Long-term clinical outcome after surgical or percutaneous coronary revascularization in hemodialysis patients

Abstract

Background: Although revascularization by coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) has been widely performed in hemodialysis (HD) patients who are at the highest risk of cardiovascular disease, there have been limited data which procedure should be optimized. We investigated long-term clinical outcome after CABG or PCI including drug-eluting stent (DES) implantation in HD patients. Methods: A total 997 maintenance HD patients electively undergoing coronary revascularization with either CABG or PCI were enrolled. Of these patients, 210 patients underwent CABG and 787 patients underwent PCI (345 with DES implantation). They were followed up to 10-year, and the incidence of major adverse cardiovascular events (MACE) as a composite endpoint including all-cause death, non-fatal myocardial infarction (MI), stroke, and target lesion revascularization (TLR) were analyzed. To reduce the selection bias between the procedures, adjusting for propensity score with all baseline covariates was also performed. Results: Prevalence of diabetes, multi-vessel disease, left main trunk lesion and left ventricular ejection fraction < 0.4 were higher in patients undergoing CABG than PCI. The rate of 30-day mortality was significantly higher in CABG group compared to PCI group (4.8% vs. 1.9%, p=0.018). During follow-up period (mean 52±39 months), 484 MACEs (death:325, MI:45, stroke:67, and TLR:274) occurred. 10-year freedom rate was higher in CABG group compared to PCI group for MACE (49.6% vs. 32.4%, p=0.0013) and for TLR (83.4% vs. 56.0%, p<0.0001), respectively. Propensity score-adjusted hazard ratio (HR) was 0.68 [95% confidence interval (CI) 0.53-0.87, p=0.0025] for MACE and 0.26 (95% CI 0.69-1.25, p<0.0001) for TLR, respectively. On the other hand, the 10-year survival rate was comparable (57.4% vs. 52.1%, p=0.65) between two groups. As a landmark analysis, adjusted HR of death was higher during 6 months after CABG compared to PCI (2.33, 95% CI 1.36-3.98, p=0.0020), but lower after 6 months onward (0.65, 95% CI 0.45-0.94, p=0.021). When compared to DES group, CABG still had advantage for TLR (HR 0.39, 95% CI 0.24-0.65, p=0.0003), however, had even for MACE (HR 0.88, 95% CI 0.67-1.16, p=0.37). Conclusion: CABG might have totally clinical advantage compared to PCI even though the survival rate was similar after these procedures.