Optimal Method of Coronary Revascularization in Patients Receiving Dialysis

Abstract

Background and objectives: Patients receiving dialysis have a high burden of cardiovascular disease. Some receive coronary artery revascularization but the optimal method is controversial.Design, setting, participants, & measurements: The authors reviewed any randomized controlled trial or cohort study of 10 or more patients receiving maintenance dialysis which compared coronary artery bypass graft (CABG) to percutaneous intervention (PCI) for revascularization of the coronary arteries. The primary outcomes were short-term (30 d or in-hospital) and long-term (at least 1 year) mortality.Results: Seventeen studies were found. There were no randomized trials: all were retrospective cohort studies from years 1977 to 2002. There were some baseline differences between the groups receiving CABG compared with those receiving PCI, and most studies did not consider results adjusted for such characteristics. Given the variability among studies and their methodological limitations, few definitive conclusions about the optimal method of revascularization could be drawn. In an exploratory meta-analysis, short-term mortality was higher after CABG compared to PCI. A substantial number of patients died over a subsequent 1 to 5 yr, with no difference in mortality after CABG compared to PCI.Conclusions: Although decisions about the optimal method of coronary artery revascularization in dialysis patients are undertaken routinely, it was surprising to see how few data has been published in this regard. Additional research will help inform physician and patient decisions about coronary artery revascularization.

Clinical Outcomes of Treatment by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery in Patients With Chronic Kidney Disease Undergoing Index Revascularization in Ontario

“…19,20 Published studies have reported conflicting longer term outcome data. 21,22 Data from Medicare enrollees and the United States Renal Data System suggest that the long-term risks of death or combined death and end-stage renal disease were lower after CABG when compared with PCI in patients with CKD or those on dialysis. 13,14 However, other studies have suggested that DES seemed to compare favorably with CABG in terms of mortality.…”

Long-Term Clinical Outcome After Surgical or Percutaneous Coronary Revascularization in Hemodialysis Patients

“…Nevis et al, in their meta-analysis, reported that long-term mortality no longer differed between the 2 procedures after excluding 2 mega studies. 11,12, 15 In this regard, the present study may be somewhat limited despite its relatively large cohort of nearly 1,000. We found, however, that CABG has a survival advantage over PCI but only after the 6 post-procedure months, and tends to have survival advantage only in patients with multivessel disease.…”

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.…”