Long-Term Survival and Repeat Coronary Revascularization in Dialysis Patients After Surgical and Percutaneous Coronary Revascularization With Drug-Eluting and Bare Metal Stents in the United States
What are the long-term survival rates and the probability of repeat coronary revascularization of dialysis patients undergoing surgical and percutaneous coronary revascularization in the contemporary era?
Using United States Renal Data System data, the authors identified 23,033 dialysis patients who underwent coronary revascularization (6,178 coronary artery bypass grafting [CABG], 5,011 bare-metal stents [BMS], 11,844 drug-eluting stents [DES]) from 2004 to 2009. Revascularization procedures decreased from 4,347 in 2004 to 3,344 in 2009. DES use decreased by 41% and BMS use increased by 85% from 2006 to 2007. Long-term survival was estimated by the Kaplan-Meier method, and independent predictors of mortality were examined in a comorbidity-adjusted Cox model.
In-hospital mortality for CABG patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28%, respectively. In-hospital mortality for DES patients was 2.7%; 1-, 2-, and 5-year survival was 71%, 53%, and 24%, respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes mellitus. Survival was significantly higher for CABG patients who received internal mammary grafts (hazard ratio, 0.83; p < 0.0001). The probability of repeat revascularization accounting for the competing risk of death was 18% with BMS, 19% with DES, and 6% with CABG at 1 year.
The authors concluded that among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after CABG, but long-term survival was superior with internal mammary grafts.
These data from a large sample of dialysis patients demonstrate the tradeoffs pertinent to clinical decisions on the optimal revascularization strategy in this high-risk population: high in-hospital mortality rates, but superior long-term survival (especially with use of internal mammary grafts) with surgical revascularization and better short-term survival, but higher probability of repeat revascularization with PCI using BMS and DES. For some patients, PCI with DES might be preferable because the higher perioperative mortality (and likely morbidity) of CABG might be a less acceptable choice, despite potentially superior long-term survival. These findings also highlight the importance of a heart team approach (i.e., deriving input from interventional cardiologists and cardiovascular surgeons to determine an individualized, optimal approach) for coronary revascularization for each individual patient.
Keywords: Hospital Mortality, Morbidity, Drug-Eluting Stents, Angioplasty, Balloon, Coronary, Percutaneous Coronary Intervention, Stents, Survivors, Renal Dialysis, Survival Rate, Heart Failure, Peritoneal Dialysis, Coronary Artery Bypass, United States, Diabetes Mellitus
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