Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for the Treatment of Multivessel Coronary Artery Disease in Patients With Chronic Kidney Disease

Abstract

ercutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are optional treatments for patients with multivessel coronary artery disease (CAD). Multiple studies comparing CABG with PCI for the treatment of multivessel CAD demonstrate similar mortality rates, but increased incidences of repeat revascularization after PCI. [1][2][3][4][5][6][7][8][9][10][11][12] In contrast, several large clinical registries reported that, compared with coronary stenting, CABG was associated with long-term survival benefits. [13][14][15] Importantly, in some meta-analyses and registries, CABG demonstrated greater benefit in mortality and myocardial infarction (MI) in high-risk patient subsets, such as those with diabetes or left ventricular (LV) dysfunction. [14][15][16][17] Chronic kidney disease (CKD) is common in patients with coronary heart disease, estimated to affect approximately 25% of patients requiring coronary revascularization. [18][19][20][21][22][23][24][25] It has been reported that the presence of CKD is associated with a higher risk of mortality among patients with CAD. [26][27][28] Multiple studies have also shown that CKD is a potent independent predictor of death and subsequent cardiac events in patients undergoing revascularization. [18][19][20][21][22] However, the data on whether CABG or PCI offers a better clinical outcome among CKD patients requiring coronary revascularization are very limited. Although several observational studies have compared the outcomes of participants with CKD and multivessel CAD who were assigned to CABG or PCI, those patients were not examined in the setting of the current practice of coronary implantation with a drug-eluting stent (DES) versus CABG. 23,24 Therefore, in the present registry study, we compared the long-term outcomes of PCI with DES versus CABG in patients with multivessel CAD and CKD at a single high-volume center. Methods Study PopulationUsing the comprehensive revascularization database from Beijing Anzhen Hospital, whereby charts from patients undergoing a coronary intervention were reviewed by dedicated, independent investigators unaware of the objectives or purpose of the study, we evaluated 1,069 consecutive patients with multivessel CAD and CKD who underwent DES implantation or CABG between January 2004 and June 2006. We defined 2-and 3-vessel disease as the presence of 2 or 3 major epicardial coronary arteries with ≥70% diameter stenosis, determined visually by the cardiologist performing the first angiographic procedure. The method of revascularization was at the physician's and/or patient's (Received November 28, 2008; revised manuscript received February 4, 2009; accepted February 11, 2009; released Background: Chronic kidney disease (CKD) is a strong predictor of mortality after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), but the relative efficacy of the 2 revascularization strategies in this context remains unknown. Methods and Results:The 1,069 patients with CKD undergoing revasculariz...

Multivessel Coronary Revascularization Strategies in Patients with Chronic Kidney Disease: A Meta-Analysis

“…Most characteristics were similar between the two groups (PCI and CABG), but patients with more complex coronary lesions were more likely to choose CABG. Three studies excluded patients with left main artery disease, and 1 study did not report the number of vessel involvements [8, 17-19]. Although some studies included single-vessel disease patients, the small number did not influence our analysis.…”

“…Although some studies included single-vessel disease patients, the small number did not influence our analysis. Six studies included all types of dialysis patients [9, 18, 20-23], 10 studies included DES-only patients, and 1 study included bare-metal stent-only patients [8, 10, 11, 17, 19, 21-26]. Four studies included both DES and bare-metal stent patients [18, 20, 27, 28], and 2 studies did not report the type of stent used [9, 29].…”

Clinical Outcomes of Treatment by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery in Patients With Chronic Kidney Disease Undergoing Index Revascularization in Ontario

“…In contrast, other studies have suggested that PCI with DES seemed to compare favorably with CABG in terms of mortality. 15,16,23,41 Most of these studies, however, were single center or with smaller study populations 15,16,23,41 or with a focus on only dialysis patients, 16,23 limiting the generalizability of their findings.…”

“…13,14 However, other studies have suggested that DES seemed to compare favorably with CABG in terms of mortality. 15,16,23 Therefore, we aimed to evaluate the long-term clinical outcomes of PCI using DES versus CABG in a large cohort of patients with CKD undergoing index revascularization in the province of Ontario, Canada.…”

What Is Optimal Revascularization for Hemodialysis Patients?

“…4 The superiority of CABG with regard to major adverse cardiac events compared with PCI is emphasized; however, refinements of DES may overcome this disadvantage. Sakakibara et al found that use of the everolimus-eluting stent (EES) was as safe as that of the sirolimus-eluting stent (SES), and that the EES significantly prevented restenosis in patients on maintenance HD compared with the SES at 8-month follow-up.…”