Revascularisation of patients with end-stage renal disease on chronic haemodialysis: bypass surgery versus PCI—analysis of routine statutory health insurance data

Abstract

ObjectivesWe aimed to analyse the short-term and long-term outcome of patients with end-stage renal disease (ESRD) undergoing percutaneous intervention (PCI) as compared to coronary artery bypass surgery (CABG) to evaluate the optimal coronary revascularisation strategy.DesignRetrospective analysis of routine statutory health insurance data between 2010 and 2012.Main outcome measuresPrimary outcome was adjusted all-cause mortality after 30 days and major adverse cardiovascular and cerebrovascular events at 1 year. Secondary outcomes were repeat revascularisation at 30 days and 1 year and bleeding events within 7 days.ResultsThe total number of cases was n=4123 (PCI; n=3417), median age was 71 (IQR 62–77), 30.4% were women. The adjusted OR for death within 30 days was 0.59 (95% CI 0.43 to 0.81) for patients undergoing PCI versus CABG. At 1 year, the adjusted OR for major adverse cardiac and cerebrovascular events (MACCE) was 1.58 (1.32 to 1.89) for PCI versus CABG and 1.47 (1.23 to 1.75) for all-cause death. In the subgroup of patients with acute myocardial infarction (AMI), adjusted all-cause mortality at 30 days did not differ significantly between both groups (OR 0.75 (0.47 to 1.20)), whereas in patients without AMI the OR for 30-day mortality was 0.44 (0.28 to 0.68) for PCI versus CABG. At 1 year, the adjusted OR for MACCE in patients with AMI was 1.40 (1.06 to 1.85) for PCI versus CABG and 1.47 (1.08 to 1.99) for mortality.ConclusionsIn this cohort of unselected patients with ESRD undergoing revascularisation, the 1-year outcome was better for CABG in patients with and without AMI. The 30-day mortality was higher in non-AMI patients with CABG reflecting an early hazard with surgery. In cases where the patient's characteristics and risk profile make it difficult to decide on a revascularisation strategy, CABG could be the preferred option.

Percutaneous coronary intervention versus coronary artery bypass graft surgery in dialysis‐dependent patients: A pooled meta‐analysis of reconstructed time‐to‐event data

“…After full‐text review, 12 6,12–22 studies met our eligibility criteria, as summarized in the PRISMA flowchart (Figure 1). A total of nine studies were excluded due to overlapping populations 23–31 . A total of 42,144 patients on renal replacement therapy who underwent coronary revascularization were identified.…”

“…12,33,35,36 However, many discrepancies are noted between studies reporting solely on dialysisdependent patients regarding survival. 6,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]37,38 A possible interpretation of these discrepancies could be the fact that dialysis-dependent patients have several comorbidities and, overall, a decreased life expectancy compared to the general population and patients with CKD who are not on dialysis. 39 This shortened life expectancy might decrease the duration of the follow-up, and along with the decreased number of included patients, could conceal a possible statistically significant difference between the two revascularization modalities.…”

“…Indeed, in the ESRD population, some individual studies and prior meta‐analyses have shown improved survival after CABG 12,33,35,36 . However, many discrepancies are noted between studies reporting solely on dialysis‐dependent patients regarding survival 6,12–31,37,38 . A possible interpretation of these discrepancies could be the fact that dialysis‐dependent patients have several comorbidities and, overall, a decreased life expectancy compared to the general population and patients with CKD who are not on dialysis 39 .…”

“…A total of nine studies were excluded due to overlapping populations. [23][24][25][26][27][28][29][30][31] A total of 42,144 patients on renal replacement therapy who underwent coronary revascularization were identified.…”

In-Hospital outcomes in acute coronary syndrome patients with concomitant severe chronic kidney disease undergoing percutaneous coronary intervention

“…Results after revascularization in CKD patients are more limited. In the study from the European registry by Möckel et al, STEMI patients had a higher risk of death with an OR of 2.16 22. In the study by Shroff et al the patients with AMI and multi-vessel disease derived greater benefit from CABG as compared to PCI with DES; HR 0.92 for predicting mortality in DES versus CABG 23.…”