Coronary Artery Bypass Surgery Is Superior to Percutaneous Coronary Intervention With Drug-Eluting Stents for Patients With Chronic Renal Failure on Hemodialysis

doi:10.1016/j.athoracsur.2010.02.080

The Annals of Thoracic Surgery

Volume 89, Issue 6, June 2010, Pages 1896-1900

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

https://doi.org/10.1016/j.athoracsur.2010.02.080 Get rights and content

Background

Improvements in the results of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have been extending their use in patients with all forms of coronary artery disease. The purpose of this study was to compare the midterm clinical results of coronary artery bypass surgery (CABG) and PCI with DES in patients with chronic renal failure on hemodialysis.

Methods

From January 2002 to December 2006, 29 patients underwent CABG, and 75 patients underwent PCI with DES. For CABG, 24 patients had off-pump surgery. The mean follow-up was 32.0 ± 22.0 months for CABG and 23.5 ± 14.8 months for PCI. Survival, cardiac death, major adverse cardiac events (cardiac death, myocardial infarction, revascularization), and target lesion revascularization were analyzed using the Kaplan-Meier method.

Results

Preoperative characteristics and risk factors were compatible between the groups except for the European System for Cardiac Operative Risk Evaluation (7.3 ± 2.7 for CABG and 5.0 ± 2.4 for PCI, p < 0.0001) and the presence of a left main trunk lesion (53.3% for CABG and 18.7% for PCI). Thirty-day mortality was 3.3% for CABG and 4.0% for PCI. The 2-year survival rate was 84.0% for CABG and 67.6% for PCI (p = 0.0271). The cardiac death-free curve at 2 years was 100% for CABG and 84.1% for PCI (p = 0.0122). The major adverse cardiac events-free rate at 2 years was 75.8% for CABG and 31.5% for PCI (p < 0.0001). During the follow-up period, there were 6 late deaths in the CABG group and 27 late deaths (including 6 sudden deaths) in the PCI group.

Conclusions

Coronary artery bypass grafting was superior to PCI with DES in patients with chronic renal failure on hemodialysis in terms of long-term outcomes for cardiac death, major adverse cardiac events, and target lesion revascularization. The DES carried a higher risk for sudden death, which might be associated with stent thrombosis.

Section snippets

Patients and Methods

The Institutional Review Board of Kurashiki Central Hospital approved this study, and waived the individual consent because this study was retrospective. A total of 104 consecutive patients with hemodialysis were treated in our institution between January 2002 and June 2006. Twenty-nine patients were treated by CABG (CABG group) and 75 patients by percutaneous coronary intervention (PCI) with DES (DES group). The study cohort excluded patients who had suffered from acute myocardial infarction

Results

The patients' baseline clinical characteristics are summarized in Table 1. There were important differences between the two groups. Emergent cases, left main trunk disease, and 3-vessel disease were more prevalent in the CABG group. The mean predicted mortality based on the European System for Cardiac Operative Risk Evaluation was significantly higher in the CABG group (7.3 ± 2.7) than in the DES group (5.0 ± 2.4, p < 0.0001).

In the CABG group, the off-pump technique was used in 83%, the

Comment

Even in previously reported papers, the mortality and complication rates of open heart surgery for hemodialysis patients were high [6, 7]. The number of dialysis patients increases each year, and their coronary lesions are complicated, with calcified lesions and many branch lesions. It remains controversial whether coronary artery disease in such patients needs aggressive treatment with coronary bypass surgery or less invasive treatment with DES. With respect to hospital mortality, there was no

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Cited by (63)

Coronary Artery Bypass Grafting in Dialysis-Dependent Patients – Key Peri-Operative Considerations
2023, Cardiovascular Revascularization Medicine
Cardiovascular disease represents the leading cause of mortality in dialysis-dependent (DD) patients, with the great majority of these patients afflicted by severe coronary artery disease. As rates of end-stage renal disease increase worldwide, DD patients represent a growing proportion of the coronary artery bypass grafting (CABG) cohort. Yet, these patients are complex, with crucial changes in their haemodynamic and physiologic profiles that complicate revascularisation surgery. First, this comprehensive literature review explores the outcomes and prognostic factors for DD patients undergoing CABG. We then summarise the intricacies relating to important peri-operative decisions such as use of cardio-pulmonary bypass and choice of conduit.
Impact of coronary-subclavian steal after surgical myocardial revascularization with internal thoracic artery in chronic hemodialysis patients: A meta-analysis
2023, Trends in Cardiovascular Medicine
Patients in hemodialysis with an arm arteriovenous fistula undergoing coronary artery bypass grafting (CABG) with an internal thoracic artery have been reported to suffer from coronary-subclavian steal (CSS) during dialysis session. However, its occurrence is still debated. A systematic literature review was performed to identify all studies investigating the occurrence of a CSS event in this subset of patients. The primary endpoint was the analysis of CSS and the following early and late survival outcomes. Independent determinants of CSS and the impact of the distance between the arteriovenous fistula (upper arm vs forearm) and the ipsilateral internal thoracic artery graft on CSS events and mortality were studied. Early and late survival outcomes were analyzed by comparing ipsilateral versus contralateral arteriovenous fistula. Of the 1,383 retrieved articles, 10 were included (n = 643 patients). The pooled event rate of CSS was 6.46% [95%CI=2.10–18.15], while of symptomatic CSS incidence was 3.99% [95%CI=0.95–15.25]. No survival differences were noted when comparing ipsilateral to contralateral arteriovenous fistula-internal thoracic artery combinations. On meta-regression, the upper arm was associated with more CSS events, while the forearm to lower late mortality rates. Independently from arteriovenous fistula-internal thoracic artery combination, CSS was not associated to higher mortality rates. Particular attention is warranted when selecting the type of conduits for CABG in patients with an arteriovenous fistula or if highly expected to need one in the near future after surgery. A contralateral arteriovenous fistula-internal thoracic artery combination is preferable. If this is not possible, a forearm arteriovenous fistula position should be preferred.
Coronary Artery Bypass Grafting Versus Percutaneous Transcatheter Coronary Interventions: Analysis of Outcomes in Myocardial Revascularization
2019, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
The optimal strategy for coronary revascularization in these patients is not clear and is frequently opinion based.9 Societal recommendations have been made from conflicting conclusions in various studies.47-51 In these mostly observational studies, the definition and severity of patient kidney disease are often inconsistent.
Coronary patients on dialysis: Coronary artery bypass grafting or percutaneous coronary intervention? A complex question for a complex scenario
2019, Journal of Thoracic and Cardiovascular Surgery
Impact of Arteriovenous Fistula for Hemodialysis on Clinical Outcomes of Coronary Artery Bypass
2018, Annals of Thoracic Surgery
This study compared clinical outcomes between the use of in situ and free internal thoracic artery grafts in patients with upper extremity arteriovenous fistula who underwent coronary artery bypass.
We reviewed 85 hemodialysis-dependent patients with upper extremity arteriovenous fistula who underwent coronary artery bypass with internal thoracic artery grafts. The patients were categorized into 2 groups; 48 (56%) with in situ graft ipsilateral to the arteriovenous fistula (group I) and 37 (44%) with free grafts anastomosed to the ascending aorta (group F). The follow-up period was 32.0 ± 38.1 months.
The estimated overall survival rates at 3, 5, and 10 years were 89.5%, 81.6%, and 53%, respectively, for all discharged patients. There was no significant difference in in-hospital mortality, all-cause mortality, and freedom from major adverse cardiac events between the groups, although cardiac-related deaths occurred only in group I (n = 5). Ipsilateral in situ grafts were associated with hemodialysis-induced chest pain (odds ratio, 5.528; 95% confidence interval, 1.079 to 28.333; p = 0.040). The incidence of dialysis-induced chest pain in patients with in situ noncomposite, in situ composite, and free grafts was 45.5%, 19.4%, and 5.7%, respectively (p = 0.009).
Mortality was not influenced by using the internal thoracic artery as an ipsilateral in situ graft in patients with upper extremity arteriovenous fistula. However, there was a risk of increased incidence of hemodialysis-induced chest pain that is most likely related to coronary steal. A free internal thoracic artery graft would be an alternative option in these patients.
Comparison of coronary artery bypass grafting and drug-eluting stents in patients with chronic kidney disease and multivessel disease: A meta-analysis
2017, European Journal of Internal Medicine
Citation Excerpt :
A flow-chart of the detailed results of the search strategy was presented in Fig. 1. A total of 11 retrospective studies [13,14,19–27] were identified in this meta-analysis. Of them, two were matched cohort studies [13,20].
The optimal revascularization strategy of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention with drug-eluting stent (PCI-DES) in patients with chronic kidney disease (CKD) and multivessel disease (MVD) remains unclear.
Pubmed, EMBASE and Cochrane Library electronic databases were searched from inception until June 2016. Studies that evaluate the comparative benefits of DES versus CABG in CKD patients with multi-vessel disease were considered for inclusion. We pooled the odds ratios from individual studies and conducted heterogeneity, quality assessment and publication bias analyses.
A total of 11 studies with 29,246 patients were included (17,928 DES patients; 11,318 CABG). Compared with CABG, pooled analysis of studies showed DES had higher long-term all-cause mortality (OR, 1.22; p < 0.00001), cardiac mortality (OR, 1.29; p < 0.00001), myocardial infarction (OR, 1.89; p = 0.02), repeat revascularization (OR, 3.47; p < 0.00001) and major adverse cardiac and cerebrovascular events (MACCE) (OR, 2.00; p = 0.002), but lower short-term all-cause mortality (OR, 0.33; p < 0.00001) and cerebrovascular accident (OR, 0.64; p = 0.0001). Subgroup analysis restricted to patients with end-stage renal disease (ESRD) yielded similar results, but no significant differences were found regarding CVA and MACCE.
CABG for patients with CKD and MVD had advantages over PCI-DES in long-term all-cause mortality, MI, repeat revascularization and MACCE, but the substantial disadvantage in short-term mortality and CVA. Future large randomized controlled trials are certainly needed to confirm these findings.

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Original articleAdult cardiacCoronary Artery Bypass Surgery Is Superior to Percutaneous Coronary Intervention With Drug-Eluting Stents for Patients With Chronic Renal Failure on Hemodialysis

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

ACC/AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

J Am Coll Cardiol

Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery

Circulation

Original article
Adult cardiac
Coronary Artery Bypass Surgery Is Superior to Percutaneous Coronary Intervention With Drug-Eluting Stents for Patients With Chronic Renal Failure on Hemodialysis