Coronary Artery Bypass Grafting vs. Drug-Eluting Stent Implantation for Multivessel Disease in Patients with Chronic Kidney Disease

Meta-analysis of clinical adverse events after CABG vs. PCI in patients with chronic kidney disease and coronary artery disease

AIM

To investigate the efficacy and postoperative clinical adverse events of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for chronic kidney disease (CKD) study participants combined with coronary artery disease (CAD).

METHODS

All randomized controlled trials (RCTs) that focus on the therapeutic effect evaluation of CABG and PCI and their effect on postoperative clinical adverse events as well as main adverse cardiovascular and cerebrovascular events (MACCEs) in CKD study participants with CAD were screened from the following databases, including CNKI, CBM, Wan Fang, VIP, Embase, PubMed, as well as Cochrane library clinical controlled trials. The study was conducted under the PRISMA 2020 criteria. Data were extracted, and quality control was evaluated from the modified Jadad rating scale. Meta-analysis was then undertaken through STATA 16.0 software.

RESULTS

A total of 5 RCTs were obtained, including 1198 patients. Study participants were subdivided into two groups, including the PCI group (n = 604) and the CABG group (n = 594). Meta-analysis of clinical adverse events results showed that the long-term survival results of CAD patients with CKD who underwent PCI were worsened compared to CABG, such as long-term MACCEs (RR = 1.59, 95%CI: 1.04-2.43) and the long-term repeated revascularization (RR = 2.48, 95%CI: 1.76-3.49). Also, cardiac death (RR = 1.68, 95%CI:1.04-2.71), as well as cerebrovascular accident (RR = 1.74, 95%CI:1.04-2.90) in CABG group was significantly lower than that in PCI group.

CONCLUSION

This meta-analysis showed that CABG provided a better therapeutic effect than PCI in CKD patients with CAD when considering long-term prognosis. However, more prospective RCTs are needed to define the proper revascularization strategy for CAD patients with CKD.

Comparison of Coronary Artery Bypass Grafting and Drug-Eluting Stent Implantation in Patients With Chronic Kidney Disease: A Propensity Score Matching Study

Objectives

To compare the long-term outcomes of coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) for coronary artery disease (CAD) patients with chronic kidney disease (CKD).

Methods

Coronary artery disease patients with decreased kidney function (estimated glomerular filtration rate <60 ml/min/1.73 m2) who underwent CABG (n = 533) or PCI with DES (n = 952) from 2013 to 2020 were enrolled at a single center. The baseline characteristics and clinical outcomes were compared between the CABG and PCI groups for each matched pair of patients with CKD. The primary endpoint was the occurrence of all-cause death. The secondary endpoints were major adverse cardiovascular events (MACCEs) such as death, myocardial infarction (MI), stroke, and repeat revascularization.

Results

A total of 1,485 patients underwent revascularization, such as 533 CABG and 952 patients with PCI. The median follow-up duration was 55.6 months (interquartile range 34.3–74.7 months). Multivariable Cox regression models were used for risk adjustment, and after propensity score matching (PSM), 399 patients were well matched in each group. The in-hospital mortality rate in the CABG group was higher than that in the PCI group, but the difference was not statistically significant (5.0 vs. 2.5%, p = 0.063). At the 1-year follow-up, CABG was associated with a lower survival rate than PCI (94.2 vs. 98.0%, hazard ratio [HR] of 3.72, 95% CI = 1.63–8.49, p < 0.01). At the end of the 5-year follow-up, the freedom from MI and the freedom from repeated revascularization were both better in the CABG group compared to the PCI group (89.1 vs. 81.7%, HR of 0.59, 95% CI = 0.38–0.92, p = 0.019; 86.9 vs. 73.8%, HR of 0.54, 95% CI = 0.36–0.81, p = 0.003, respectively). Furthermore, the freedom from MACCEs was also better in the patients of CABG compared with the patients of PCI (58.5 vs. 51.3%, HR of 0.71, 95% CI = 0.55–0.91, p = 0.030). CABG had a higher cumulative survival rate (68.4 vs. 66.0%) but without a statistically significant difference (HR of 0.92, 95% CI = 0.67–1.27, p = 0.602) compared with that of PCI.

Conclusions

Compared to the use of PCI with a drug-eluting stent among patients with CKD, the use of CABG was associated with a lower MI rate, repeat revascularization rate, and lower number of MACCEs during the long-term follow-up. At a follow-up of 1 year, the number of MACCEs and other adverse events were comparable between the two cohorts, but CABG showed a lower survival rate than PCI.

Coronary revascularisation in patients with chronic kidney disease and end-stage renal disease: A meta-analysis

OBJECTIVES

To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for revascularising coronary arteries in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). CKD is described as a continuous decrease in the glomerular filtration rate or abnormalities in kidney structure or function.

METHODS

PubMed, Cochrane Library and Embase databases were searched for studies on the revascularisation of coronary arteries in patients with CKD and ESRD.

RESULTS

Since no randomised controlled trials (RCTs) have addressed this issue so far, 31 observational studies involving 74 805 patients were included in this meta-analysis. Compared with PCI, patients undergoing CABG have significantly higher early mortality (CKD: RR = 1.62, 95% CI: 1.17-2.25, pheterogeneity = 0.476, I²  = 0; ESRD: RR = 1.99, 95% CI: 1.46-2.71, pheterogeneity = 0.001, I²  = 66.9%). Patients with ESRD undergoing CABG have significantly lower all-cause mortality (RR = 0.95, 95% CI: 0.93-0.96, pheterogeneity < 0.001, I²  = 82.9%) and cardiac mortality (RR = 0.73, 95% CI: 0.58-0.92, pheterogeneity = 0.908, I²  = 0). The long-term risk of repeat revascularisation (CKD: RR = 0.24, 95% CI: 0.19-0.30, pheterogeneity = 0.489, I²  = 0; ESRD: RR = 0.23, 95% CI: 0.15-0.34, pheterogeneity = 0.012, I²  = 54.4%) and myocardial infarction (CKD: RR = .57, 95% CI: 0.38-0.85, pheterogeneity = 0.025, I²  = 49.9%; ESRD: RR = 0.42, 95% CI: 0.40-0.44, pheterogeneity = 0.49, I²  = 0) remained significantly higher in the PCI group.

CONCLUSIONS

Patients with ESRD, but not CKD, who underwent CABG had significantly lower all-cause mortality and cardiac mortality. However, CABG was associated with an increased risk of early mortality in patients with CKD or ESRD. Adequately powered, contemporary, prospective RCTs are needed to define the optimal revascularisation strategy for patients with CKD and ESRD.

Coronary artery bypass grafting versus percutaneous coronary intervention in end-stage kidney disease: A systematic review and meta-analysis of clinical studies

The most significant complication of end-stage kidney disease (ESKD) is cardiovascular disease, mainly coronary artery disease (CAD). Although the effective treatment of CAD is an important prognostic factor, whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is better for treating CAD in this group of patients is still controversial. We searched Pubmed/Medline, Web of Science, Embase, the Cochrane Central Register of Controlled Trials articles that compared the outcomes of CABG versus PCI in patients with ESKD requiring dialysis. A total of 10 observational studies with 39,666 patients were included. Our analysis showed that when compared to PCI, CABG had lower risk of need for repeat revascularization (relative risk [RR] = 2.25, 95% confidence interval [CI] 2.1-2.42, p < 0.00001) and cardiovascular death (RR = 1.19, 95% CI 1.14-1.23, p < 0.00001) and higher risk for short-term mortality (RR = 0.43, 95% CI 0.38-0.48, p < 0.00001). There was no statistically significant difference between the PCI and CABG groups in the risk for late mortality (RR = 1.05, 95% CI 0.97-1.14, p = 0.25), myocardial infarction (RR = 1.05, 95% CI 0.46-2.36, p = 0.91) or stroke (RR = 1.02, 95% CI 0.64-1.61, p = 0.95). This meta-analysis showed that in ESKD patients requiring dialysis, CABG was superior to PCI in regard to cardiovascular death and need for repeat revascularization and inferior to PCI in regard to short term mortality. However, this meta-analysis has limitations and needs confirmation with large randomized controlled trials.

The Better Option of Revascularization in Complex Coronary Artery Disease Patients Complicate With Chronic Kidney Disease: A Review and Meta-Analysis

The treatment of complex coronary artery disease (CAD) combined with chronic kidney disease (CKD) faces great challenges. We thus did a systematic review and meta-analysis to assess the effect of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). We systematically searched PubMed, Embase, Cochrane Library and other relevant articles refer to reference. Our main endpoints were main adverse cardiovascular and cerebrovascular events (MACCE), all cause death, myocardial infarction (MI), repeat revascularization and stoke. 24 studies were included in our analysis. Compared with PCI, CABG improved outcomes such as MACCE (Odds Ratio [OR] 1.75; 95%CI 1.26-2.42), all cause death (OR 1.13; 95%CI 1.00-1.28), repeat revascularization (OR 4.24; 95%CI 3.29-5.47) and MI (OR 2.16; 95%CI 1.59-2.91), but stoke (OR 0.84, 95%CI 0.61-1.17). CABG shows absolute advantage in complex CAD complicated with CKD and ESRD patients than stent implantation in the long-term following-up.

Medical Therapy Versus Revascularization in Patients with Stable Ischemic Heart Disease and Advanced Chronic Kidney Disease

PURPOSE OF REVIEW

This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD).

RECENT FINDINGS

A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.

Comparison of coronary artery bypass graft versus drug-eluting stents in dialysis patients: an updated systemic review and meta-analysis

INTRODUCTION

As percutaneous coronary intervention (PCI) technologies have been far improved, we hence conducted an updated systemic review and meta-analysis to determine the comparability between coronary artery bypass graft (CABG) and PCI with drug-eluting stent (DES) in ESRD patients.

METHODS

We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of cardiovascular outcomes among dialysis patients with CABG and DES. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Subgroup analyses and meta-regression were performed to explore heterogeneity.

RESULTS

Thirteen studies were included in this analysis, involving total 56 422 (CABG 21 740 and PCI 34 682). Compared with DES, our study demonstrated CABG had higher 30-day mortality [odds ratio (OR) 3.85, P = 0.009] but lower cardiac mortality (OR 0.78, P < 0.001), myocardial infarction (OR 0.5, P < 0.001) and repeat revascularization (OR 0.35, P < 0.001). No statistical differences were found between CABG and DES for long-term mortality (OR 0.92, P = 0.055), composite outcomes (OR 0.88, P = 0.112) and stroke (OR 1.49, P = 0.457). Meta-regression suggested diabetes and the presence of left main coronary artery disease as an effect modifier of long-term mortality.

CONCLUSION

PCI with DES shared similar long-term mortality, composite outcomes and stroke outcomes to CABG among dialysis patients but still was associated with an improved 30-day survival. However, CABG had better rates of myocardial infarction, repeat revascularization and cardiac mortality.

Influence of chronic kidney disease on early clinical outcomes after off-pump coronary artery bypass grafting

Background

Patients with chronic kidney disease (CKD) have a high incidence of coronary heart disease, which is the leading cause of death in these patients. Coronary artery bypass grafting (CABG) significantly increases short-term mortality and decreases long-term mortality in patients with CKD compared with percutaneous coronary intervention (PCI). The effect of CKD on the early outcomes of off-pump CABG is not well-studied. We aimed to investigate the effect of CKD on early postoperative mortality and complications following off-pump CABG.

Methods

We retrospectively analyzed preoperative baseline and surgery data for 1173 patients undergoing off-pump CABG from January 2010 to December 2017 in the Department of Cardiac Surgery, Peking University First Hospital. Outpatient follow-up was performed until 30 days postoperatively. Patients with estimated glomerular filtration rates calculated according to the Chronic Kidney Disease Epidemiology Collaboration equation of ≥60 mL/min/1.73 m² were assigned to the normal renal function group (normal group, n = 924), and those with a rate < 60 mL/min/1.73 m² were assigned to the CKD group (CKD group, n = 249).

Results

Patients in the CKD group were seriously ill with multiple complications, and postoperative 30-day mortality and complication rates were significantly higher than those in the normal group. In the logistic regression analysis, after correcting for common confounding factors, namely sex, age, and left ventricular ejection fraction, preoperative CKD was a risk factor for postoperative acute kidney injury, perioperative myocardial infarction, gastrointestinal bleeding, secondary tracheal intubation, stroke, chest wound infection, prolonged mechanical ventilation (≥ 24 h), prolonged intensive care unit stay (≥ 72 h), prolonged length of stay (≥ 14 d), dialysis requirement, and postoperative death within 30 days.

Conclusions

Patients with CKD had more preoperative complications, and their postoperative 30-day mortality and complication rates after off-pump CABG were significantly higher than those of patients with normal renal function. For CABG patients with CKD, the risk of surgery should be assessed carefully, and comprehensive measures should be taken to strengthen perioperative management, with an aim to reduce complications and mortality and improve surgical outcomes.

Multivessel Coronary Revascularization Strategies in Patients with Chronic Kidney Disease: A Meta-Analysis

Background: Early revascularization can lead to better prognosis in multivessel coronary artery disease (CAD) patients with chronic kidney disease (CKD). However, whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is better remains unknown. Methods: We searched PubMed and the Cochrane Library database from inception until December 9, 2017, for articles that compare outcomes of CABG and PCI in multivessel CAD patients with CKD. We pooled the odds ratios with a fixed-effects model when I2 < 50% or a random-effects model when I2 > 75% and conducted heterogeneity and quality assessments as well as publication bias analyses. Results: A total of 17 studies with 62,343 patients were included. Compared with CABG, the pooled analysis showed that PCI had a lower risk of short-term all-cause death (OR, 0.56; 95% CI, 0.37–0.84) and cerebrovascular accidents (OR, 0.65; 95% CI, 0.53–0.79) but a higher risk of cardiac death (OR, 1.29; 95% CI, 1.21–1.37), myocardial infarction (MI) (OR, 1.73; 95% CI, 1.35–2.21), and repeat revascularization (RR) (OR, 3.9; 95% CI, 2.99–5.09). There was no significant difference in the risk of long-term all-cause death (OR, 1.08; 95% CI, 0.95–1.23) and major adverse cardiac and cerebrovascular events (MACCE) (OR, 1.58; 95% CI, 0.99–2.52) between the PCI and CABG groups. A subgroup analysis restricted to patients treated with dialysis or with PCI-drug-eluting stent yielded similar results. Conclusions: PCI for patients with CKD and multivessel disease (multivessel CAD) had advantages over CABG with regard to short-term all-cause death and cerebrovascular accidents, but disadvantages regarding the risk of myocardial death, MI, and RR; there was no significant difference in the risk of long-term all-cause death and MACCE. Large randomized controlled trials are needed to confirm our findings.