Native Coronary Artery Versus Saphenous Vein Graft Percutaneous Coronary Intervention in Patients with Prior Coronary Artery Bypass Grafting: An Updated Systematic Review and Meta-Analysis

Background/Objectives: Patients with prior coronary artery bypass grafting (CABG) frequently require repeat percutaneous coronary intervention (PCI), but the optimal target—native coronary artery or saphenous vein graft (SVG)—remains uncertain. We performed an updated systematic review and random-effects meta-analysis comparing clinical and procedural outcomes of native coronary artery PCI versus SVG PCI. Methods: PubMed, Embase, and the Cochrane Library (Cochrane Central Register of Controlled Trials) were searched from inception through May 2026. Results: Twenty-five studies (343,524 patients) were included, with 21 contributing to the MACE and/or all-cause mortality analyses. Compared with native-vessel PCI, SVG PCI was associated with higher rates of major adverse cardiovascular events (MACE) (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.05–1.60; p = 0.017), all-cause mortality (RR 1.47, 95% CI 1.19–1.81; p < 0.001), myocardial infarction (RR 1.64, 95% CI 1.31–2.05; p < 0.001), in-stent restenosis (RR 1.71, 95% CI 1.19–2.44; p = 0.004), and target lesion revascularization (RR 1.70, 95% CI 1.16–2.47; p = 0.006). After exclusion of the single randomized trial, associations for MACE (RR 1.38, 95% CI 1.12–1.71) and all-cause mortality (RR 1.50, 95% CI 1.21–1.85) were slightly stronger. Cardiac death, stroke, and bleeding did not differ significantly. Findings for MACE and target lesion revascularization were sensitive to the omission of single studies. In the exploratory drug-eluting stent-predominant subgroup, effect directions were generally consistent. Despite these associations, most included studies were observational, and substantial heterogeneity and residual confounding remain important limitations (95% prediction intervals for MACE and mortality included the null), and the certainty of evidence (GRADE) was low to very low. Conclusions: SVG PCI was associated with less favorable long-term outcomes than native coronary artery PCI, although these findings do not establish causality and should be interpreted alongside randomized evidence supporting individualized, anatomy-based target selection. Adequately powered randomized trials with extended follow-up are needed to define the optimal revascularization strategy across the spectrum of post-CABG anatomy.