Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease: Everolimus-Eluting Stents Versus Coronary Artery Bypass Graft Surgery

Abstract

Background: Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD).

Objectives: This study evaluated outcomes of PCI versus CABG in patients with CKD.

Methods: Patients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.

Results: Of 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG.

Conclusions: In patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI.

Keywords: chronic kidney disease; multivessel disease; percutaneous coronary intervention.

Figure 1

Everolimus eluting stent (EES) versus Coronary Artery Bypass Graft surgery (CABG) for the risk of longer-term death. In the propensity score matched cohort of patients who underwent either percutaneous coronary intervention with EES or CABG there was no statistically significant difference in death between the two cohorts.

Figure 2

Everolimus eluting stent (EES) versus Coronary Artery Bypass Graft surgery (CABG) for the risk of longer-term myocardial infarction (MI). In the propensity score matched cohort of patients there was a higher risk of MI in the cohort who underwent percutaneous coronary intervention with EES when compared with those who underwent CABG. In the subgroup of patients who underwent who underwent complete revascularization with PCI, the increased risk of MI was no longer statistically significant [HR=1.18, 95% CI=0.67-2.09].

Figure 3

Everolimus eluting stent (EES) versus Coronary Artery Bypass Graft surgery (CABG) for the risk of longer-term stroke. In the propensity score matched cohort of patients there was a lower risk of stroke in the cohort who underwent percutaneous coronary intervention with EES when compared with those who underwent CABG.

Figure 4

Everolimus eluting stent (EES) versus Coronary Artery Bypass Graft surgery (CABG) for the risk of longer-term repeat revascularization. In the propensity score matched cohort of patients there was a higher risk of repeat reavscularization in the cohort who underwent percutaneous coronary intervention with EES when compared with those who underwent CABG.