Author + information
- Milan Milojevic1,
- Stuart Head2,
- Michael Mack3,
- Friedrich Mohr4,
- Marie-Claude Morice5,
- Keith Dawkins6,
- David Holmes Jr.7,
- Patrick Serruys8 and
- A. Pieter Kappetein2
- 1Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- 2Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
- 3The Heart Hospital Baylor Plano, Plano, Texas, United States
- 4Heart Center, Leipzig, Germany
- 5Institut Cardiovasculaire Paris Sud, Massy, France
- 6Boston Scientific Corporation, Natick, Massachusetts, United States
- 7Mayo Clinic, Rochester, Minnesota, United States
- 8Imperial College, London, United Kingdom
Limited data from randomized trials on coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) are available to aid decision-making to select a specific myocardial revascularization strategy that optimizes longer term outcomes in patients with chronic kidney disease (CKD).
Of 1800 patients in the SYNTAX trial, the baseline glomerular filtration rate (GFR) estimates were available in 1638 patients (PCI=852, CABG=786). The Chronic Kidney Disease Epidemiology Collaboration equation was used to calculate GFR values and the Kidney Disease Improving Global Outcomes threshold used to define staging of CKD. Patients with a normal kidney function (stage 1) had a GFR of ≥90 mL/min per 1.73 m2. Impaired (stage 2) kidney function was defined by a GFR between 60 and 90, and moderate/severe CKD (stage 3,4 and 5) by a GFR <60. In addition, we evaluated the effect of diabetes on the outcome.
Kidney function was normal in 428 patients (PCI=219, CABG=209). The majority of patients were in stage 2 (PCI=475 and CABG=426), and 158 PCI (18.5%) and 151 CABG (19.2%) patients were with CKD. After both PCI and CABG, outcomes at 5-year follow-up were similar between patients with normal and impaired kidney function, but showed a significant increase in all-cause mortality in patients with CKD for PCI (10.8 vs 10.9 vs 26.7%, respectively) and CABG (10.6 vs 9.3 vs 21.2%, respectively). The rate of the composite of all-cause mortality, stroke, and myocardial infarction was comparable between PCI and CABG in patients with stage 1 (18.4% vs 16.5%, respectively; P=0.37) and stage 2 (17.7% vs 15.3%, respectively; P=0.33), but in patients with CKD CABG showed improved outcomes (31.9% vs 25.5%, respectively; P=0.096). In patients with CKD, all-cause mortality of PCI compared to CABG were significantly worse when diabetes was present (HR for PCI=3.39, 95% CI 1.41-8.13), but comparable in non-diabetic patients with CKD (HR for PCI=0.94, 95% CI 0.51-1.71).
During the 5-year follow-up, patients with CKD who underwent both PCI and CABG treatment experiencing a high incidence of adverse events. PCI is an alternative to CABG in patients with CKD without diabetes while CABG is clearly superior to PCI in patients with combined CKD and diabetes.
CORONARY: PCI Outcomes