Everolimus-Eluting Stents vs. CABG for Chronic Kidney Disease

Study Questions:

What are the outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with chronic kidney disease (CKD)?

Methods:

Patients were identified using the New York State Percutaneous Coronary Intervention Reporting System (PCIRS) and Cardiac Surgery Reporting System (CSRS) registries. Patients with CKD who underwent PCI using everolimus-eluting stents (EES) were propensity score-matched to patients who underwent isolated CABG for multivessel coronary disease in New York. 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 were propensity score-matched. At short term, PCI was associated with a lower risk of death (hazard ratio [HR], 0.55; 95% confidence interval [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) compared with CABG. At longer term, PCI was associated with a similar risk of death (HR, 1.07; 95% CI, 0.92-1.24), higher risk of MI (HR, 1.76; 95% CI, 1.40-2.23), 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 with complete revascularization with PCI, the increased risk of MI 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 significantly higher risk of death (HR, 2.02; 95% CI, 1.40-.93) and repeat revascularization (HR, 2.44; 95% CI, 1.50-3.96) compared with CABG.

Conclusions:

The authors concluded that among 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, with no long-term mortality difference.

Perspective:

This registry analysis reports that PCI using the latest-generation stents (EES) was associated with lower short-term risk (death, stroke, and repeat revascularization), similar long-term risk of death, higher risk of MI (in those with incomplete revascularization), and a lower risk of stroke, but a higher risk of repeat revascularization when compared with CABG. However, in patients on dialysis, the results favored CABG over PCI. Given the analysis does not control for unmeasured confounders, a prospective randomized trial would be needed to guide optimal strategy for patients with CKD undergoing myocardial revascularization. For now, a multidisciplinary team approach to decision making is indicated for these high-risk patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and Coronary Artery Disease

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Drug-Eluting Stents, Kidney Failure, Chronic, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Renal Dialysis, Stents, Stroke


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