Comparison of First- and Second-Generation Drug-Eluting Stents in Saphenous Vein Grafts Used as Aorto-Coronary Conduits Charis Costopoulos, MD a,b,c , Azeem Latib, MD a,b , Toru Naganuma, MD a,b , Alessandro Sticchi, MD a , Alaide Chieffo, MD a , Filippo Figini, MD a , Mauro Carlino, MD a , Matteo Montorfano, MD a , Charbel Naim, MD a , Masanori Kawaguchi, MD a,b , Francesco Giannini, MD a , and Antonio Colombo, MD a,b, * Saphenous vein grafts (SVGs) are prone to an aggressive atherosclerotic process, and the efficacy of drug-eluting stents (DES) in treating this is still debated. In recent years, second- generation DES have been increasingly used in SVG intervention. The main objective of this study was to compare midterm clinical outcomes between first- and second-generation DES in SVGs because data regarding the use of second-generation DES in SVG are lacking. Patients treated with first-generation DES (127 patients with 143 lesions) and those treated with second-generation DES (84 patients with 100 lesions) were included in the study. Major adverse cardiac events, defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization, as well as target vessel revascularization and target lesion revascularization separately, were evaluated at 30-day, 12-month, and 18-month follow-up. Baseline characteristics were similar between the 2 groups. Older grafts were treated with second-generation DES (11.6 – 5.3 vs 14.3 – 6.0 years, p [ 0.001). Stent length was longer in the first-generation group (34.1 – 25.1 vs 30.5 – 19.4 mm, p [ 0.006), and maximum balloon diameter was smaller in the second-generation group (3.42 – 0.42 vs 3.30 – 0.41 mm, p [ 0.003). Embolic protection device use was higher in the second-generation DES group (55.2% vs 72.0%, p [ 0.012). At 18-month follow-up, rates of major adverse cardiac events, target vessel revascularization, and target lesion revascularization for the first- and second-gener- ation groups were 24.4% versus 20.2% (p [ 0.479), 18.1% versus 14.2% (p [ 0.465), and 15.0% versus 10.7% (p [ 0.373), respectively. In conclusion, second-generation DES are at least comparable with first-generation DES with regard to clinical outcomes at midterm follow-up. Ó 2013 Elsevier Inc. All rights reserved. (Am J Cardiol 2013;112:318e322) Saphenous vein grafts (SVG) are the most common type of graft used in coronary artery bypass graft surgery. Graft attrition rate, however, is high, at 15% at 1 year and up to 45% at 5 years, and with the risks of repeat surgery not being negligible, percutaneous coronary intervention (PCI) is the preferred treatment when revascularization is indicated. 1 SVG interventions represent 6% to 15% of all PCIs, a figure that may increase given some evidence that SVG stenoses of 30% to 60% may benefit from stent implantation. 2e5 Small, randomized trials and subsequent meta-analyses comparing drug-eluting stents (DES) to bare-metal stents (BMS) in SVG PCI have favored the use of DES in this setting. 6e11 In the largest randomized trial, Is Drug-Eluting Stenting Associated With Improved Results in Coronary Artery Bypass Grafts? (ISAR-CABG), DES were found to be superior to BMS with regard to major adverse cardiac events (MACEs) and ischemia-driven target lesion revascularization (TLR) and target vessel revascularization (TVR). 11 However, other smaller trials failed to show similar benefits. 12 A previous study by our group comparing clinical outcomes at 2 years in patients with SVG PCI with either BMS or first-generation DES suggested that the latter were associated with reduced revascularization rates. 13 In recent years and with the evolution of stent technology, newer generation DES have been used for the treatment of SVG disease. To date, however, there are no published data, to our knowledge, with regard to their safety and efficacy at short-term and midterm follow-up. Here, we report and compare short-term and midterm clinical outcomes in patients who underwent SVG PCI with either first- or second-generation DES at 2 high- volume centers in Milan, Italy. Methods All consecutive patients successfully treated with pacli- taxel-eluting stents or sirolimus-eluting stents from April 2002 to March 2006, as well as consecutive patients suc- cessfully treated with either everolimus-eluting or zotar- olimus-eluting stents from January 2005 to April 2011 in whom 18-month follow-up was available were included in the study. We thus identified 127 consecutive patients (with 143 lesions) who underwent percutaneous revascularization of SVG lesions with first-generation DES (the first-generation DES group) and 84 consecutive patients (with 100 lesions) a Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; b Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy; and c Department of Cardiology, Imperial College London, London, United Kingdom. Manuscript received February 5, 2013; revised manuscript received and accepted March 16, 2013. See page 322 for disclosure information. *Corresponding author: Tel: 39-024812920; fax: 39-0248193433. E-mail address: info@emocolumbus.it (A. Colombo). 0002-9149/13/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. www.ajconline.org http://dx.doi.org/10.1016/j.amjcard.2013.03.033