One-Year Clinical Outcomes of Dialysis Patients After Implantation With Sirolimus-Eluting Coronary Stents

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...

Section: Discussioncontrasting

confidence: 79%

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

Wang

Zhou

Liu

et al. 2009

“…[16][17][18] However, recent reports from Japan have shown that the TLR rate is similar between SES and BMS groups of dialysis patients. 11,19,20 As discussed in those reports, a higher rate of angiographic follow-up may explain the increasing rate of TLR in Japan. Furthermore, different percentages of patients with complex and highly calcified lesions may contribute to the relatively high rate of TLR.…”

Section: Discussionmentioning

confidence: 84%

“…11 Coronary plaques in dialysis patients are characterized by increased medial thickness and marked calcification, which are potential risks for suboptimal stent expansion. 12 According to IVUS analysis, under-expansion seems to be the most common mechanism of SES restenosis.…”

Section: Discussionmentioning

confidence: 99%

“…From our results, dialysis seems to be the specific factor involved in the limited effect of SES. Among studies of the effect of DES in dialysis patients, those in Japan have included only SES, 11,19,20 whereas other studies have included SES and paclitaxel-eluting stents. [16][17][18] The different results from these studies may reflect a class effect between the DES used in dialysis patients.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Clinical Outcomes of Sirolimus-Eluting Stenting After Rotational Atherectomy

Tamekiyo

Hayashi

Toyofuku

et al. 2009

Self Cite

PCIAll procedures were performed according to standard techniques, and all decisions concerning the strategy to be used were made by an experienced interventional cardiologist Received April 9, 2009; revised manuscript received July 7, 2009; accepted July 24, 2009 The efficacy of drug-eluting stents after rotational atherectomy (ROTA) has not been clarified. Methods and Results:The 704 consecutive patients who underwent percutaneous coronary intervention (PCI) with a sirolimus-eluting stent (SES) (79 with and 625 without ROTA) were enrolled. The 2-year clinical outcome of these patients was compared with that of a group of 1,123 consecutive patients treated with bare-metal stents (BMS) (144 with and 979 without ROTA). At 2 years after index PCI, the use of SES after ROTA was associated with a lower crude incidence of major adverse cardiac events (MACE) than were BMS after ROTA (30.1% vs 43.1%, P=0.024). The difference was mainly derived from the reduction in target lesion revascularization (TLR) (25.0% vs 39.1%, P=0.022). After adjusting for confounders, ROTA-SES was associated with a reduction in MACE and TLR, with a similar hazard ratio to the non-ROTA group only with SES implantation. In a subgroup of dialysis patients, the incidence of TLR after ROTA with SES and BMS was similarly high. Conclusions:The use of SES after ROTA is an appropriate method for selected hard lesions, but has a limited effect in dialysis patients, even after lesion preparation with ROTA. (Circ J 2009; 73: 2042 -2049

“…Several studies have suggested that dialysis is a major risk factor for restenosis after DES implantation, although the rates of restenosis are relatively lower than those of BMS. [20][21][22][23][24] There have been several reports suggesting differences in the properties of calcification between the dialysis patients and the non-dialysis patients. First, it has been reported that arterial calcification can be divided into intimal calcification, and medial calcification.…”

Section: Dialysis Patientsmentioning

confidence: 99%

Impact of Calcification on the Long-Term Outcomes of Sirolimus-Eluting Stent Implantation - Subanalysis of the Cypher Post-Marketing Surveillance Registry -

Fujimoto

Nakamura

Yokoi

2012

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp evere calcification of coronary artery lesions is associated with a high risk of restenosis after bare metal stent (BMS) implantation. 1-4 Sirolimus-eluting stent (SES) was the first drug-eluting stent (DES) introduced into clinical practice, and its safety and efficacy have been the standard for subsequently developed DES. Although SES have reduced the rates of in-stent restenosis (ISR) and target lesion revascularization (TLR) compared with BMSs, 5-8 inadequate stent expansion is a major risk factor for restenosis after SES implantation. 9,10 Severe calcification often disturbs stent expansion, and may affect the long-term outcomes of DES implantation. The long-term outcome of SES implantation in calcified lesions, however, is unclear because many previous studies include both dialysis and non-dialysis patients, and results do not allow for discrimination between the effects of calcification and dialysis. 11-15In the present study based on multicenter registry data, we retrospectively investigated 240-day angiographic outcomes, and 1,080-day clinical outcomes of SES implantation in calcified and non-calcified coronary lesions in both non-dialysis patients and dialysis patients. Methods SubjectsThe Cypher stent Japan Post-Marketing Surveillance Registry (J-PMS) is a post-marketing surveillance registry that was mandated by the Japanese government to fulfill one of the regulatory approval conditions. The major objective of the registry is to evaluate the efficacy and safety of SES in Japanese patients in daily practice use. A total of 2,000 patients who underwent implantation of SES were planned for consecutive enrollment from September 2004 through September 2005 at 50 hospitals in Japan. Angiographic follow-up at 8 months was mandated.We reviewed data from the Registry enrolling 2,458 lesions in 2,050 patients, and compared the angiographical outcomes at 240 days and the clinical outcomes at 1,080 days after SES implantation between calcified and non-calcified lesions in dialysis and non-dialysis patients. Data Collection and ManagementThe post-marketing surveillance databases were developed by The aim of the present study was to investigate the long-term outcome of sirolimus-eluting stent (SES) implantation in lesions with severe calcification that may disturb adequate stent expansion and increase the risk of restenosis and target lesion revascularization (TLR).