Coronary revascularisation in patients with chronic kidney disease

The PCR Textbook

Summary

Chronic kidney disease (CKD), as defined as low glomerular filtration rate and/or presence of marker of renal damage, is a widespread disease with a global prevalence of more than 9%. It is among the strongest predictors of adverse outcomes in patients with coronary artery disease (CAD) undergoing myocardial revascularization. In turn, cardiovascular morbidity, and especially CAD, is the main cause of death in patients with CKD. 

Even though CKD patients have an increased cardiovascular risk profile, they have lower rates of cardiac catheterization and myocardial revascularization procedures, and they are less likely to receive optimal guidelines-directed medical therapy compared to patients with preserved renal function. 

Management of CAD in CKD requires careful evaluation of risks and benefits, taking into account the potential threat posed by endovascular or surgical procedures and iodinated contrast medium administration. 

The stage of renal dysfunction, the presence of severe comorbidities, the extension and severity of CAD, and the overall life expectancy of the patient are key factors for individualizing the revascularization strategy. A surgical approach is generally recommended for patients with multi-vessel CAD and moderate CKD (stage 3 or lesser), with an acceptable risk profile and reasonable life expectancy, due to the lower risk of recurrent ischemia, especially in diabetic subjects. In patients with severe CKD (stages 4 to 5) or under dialytic treatment, the revascularization strategy must be carefully considered, and multidisciplinary discussion should be carried out, with the less invasive approach being more appropriate for the most fragile and compromised patients.

When a percutaneous coronary intervention (PCI) is performed in patients with advanced CKD and diffuse or calcified CAD, accurate lesion preparation, comprising the use of special balloons and tools like rotational or orbital atherectomy, or coronary lithotripsy, is essential to obtain an adequate procedural result. The expertise and confidence level of the interventional team with the more appropriate dedicated devices for plaque modification should be considered for the most complex cases. Dedicated ultra-low/zero contrast volume PCI protocols may be considered in high-risk patients. Similarly, the use of contrast-free intracoronary imaging and physiology assessment should be implemented both for renal protection and procedural optimization.

Being CKD a risk factor for contrast-induced acute kidney injury (CI-AKI), every effort should be made to prevent its onset after a contrast-based procedure either diagnostic or interventional. Several specific techniques and devices have been developed to prevent CI-AKI, even though adequate pre- and post-procedural hydration (tailored to the patient’s left ventricle end-diastolic pressure or central venous pressure) and contrast volume minimization remain the most effective preventive measures. This last topic is the subject of a dedicated chapter, by Bartorelli A.L. et al

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