Propensity-matched analysis of the impact of saphenous vein graft external stenting on clinical outcomes in coronary bypass surgery: The RESTART study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Multivessel coronary artery disease requiring CABG (n=2994). Intervention: External saphenous vein graft stent (VEST) vs. Routine CABG (no external stent). Primary outcome: Major adverse cardiovascular and cerebrovascular events (MACCE) at 1 year (composite of all-cause mortality, myocardial infarction, any revascularization, and cerebrovascular accident) (HR 0.60, 95% CI 0.38-0.94, p=.03).

Q: What does this research mean for the field?

External saphenous vein graft stenting is associated with a significantly reduced risk of adverse clinical outcomes up to 5 years after coronary artery bypass surgery compared with standard of care. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Luca Weltert; Eric A. Secemsky; Gil Bolotin; Tom Friedman; Paolo Centofanti; Viviana Sebastiano; Samuel Fusca; Sigrid Sandner; Marija Pljakova; Stefanos Demertzis; Tiziano Torre; Ivar Friedrich; Siling Li; Marcus Flather; Stephen Gerry; David P. Taggart

doi:10.1016/j.xjon.2025.09.048

October 25, 2025JTCVS OpenOpen Access

Propensity-matched analysis of the impact of saphenous vein graft external stenting on clinical outcomes in coronary bypass surgery: The RESTART study

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Key result

External saphenous vein graft stenting linked to ~40% lower 1-year MACCE risk in CABG.

HR 0.60
95% CI 0.38-0.94
P=.03
n=2,994

Figures

Graphical abstract published by JTCVS Open — Graphical abstract · Published by JTCVS Open · CC BY

Why the study?

While external saphenous vein graft stenting reduces intimal hyperplasia, lumen irregularities, and flow disturbances after CABG, its effect on clinical outcomes up to 5 years remained to be evaluated.

Does external saphenous vein graft stenting reduce major adverse cardiovascular and cerebrovascular events in patients undergoing coronary artery bypass grafting compared to standard surgical practice?

Study Design

Type

Cohort (n=2,994)

Multicenter

Yes

Structured PICO

Does external saphenous vein graft stenting reduce major adverse cardiovascular and cerebrovascular events in patients undergoing coronary artery bypass grafting compared to standard surgical practice?

P

Population

2,994 patients undergoing coronary artery bypass grafting with at least one saphenous vein graft, comparing a real-world stented cohort to a historical trial cohort followed for up to 5 years.

E

Exposure

External saphenous vein graft stenting using a tubular scaffold composed of braided, deformable cobalt-chromium wires (venous external support, VEST). Deployed intraoperatively and positioned over the autologous saphenous vein graft before anastomotic completion.

C

Comparator

Standard coronary artery bypass grafting without external vein graft stenting (historical control group derived from the Arterial Revascularization Trial [ART]), propensity score-matched.

O

Outcome

Cumulative incidence of major adverse cardiovascular and cerebrovascular events (MACCE) at 1 year after CABG surgery, defined as a composite of all-cause mortality, any myocardial infarction >3 days postprocedure, any revascularization (including PCI or repeat CABG), and cerebrovascular accident (CVA).composite

Main Result

Hazard Ratio: 0.6 (95% CI 0.38–0.94)

Absolute Event Rate: 4.13% vs 6.53%

Absolute Risk Reduction: 2.4%

p-value: p=.03

Limitations

Observational comparative design is subject to potential unmeasured confounding despite rigorous propensity score matching.
The control ART trial enrolled patients nearly two decades ago, whereas the VEST cohort is contemporary, introducing possible differences in practice patterns and treatment approaches.
Detailed vein harvesting and storage data were not available in the historical ART database.
Low event rates for secondary endpoints such as MI and CVA resulted in wide confidence intervals and limited statistical power.
Observational comparative analysis subject to potential biases and unmeasured confounding despite propensity matching
Historical control group (ART trial enrolled patients nearly two decades ago vs contemporary VEST cohort, introducing time-dependent confounding)
Lack of detailed vein harvesting and storage data in the ART database
Low event rates for secondary endpoints (MI and CVA) resulting in wide confidence intervals and limited power

Implication

External stenting of saphenous vein grafts during CABG was associated with a significantly lower risk of major adverse cardiovascular and cerebrovascular events up to 5 years post-surgery compared with standard CABG.

Abstract

Objective: External saphenous vein graft stenting has been shown to reduce intimal hyperplasia, lumen irregularities, and flow disturbances after coronary artery bypass grafting (CABG). The objective of this study is to evaluate the effect of saphenous vein graft external stenting on clinical outcomes up to 5 years. Methods: Outcomes for patients who received external vein graft stenting in an international, real-world cohort were compared in a propensity matched analysis with patients from the Arterial Revascularization Trial (ISRCTN46552265). All eligible patients required an internal mammary artery graft to the left anterior descending coronary artery, received at least one vein graft, and survived to discharge. The primary end point was major adverse cardiovascular and cerebrovascular events at 1 year after surgery, consisting of all-cause mortality, myocardial infarction, repeat revascularization, and cerebrovascular accident. Secondary end points included 5-year major adverse cardiovascular and cerebrovascular events with and without stroke and annualized target vessel revascularization. Conclusions: The current study demonstrates that external vein graft stenting is associated with a significantly lower risk of experiencing adverse clinical outcomes up to 5 years after surgery compared with standard of care.

Discussion

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Cite This Study

Weltert et al. (2025) conducted a cohort in Multivessel coronary artery disease requiring CABG (n=2,994). External saphenous vein graft stent (VEST) vs. Routine CABG (no external stent) was evaluated on Major adverse cardiovascular and cerebrovascular events (MACCE) at 1 year (composite of all-cause mortality, myocardial infarction, any revascularization, and cerebrovascular accident) (HR 0.60, 95% CI 0.38-0.94, p=.03). External stenting of saphenous vein grafts during CABG significantly reduced the risk of major adverse cardiovascular and cerebrovascular events at 1 year by 40% compared to routine CABG (HR 0.60).

synapsesocial.com/papers/6a7d8d10c6a15178113396ec https://doi.org/10.1016/j.xjon.2025.09.048

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Propensity-matched analysis of the impact of saphenous vein graft external stenting on clinical outcomes in coronary bypass surgery: The RESTART study

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Propensity-matched analysis of the impact of saphenous vein graft external stenting on clinical outcomes in coronary bypass surgery: The RESTART study

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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