Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting in Patients with Diabetic Nephropathy and Left Main Coronary Artery Disease

Impact of Acute Kidney Injury and Baseline Renal Impairment on Prognosis Among Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Both chronic kidney disease (CKD) and acute kidney injury (AKI) are associated with adverse consequences among patients undergoing percutaneous coronary intervention (PCI). However, it remains undetermined whether the impact of CKD and post-PCI AKI are similar. We aimed to discriminate between the impact of CKD and post-PCI AKI on short- and long-term outcomes.

METHODS

This retrospective cohort study included 1,100 patients undergoing PCI at a tertiary hospital. Based on baseline kidney function, patients were categorized as having preserved or impaired renal function, defining as an estimated glomerular filtration rate (eGFR) of ≥ and < 45 ml/min/1.73 m², respectively. Post-PCI AKI was defined as ≥ 100% relative increase between baseline and post-procedural serum creatinine.

RESULTS

Post-PCI AKI was associated with an increased risk of 90-day mortality [odds ratio (OR): 22.03, 95% confidence interval (CI): 10.36-46.88], long-term mortality [hazard ratio (HR): 6.63, 95% CI: 4.31-10.20], and composite endpoint of future end-stage renal disease (ESRD) and death (HR: 6.19, 95% CI: 4.06-9.42). Impaired kidney function at baseline was associated with an increased risk of future ESRD and composite endpoint of ESRD and death (for every 10 unit increase in eGFR, HR: 0.25, 95% CI: 0.14-0.43, and HR: 0.89, 95% CI: 0.82-0.97, respectively). The impact of post-PCI AKI outweighed that of impaired baseline renal function on short- and long-term prognosis. Patients with impaired baseline renal function who developed AKI following PCI had the worst prognosis.

CONCLUSIONS

Both post-PCI AKI and CKD were associated with a poor prognosis. Post-PCI AKI was more important than baseline renal function to predict long-term mortality and composite outcomes. The systemic pathophysiologic change accompanying AKI, rather than renal function per se, may play a crucial role.

Long-Term Outcomes in Coronary Artery Bypass Graft Patients Using Internal Thoracic Artery with Ipsilateral Arteriovenous Shunt for Hemodialysis

Background

The goal of this study was to evaluate the long-term results of coronary artery bypass grafting (CABG) using internal thoracic artery (ITA) grafts in hemodialysis (HD) patients with arteriovenous (AV) fistulae or AV grafts involving the ipsilateral or contralateral brachial artery or radial artery.

Methods

From March 2007 to May 2017, 76 end-stage renal disease (ESRD) patients with an upper limb AV fistula or graft for HD underwent CABG at a single center. Group A included 23 patients who underwent CABG using an ITA graft ipsilateral to the AV vascular access (AVVA); Group B included 22 patients who underwent CABG using a contralateral ITA with AVVA; and Group C included 29 patients who underwent CABG with AVVA without the use of an ITA graft. The primary end-point was death from any cause.

Results

The average follow-up period was 34.4 ± 26.9 months. Death from any cause occurred in 6 (26.09%) patients in Group A, 8 (36.36%) patients in Group B, and 17 (58.62%) patients in Group C (log-rank p = 0.04). There was no significant difference in death rate between Groups A and B. The risk of death was lower in the patients with CABG using an ITA graft (ITA CABG) compared to the patients without ITA CABG [HR 0.41 (95% CI, 0.20-0.84), p = 0.015].

Conclusions

The HD patients who underwent CABG with an ipsilateral location of the ITA and AVVA did not have an increased risk of death compared to the patients who underwent CABG with a contralateral location of the ITA and AVVA. In addition, the use of ITA in CABG resulted in better outcomes in the HD patients.

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.

Reassessing Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention in Patients with Type 2 Diabetes Mellitus: A Brief Updated Analytical Report (2015-2017)

INTRODUCTION

In this analysis, we aimed to systematically compare percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) in terms of adverse outcomes utilizing data from a recent (2015-2017) population of patients with type 2 diabetes mellitus (T2DM).

METHODS

An electronic search of recent studies (2015-2017) was carried out using 'diabetes mellitus,' 'coronary artery bypass surgery,' and 'percutaneous coronary intervention' as the main search terms. Uncomplicated T2DM patients with stable coronary artery disease (CAD), left main CAD, and multi-vessel disease were included. RevMan software (version 5.3) was used to calculate odds ratios (OR) and 95% confidence intervals (CIs).

RESULTS

Among a total of 13,114 T2DM patients, CABG and PCI patients did not differ significantly in their rates of mortality (OR 0.90, 95% CI 0.61-1.31; P = 0.57) and cardiac death (OR 1.00, 95% CI 0.78-1.30; P = 0.98). However, rates of major adverse events, repeat revascularization, and myocardial infarction were significantly higher in the PCI group. Stroke rates did not significantly differ between the two groups.

CONCLUSION

Mortality (1-5 years) did not significantly differ between the CABG and PCI patients with T2DM. However, rates of other major adverse events were significantly higher in the PCI patients, suggesting that CABG is more advantageous than PCI in patients with T2DM.