Outcome after coronary artery bypass grafting and percutaneous coronary intervention in patients with stage 3b-5 chronic kidney disease
Selected in European Journal of Cardio-Thoracic Surgery by Rylski
Lautamäki A, Kiviniemi T, Biancari F, Airaksinen J, Juvonen T, Gunn J.
Eur J Cardiothorac Surg. 2016 Mar;49(3):926-30
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The aim of this study was to compare the outcome after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) with chronic kidney disease (eGFR of <45 ml/min/m2).
- Retrospective study with 110 PCI and 148 CABG, median follow-up 25 months, 54 propensity score-matched pairs
- Postoperative de novo dialysis was required at 30 days and 3 years in 3.4 and 16.2 CABG and 0 and 6.6 % PCI patients (P=0.1)
- At 3 years PCI was associated with higher mortality (50.4 vs 32.9, HR 1.77, 95% CI 1.13-2.77) and higher major adverse cardiac and cerebrovascular events (57.8 vs. 34.3%, HR 2.19, 95% CI 1.41-3.40).
- Among propensity score-matched pairs, the risk of dialysis at 30 days and 3 years was 4.7 and 9.3% after CABG and 0 and 2.5% after PCI (P = 0.17), respectively. PCI patients had higher risk of mortality (at 3 years, 46.7 vs 30.1%, P = 0.041), major events (at 3 years, 25.9 vs 0%, P < 0.0001), repeat revascularization (at 3 years, 10.2 vs 0%, P = 0.036) and MACCE (at 3 years 57.8 vs 32.1%, P = 0.01) than those who underwent CABG.
There are no randomized trials comparing CABG with PCI in patients with severe renal impairment or dialysis. In this propensity score-matched study the authors provided data on the rate of postoperative de novo dialysis, MACCEEs and cardiac mortality. There was no statistically significant difference in the risk of late dialysis. Survival and freedom from MACCEs was significantly better in patients after CABG.
Patients with chronic advanced renal insufficiency represent a frail patients population. Both revascularisation methods carry significant risks of complications. CABG is associated with better survival and freedom from cardiovascular events than PCI and should not be denied based on kidney function alone.