FFR‐guided versus coronary angiogram‐guided CABG: A review and meta‐analysis of prospective randomized controlled trials

Abstract

Background Fractional flow reserve (FFR) is a well‐established method for the evaluation of coronary artery stenosis before percutaneous coronary intervention. However, whether FFR assessment should be routinely used before coronary artery bypass graft surgery (CABG) remains unclear. A meta‐analysis of prospectively randomized controlled trials (PRCTs) was carried out to compare the outcomes of FFR‐guided CABG vs coronary angiography (CAG)‐guided CABG. Method The meta‐analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Two PRCTs (the FARGO and GRAFFITI trials) were found and included reporting data on 269 patients with 6 and 12 month follow‐up. Primary endpoints were rates of overall death, MACCE, target vessel revascularization, and spontaneous myocardial infarction (MI). Secondary endpoints were overall graft patency and patency of arterial and venous grafts. Results There were no significant differences between the FFR‐guided and CAG‐guided groups in the rates of overall death, MACCE, target vessel revascularization, spontaneous MI and graft patency. Meta‐analysis of FARGO and GRAFFITI PRCTs showed that FFR‐guided CABG and CAG‐guided CABG produced similar clinical outcomes with similar graft patency rates up to a year postoperatively. Conclusion Currently available PRCTs showes no sufficient evidence to support the use FFR in CABG.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…Multiple small observational studies, as well as RCTs and meta-analyses of these trials, suggest that fewer distal anastomoses are performed, and off-pump CABG is more often chosen in patients undergoing CABG with FFR-guided revascularization than in those undergoing CABG with angiogram-guided revascularization. 11-14 However, in these studies, no differences were found in clinical outcomes in patients undergoing CABG with FFR guidance compared with patients undergoing CABG with angiogram guidance. 11-14 Additionally, not all studies included an angiogram-guided comparison group.…”

“…11-14 However, in these studies, no differences were found in clinical outcomes in patients undergoing CABG with FFR guidance compared with patients undergoing CABG with angiogram guidance. 11-14 Additionally, not all studies included an angiogram-guided comparison group. Large, randomized trials that are appropriately powered are warranted to guide the use of FFR in patients undergoing surgical revascularization.…”

Fractional Flow Reserve: Patient Selection and Perspectives

“…The FFR-guided patients received a lower number of anastomoses, more arterial grafts and more frequently underwent off-pump procedures, which are associated with a reduction of (short-term) complications. [59][60][61][62] Moreover, a significant improvement in graft patency compared to ICA-guided CABG is observed. 59 A possible explanation for the apparent lack of benefits for FFR-guided CABG can be found in a process called surgical collateralizationgrafting might protect against the effects of progression of coronary lesions in proximal segments.…”

The Impact of Fractional Flow Reserve on Clinical Outcomes after Coronary Artery Bypass Grafting: A Meta-analysis

“…progresses after surgery was suggested as a concern regarding the FFR-guided revascularization strategy [15]. Due to great interest in this field, several meta-analyses have compared the results of FFR-guided CABG with those of the angiography-guided approach, despite the limited data regarding the role of FFR in the surgical setting [23][24][25][26][27]. However, previous meta-analyses failed to search all relevant references to identify recent studies [16,17].…”