Predialysis coronary revascularization and postdialysis mortality

Abstract

Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with mild-to-moderate chronic kidney disease (CKD) and End-Stage Renal Disease (ESRD). However, the optimal strategy for coronary artery revascularization in advanced CKD patients who transition to ESRD is unclear. Methods: We examined a contemporary national cohort of 971 US veterans with incident ESRD, who underwent first CABG or PCI up to 5 years prior to dialysis initiation. We examined the association of a history of CABG versus PCI with all-cause mortality following transition to dialysis, using Cox proportional hazards models adjusted for time between procedure and dialysis initiation, socio-demographics, comorbidities and medications. Results: 582 patients underwent CABG and 389 patients underwent PCI. The mean age was 66±8 years, 99% of patients were male, 79% were white, 19% were African Americans, and 84% were diabetics. The all-cause post-dialysis mortality rates after CABG and PCI were 229/1000 patient-years (PY) [95% CI: 205-256] and 311/1000PY [95% CI: 272-356], respectively. Compared to PCI, patients who underwent CABG had 34% lower risk of death [multivariable adjusted Hazard Ratio (95% CI) 0.66 (0.51-0.86), p=0.002] after initiation of dialysis. Results were similar in all subgroups of patients stratified by age, race, type of intervention, presence/ absence of myocardial infarction, congestive heart failure and diabetes. Conclusion: CABG in advanced CKD patients was associated lower risk of death after initiation of dialysis compared to PCI.

Coronary artery bypass graft surgery versus stenting for patients with chronic kidney disease and complex coronary artery disease: a systematic review and meta-analysis

“…Eleven studies involving 26,441 patients (PCI group: 13,217; CABG group: 13,224) were included in the final analysis, including five subanalyses of RCTs and six propensity-matched registries, [17][18][19][20][21][22][23][24][25][26][27] published between 2005 and 2019 ( Figure 1). The main characteristics of the eligible studies are presented in Table 1.…”

“…Of the 11 studies, two compared PCI using bare-metal stent (BMS) versus CABG, 17,25 five compared PCI using DES versus CABG, 20,21,23,24,26 and the remaining four compared PCI using mixtures of BMS and DES versus CABG. 18,19,22,27 Overall, nine studies included multivessel disease with no or very few left main disease, [17][18][19][20][21][22][23]25,27 one study enrolled both multivessel and left main disease, 26 and the remaining one study enrolled only left main disease. 24 The clinical characteristics of the patients appear in Table 2.…”

Cardiac Surgery 2019 Reviewed

“…1C). 14 Finally, the 5-year results of the EXCEL trial were presented. The trial compared CABG versus PCI in patients with left main CAD and a SYNTAX score less than 32.…”

Comparison of long-term cardiovascular and renal outcomes between percutaneous coronary intervention and coronary artery bypass grafting in multi-vessel disease with chronic kidney disease

“…Patients with CKD are also at risk for acute kidney injury (AKI), a common complication after CABG or PCI (5), and for progression to end-stage renal disease (6). Although many studies have concluded that PCI preserves renal function better (5,7), most of these studies have been conducted on a short-term follow-up, and data on other kidney-related outcomes such as initiation of dialysis or kidney transplant are scarce.…”