B- CRF : Cardiovascular complications
E- 05 : Coronary angioplasty or surgery
F- 08 : Cardiovascular complications
Long-Term Survival and Repeat Coronary Revascularization in Dialysis
Patients
Following
Surgical
and
Percutaneous
Coronary
Revascularization with Drug-Eluting and Bare Metal Stents in the
United States
Gautam R. Shroff, MBBS,1 Craig A. Solid, PhD,2 and Charles A. Herzog, MD1,2
Journal : Circulation
Year : 2013 / Month : May
Volume : 127
Pages : 1861–1869.
ABSTRACT
Background
Few published data describe long-term survival of dialysis patients undergoing surgical versus
percutaneous coronary revascularization in the era of drug-eluting stents (DES).
Methods and Results
Using United States Renal Data System data, we identified 23,033 dialysis patients who
underwent coronary revascularization (6178 coronary artery bypass grafting [CABG], 5011 baremetal stent [BMS], 11,844 DES), 2004–2009. Revascularization procedures decreased from
4347 in 2004 to 3344 in 2009. DES use decreased by 41% and BMS use increased by 85%
2006–2007. Long-term survival was estimated by the Kaplan-Meier method and independent
predictors of mortality 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. Survival was significantly higher for CABG patients who received internal mammary
grafts (IMG) (HR 0.83, P<0.0001). 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.
Conclusions
Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher
after CABG but long-term survival was superior with IMGs. In-hospital mortality was lower for
DES patients, but probability of repeat revascularization was higher and comparable to BMS
patients. Revascularization decisions for dialysis patients should be individualized.
Keywords: coronary, dialysis, drug-eluting stent, survival
COMMENTS
Cardiac disease is a major cause of mortality among dialysis patients; according to recent
estimates, it accounts for about 38% of all-cause deaths, and about 13% of cardiac deaths are
ascribed to myocardial infarction.Patients with end-stage renal disease (ESRD) undergoing
maintenance dialysis have been excluded from any randomized evaluation of the comparative
efficacy of coronary revascularization strategies.
Thus, the optimal option for coronary revascularization in dialysis patients remains a matter of
debate.. Using USRDS data, the authors sought to evaluate long-term survival rates and
probability of repeat coronary revascularization of dialysis patients undergoing surgical and
percutaneous coronary revascularization in the contemporary era, and to identify independent
predictors of mortality.
From the Registry, 6178 CABG patients, 5011 BMS patients, and 11,844 DES patients were
identified in the study period. Median follow-up periods were 1.63 years for CABG (25th
percentile, 0.55; 75th percentile, 2.96), 1.60 years for DES, (0.75, 2.96), and 0.99 years for BMS
(0.47, 2.26).
A greater proportion of younger patients underwent surgical revascularization procedures than
percutaneous procedures (P < 0.0001). Among patients who underwent CABG with IMG, 43%
were aged 45 to 64 years, 12% 75 to 79 years, and only 7% older than 80 years. Among patients
who underwent PCI with DES, however, 35% were aged 45 to 64 years and 31% 65 to 74 years,
and proportions in older age groups were relatively higher; 16% were aged 75 to 79 years and
14% 80 years or older.
At 12 months after the index revascularization, all-cause survival for CABG with IMG was 72%,
versus 64% for CABG without IMG. At 2 years, patients who underwent CABG with IMG had a
significant survival advantage (59.6%) compared with patients who underwent CABG without
IMG (50.6%, P < 0.0001), a difference that persisted in longer-term follow-up. For patients
undergoing percutaneous revascularization, in-hospital mortality was 2.7% for DES and 4.9% for
BMS (P < 0.0001). Thus, in-hospital mortality was significantly higher in the context of surgical vs.
percutaneous revascularization (8.2% vs. 3.4%, P < 0.0001).
Of 6178 patients who originally underwent CABG, 773 (12.5%) underwent a repeat coronary
revascularization procedure; of 11,844 patients who originally received DES, 3404 (28.7%)
underwent a repeat procedure, and of 5011 who originally received BMS, 1246 (24.9%)
underwent a repeat procedure.
In summary, regarding the optimal revascularization strategy in this high-risk population the
authors propose the alternative: high in-hospital mortality rates but superior long-term survival
(especially with use of IMGs) with surgical revascularization, and higher short-term survival but
higher probability of repeat revascularization with percutaneous revascularization using BMS and
DES. They quote also a recent shift in interventional practice patterns in US dialysis patients, with
a decrease in DES use and a corresponding rise in BMS use.
Pr. Jacques CHANARD
Professor of Nephrology