| Abstract: | Background and objectives: Patients receiving dialysis have a high burden of cardiovascular disease. Some receive coronary artery revascularization but the optimal method is controversial.Design, setting, participants, & measurements: The authors reviewed any randomized controlled trial or cohort study of 10 or more patients receiving maintenance dialysis which compared coronary artery bypass graft (CABG) to percutaneous intervention (PCI) for revascularization of the coronary arteries. The primary outcomes were short-term (30 d or in-hospital) and long-term (at least 1 year) mortality.Results: Seventeen studies were found. There were no randomized trials: all were retrospective cohort studies from years 1977 to 2002. There were some baseline differences between the groups receiving CABG compared with those receiving PCI, and most studies did not consider results adjusted for such characteristics. Given the variability among studies and their methodological limitations, few definitive conclusions about the optimal method of revascularization could be drawn. In an exploratory meta-analysis, short-term mortality was higher after CABG compared to PCI. A substantial number of patients died over a subsequent 1 to 5 yr, with no difference in mortality after CABG compared to PCI.Conclusions: Although decisions about the optimal method of coronary artery revascularization in dialysis patients are undertaken routinely, it was surprising to see how few data has been published in this regard. Additional research will help inform physician and patient decisions about coronary artery revascularization.Cardiovascular disease accounts for almost half of all deaths in patients with end-stage renal disease (1). More than two thirds of patients receiving dialysis have prevalent coronary artery disease, among whom three fourths are symptomatic and have multivessel disease (2). Coronary revascularization is often pursued in select patients who are sufficiently fit for the procedures or are symptomatic despite maximal medical therapy. The most appropriate method of revascularization is a matter of debate (3).Percutaneous coronary intervention (PCI) is an increasingly attractive treatment option for patients with stable multivessel coronary artery disease. With advances in technology, the risk of complications has declined, and success has improved (4). New advances in coronary artery bypass graft (CABG) surgery have also reduced rates of operative morbidity and mortality (5).In the general population, a recent trial suggested that survival and major cardiovascular events were no different in patients with atherosclerosis of the proximal left anterior descending artery randomized to receive either PCI or CABG surgery (4). However, the need for repeat revascularization was higher in patients receiving PCI (6). It has been highlighted that no quantitative review on this topic has been published regarding patients with kidney failure (7). Thus we undertook a systematic review to compile existing evidence on the following question: in patients receiving dialysis, what are the short and long-term risks of death for those undergoing CABG compared with those undergoing PCI? We also considered the effects of these procedures on cardiovascular outcomes of myocardial infarction and need for repeat revascularization. |
