Another battlefield for drug-eluting coronary stents: Chronic kidney disease

Drug-eluting stent implantations in patients with chronic kidney disease are useful to reduce revascularization

“…We thank Dr. Celik for his comments [1] on our recent paper [2]. In the era of drug-eluting stent (DES), it has not been determined whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) offers better clinical outcomes in patients with chronic kidney disease (CKD).…”

A commentary on the manuscript by Celik entitled “Distal embolus protection during primary percutaneous coronary intervention: Lessons learned from the clinical trials”

“…As they pointed out, [1] the Enhanced Myocardial Efficacy and removal by Aspiration of Liberalized Debris (EMERALD) trial, [3] the randomized controlled Protection Devices in PCI Treatment of Myocardial Infarction for Salvage of Endangered Myocardium (PROMISE) study [4] and the Protection of distal Embolization in High-Risk Patients with Acute Myocardial Infarction (PREMIAR) study [5] failed to demonstrate a clear benefit of the routine use of a distal protection (DP) during primary percutaneous coronary intervention (PCI) as compared with conventional PCI strategy, whereas the analyses of several single-center trials have shown that primary PCI using DP device may result in improved surrogate markers of effective reperfusion such as corrected TIMI frame count, myocardial blush grade and STsegment resolution, left ventricular function, and clinical outcomes in comparison with either historical or concurrent controls [6][7][8][9][10][11].The major reason for the different outcomes between these single-center trials and 3 randomized trials could be ascribed to differences in populations. The EMERALD, PROMISE and PREMIAR trials, however, might have included patients at a lower risk for these thrombotic complications, which could lead to a negation of the efficacy of the DP, since the incidences of distal embolization and no-reflow (defined as TIMI grade ≤ 1 flow) were markedly lower in the control arm in the EMERALD trial (5.8% and 2.5%, respectively), the PROMISE trial (8% and 0%, respectively) and the PREMIAR study (11% and 3%, respectively) compared with controls in other trials in which the benefit of the DP had been proven (9.9% to 19.8% and 6.2% to 38.1%, respectively) [6][7][8][9][10][11]. In other words, the DP seems to have been needed in very few patients in these 3 randomized trials because of excellent outcomes of primary angioplasty without using a DP device.…”