Long-term clinical outcome after fractional flow reserve– versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts Luigi Di Serafino, MD, PhD, a Bernard De Bruyne, MD, PhD, a Fabio Mangiacapra, MD, PhD, a Jozef Bartunek, MD, PhD, a Pierfrancesco Agostoni, MD, PhD, b Marc Vanderheyden, MD, PhD, a Gabriella Scognamiglio, MD, a Guy R. Heyndrickx, MD, PhD, a William Wijns, MD, PhD, a and Emanuele Barbato, MD, PhD a Aalst, Belgium; and Utrecht, The Netherlands Background Fractional flow reserve (FFR)–guided percutaneous revascularization (percutaneous coronary intervention [PCI]) of intermediate stenosis in native coronary artery is safe and associated with better clinical outcomes as compared with an angiography-guided PCI. It is unknown whether this applies to coronary artery bypass grafts (CABGs). Methods We included 223 patients with CABG and with stable or unstable angina and an intermediate stenosis involving an arterial or a venous graft. Patients were divided into 2 groups: FFR guided (n = 65, PCI performed in case of FFR ≤0.80) and angio guided (n = 158, PCI performed based on angiographic evaluation). Primary end point was major adverse cardiac and cerebrovascular event, defined as death, myocardial infarction, target vessel failure, and cerebrovascular accident (CVA). Results The 2 groups were similar in terms of demographic and clinical characteristics. Percutaneous coronary intervention was performed in 23 patients (35%) of the FFR-guided group and 90 patients (57%) of the angio-guided group (P b .01). In the FFR-guided group, PCI was more often performed in arterial grafts as compared with the angio-guided group (16 [70%] vs 12 [13%], respectively; P b .01). Follow-up was obtained in 96% of patients at a median of 3.8 years (1.6-4.0 years). At multivariate analysis, major adverse cardiac and cerebrovascular event rate was significantly lower in the FFR- guided group as compared with the angio-guided group (18 [28%] vs 77 [51%], hazard ratio 0.33 [0.11-0.96], P = .043]. Procedure costs were overall reduced in the FFR-guided group (€2240 ± €652 vs €2416 ± €522, P = .03). Conclusions An FFR-guided PCI of intermediate stenosis in bypass grafts is safe and results in better clinical outcomes as compared with an angio-guided PCI. This clinical benefit is achieved with a significant overall reduction in procedural costs. (Am Heart J 2013;166:110-8.) Percutaneous coronary interventions (PCI) in patients with previous coronary artery bypass graft surgery (CABG) are ever increasing in the catheterization laboratory. 1 In fact, PCI of bypass grafts is usually preferred to redo-surgery, 2 although it is associated with higher rates of acute and long-term events as compared with PCI of native vessels. 3 Bypass grafts intervention still represents a challenge because patients are usually older with several comorbidities. 1 Stenoses are usually complex and often thrombotic. 4 In addition, the angiographic evaluation of stenosis severity is more difficult in bypass conduits than in native arteries. Therefore, appropriateness of PCI in bypass grafts is crucial, especially in intermediate equivocal stenosis, to avoid exposing patients to unacceptable higher proce- dural risks without significant clinical benefit. Fractional flow reserve (FFR) guidance of PCI has been adopted in the catheterization laboratory to overcome the limited spatial resolution and poor specificity of noninvasive functional tests, especially in the context of multivessel disease. 5 In addition, an FFR-guided PCI of native coronary stenosis has been associated with an improved long-term clinical outcome. 6-8 In the present From the a Cardiovascular Center Aalst OLV Clinic, Aalst, Belgium, and b Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands. Submitted January 17, 2013; accepted April 17, 2013. Reprint requests: Emanuele Barbato, MD, PhD, Cardiovascular Center Aalst OLV Clinic, Moorselbaan, n. 164, B-9300 Aalst, Belgium. E-mail: emanuele.barbato@olvz-aalst.be 0002-8703/$ - see front matter © 2013, Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ahj.2013.04.007