare case of anterolateral aneurysm of the basal LV wall and a safe, efficient approach for a patch plasty sparing the native left anterior descending.

Anomalous Aortic Origin of the Right Coronary Artery: A Case Report and Review of the Literature.

Various surgical methods are available for the management of anomalous aortic origin of the right coronary artery (AAORCA), preferably unroofing when the intramural segment can be identified.Hypoplasia of the proximal segment, an acute take-off angle, and close proximity to the intercoronary pillar or commissure are limitations to unroofing, and alternative approaches are more appropriate.Coronary artery bypass graft, with either arterial or venous graft, can be performed when unroofing and reimplantation are not feasible. Measuring the distal anastomosis flow may help with a decision regarding native coronary artery ligation. It remains undetermined whether arterial or venous grafts provide superior outcomes.

459 PREOPERATIVE ANGIOGRAPHY-DERIVED FRACTIONAL FLOW RESERVE MAY PREDICT BYPASS GRAFT OCCLUSION AND DISEASE PROGRESSION AT MID-TERM FOLLOW-UP

Abstract Background Coronary artery bypass grafting (CABG) is the most common revascularization mode for patients with multivessel coronary artery disease (CAD). Despite substantial improvements in the outcome of patients undergoing CABG surgery, graft occlusion remains a weakness of this procedure and has been associated with competitive flow of native coronary arteries. Our study aims to assess graft occlusion and the progression of CAD in native vessels after CABG surgery at follow-up with coronary CT angiography (CCTA), and their relationship with angiography-derived vessel-fractional flow reserve (vFFR) performed before surgery. Methods We retrospectively selected patients from two European institutions, treated with CABG between January 2006 and December 2018, who underwent follow-up with CCTA. All patients had a preoperative angiogram performed before CABG. Results In 171 consecutive patients, serial preoperative angiograms were suitable for vFFR analysis of 298 grafted and 59 non-grafted vessels. Table 1 shows clinical and main procedural characteristics. Preoperative vFFR was assessed in 131 left anterior descending arteries (LAD), 132 left circumflex arteries (LCX) and 94 right coronary arteries (RCA) and was &amp;lt;0.80 in 255 of 298 bypassed vessels. Graft occlusion was observed at CCTA in 28 of 298 grafts. The median preoperative vFFR value of native coronaries was higher in occluded compared to patent grafts (0.75 vs. 0.60, p&amp;lt;0.001) (Figure 1) and was associated with graft type. The best vFFR cut-off to predict graft occlusion was 0.67. The functional CAD progression was higher in grafted compared to non-grafted vessels (89.6% vs 47.5% p &amp;lt; 0.001) and pre-CABG vFFR predicted disease progression of grafted native vessels (AUC=0.83) (Figure 2). Conclusions Preoperative vFFR derived from invasive coronary angiography was able to predict graft occlusion and CAD progression of grafted coronary arteries.

A novel technique of proximal optimization with kissing balloon inflation in bifurcation lesions.

Percutaneous coronary interventions (PCI) of bifurcation lesions poses a technical challenge with a high complication rate. Kissing balloon inflation (KBI) and proximal optimization technique (POT) are used to correct bifurcation carina after stenting. However, both may still lead to uncomplete strut apposition to the side branch (SB) lateral wall. Proposed herein, is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and KBI called proximal optimization with kissing balloon inflation (POKI). Bench and in-vivo evaluations were performed. For the bench visualization bifurcated silicone mock vessel was used. The POKI technique was simulated using a 3.5 mm POT balloon. For the in-vivo evaluation patients with angiographic bifurcation lesions in a native coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm, SB diameter ≥ 2.0 mm, and percentage diameter stenosis (%DS) more than 50% in the main vessel (MV) were included. Provisional stenting was the default strategy. In total 41 vessels were evaluated. The target vessel was left main in 9 (22.0%) patients, left anterior descending artery - in 26 (63.4%), left circumflex artery - in 4 (9.8%) and right coronary artery - in 2 (4.9%). The predominant type of bifurcation was Medina 1-1-1 (61.8%). Baseline proximal MV DS% was 60.0 ± 23.7%, distal MV DS% - 58.8 ± 28.9% and SB DS% 53.0 ± 32.0%. The application of POKI was feasible in 41 (100%) of the vessels. Post-PCI residual DS at proximal MV was 11.5 ± 15.4%, distal MV - 6.6 ± 9.3%, and SB - 22.9 ± 28.5%. Both procedural and angiographic success was 100%. POKI is a novel stent-optimization technique for bifurcation lesions. It showed excellent feasibility and success rate both in bench and in-vivo evaluation.

Reply from authors: Sutureless valves-expanding the surgeon's toolbox.

Reply from authors: Sutureless valves-expanding the surgeon's toolbox.

Percutaneous coronary intervention of native coronary artery versus saphenous vein graft in patients with prior coronary artery bypass graft surgery: Rationale and design of the multicenter, randomized PROCTOR trial

Patients with prior coronary artery bypass grafting (CABG) frequently require repeat percutaneous revascularization due to advanced age, progressive coronary artery disease and bypass graft failure. Percutaneous coronary intervention (PCI) of either the bypass graft or the native coronary artery may be performed. Randomized trials comparing native vessel PCI with bypass graft PCI are lacking and long-term outcomes have not been reported. PROCTOR (NCT03805048) is a prospective, multicenter, randomized controlled trial, that will include 584 patients presenting with saphenous vein graft (SVG) failure and a clinical indication for revascularization, as determined by the local Heart Team. The trial is designed to compare the clinical and angiographic outcomes in patients randomly allocated in a 1:1 fashion to either a strategy of native vessel PCI or SVG PCI. The primary study endpoint is a 3-year composite of major adverse cardiac events (MACE: all-cause mortality, non-fatal target coronary territory myocardial infarction [MI], or clinically driven target coronary territory revascularization). At 3-years, after evaluation of the primary endpoint, follow-up invasive coronary angiography will be performed. Secondary endpoints comprise individual components of MACE at 1, 3 and 5 years follow-up, PCI-related MI, MI >48 hours after index PCI, target vessel failure, target lesion revascularization, renal failure requiring renal-replacement therapy, angiographic outcomes at 3-years and quality of life (delta Seattle Angina Questionnaire, Canadian Cardiovascular Society Grading Scale and Rose Dyspnea Scale). PROCTOR is the first randomized trial comparing an invasive strategy of native coronary artery PCI with SVG PCI in post-CABG patients presenting with SVG failure.