Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease

Abstract

Background Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery have routinely excluded patients with chronic kidney disease (CKD). Objectives To evaluate the outcomes with PCI vs. CABG in patients with CKD. Methods Patients with CKD (eGFR <60mL/min/1.73m2) who underwent PCI using everolimus eluting stents (EES) were propensity score matched to patients who underwent isolated CABG surgery for multivessel coronary disease in New York State. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction(MI), stroke and repeat revascularization. Results Among 11,305 patients with CKD, 5,920 patients (2,960 pairs) were propensity score matched. At short-term (within 30 days), PCI was associated with a lower risk of death [HR=0.55; 95% CI=0.35-0.87], stroke [HR=0.22; 95% CI=0.12-0.42] and repeat revascularization [HR=0.48; 95%CI=0.23-0.98] when compared with CABG. At longer-term (mean 2.9 years), PCI was associated with a similar risk of death [HR=1.07; 95% CI=0.92-1.24], higher risk of myocardial infarction [HR=1.76; 95% CI=1.40-2.23], a lower risk of stroke [HR=0.56; 95% CI=0.41-0.76] and higher risk of repeat revascularization [HR=2.42; 95% CI=2.05-2.85]. In the subgroup of patients who underwent who underwent complete revascularization with PCI, the increased risk of myocardial infarction was no longer statistically significant [HR=1.18, 95% CI=0.67-2.09]. In the 243 pairs of patients with end stage renal disease on hemodialysis, PCI was associated with a significant higher risk of death [HR=2.02; 95% CI=1.40-2.93] and repeat revascularization [HR=2.44; 95% CI=1.50-3.96] when compared with CABG. Conclusions In subjects with CKD, CABG is associated with higher short-term risk of death, stroke and repeat revascularization whereas PCI with EES is associated with higher long-term risk of repeat revascularization and perhaps MI (in those with incomplete revascularization), with no mortality difference between CABG and PCI long-term. However, in the subgroup on dialysis, the results favored CABG over PCI.

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].…”

Impact of Hemodialysis on Procedural Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion: Insights From the Japanese Multicenter Registry

“…Among hemodialysis patients, the proportion of coronary revascularization of target CTO lesions has been reported to be as high as 20% 5. Recent observational reports6, 7, 8 have consistently shown the long‐term survival advantage of coronary artery bypass grafting (CABG) compared with PCI in hemodialysis patients, but this could be explained not only by a difference in the completeness of revascularization between the 2 techniques but also by inappropriate patient selection and a lack of awareness of the technical limitations of PCI. Despite the improvement in procedural outcomes of CTO‐PCI,9, 10 only limited information has been published regarding the procedures of CTO‐PCI in hemodialysis patients.…”

Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations

“…16 Studies spanning several decades have sequentially compared outcomes after CABG with outcomes after percutaneous transluminal coronary angioplasty, BMS, and DES among patients with CKD 5D and consistently showed a long-term survival advantage of CABG over percutaneous techniques. 4,5,[17][18][19] Nevis et al 20 performed a systematic review of the literature to amalgamate data between 1977 and 2002. Of the 17 studies meeting qualifications, most were small with considerable heterogeneity in patient characteristics, statistical methodology, and outcome variables, limiting the ability to derive definitive conclusions.…”

“…Accounting for high competing risks of death, the probability of repeat revascularization was much higher in the PCI group: 29% with DES and 25% with BMS versus 12.5% with CABG as the index procedure. Bangalore et al 19 assessed outcomes with CABG versus PCI with newer generation everolimus-eluting stents in multivessel CAD from 2008 to 2011. Among the 486 patients on dialysis identified from 11,305 patients with CKD, a twofold higher hazard of long-term mortality was noted with PCI versus CABG (54.3% versus 39.1%; HR, 2.02; 95% CI, 1.4 to 2.93; P,0.001), findings that contrast with findings from the general population.…”