An optimal strategy for coronary revascularization in patients with severe renal dysfunction.

OBJECTIVES: The optimal strategy for coronary revascularization in patients with renal dysfunction remains undefined. As coronary artery bypass grafting (CABG) may be associated with higher mortality, less invasive percutaneous coronary intervention (PCI) may be preferred. To date, only limited information has been published regarding the effects of severe renal dysfunction on the outcome after CABG and PCI. To address this limitation, we analysed the clinical outcomes after CABG or PCI in patients with severe renal dysfunction not on chronic haemodialysis (HD).

METHODS: Among patients enrolled in the CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) Registry (a multicentre PCI/CABG registry in Japan), we identified 374 patients with multivessel disease and an estimated glomerular filtration rate <30 ml min(-1)1.73 m(-2) (PCI: n = 229, CABG: n = 145). Patients with acute myocardial infarction (n = 221) were excluded. Then, 77 pairs were selected for further analysis using propensity score matching. The median follow-up was 2.5 years.

RESULTS: In-hospital deaths following CABG (2, 2.6%) and PCI (4, 5.2%) did not differ significantly between groups (P = 0.46). Deterioration of renal function during hospitalization occurred in 9 and 5% of the CABG and PCI groups, respectively (P = 0.35). The rate of early introduction of HD did not differ between groups: CABG, 8%; PCI, 9%. Long-term survival was not different between CABG and PCI. However, freedom from major adverse cardiac and cerebrovascular events (log-rank, P = 0.003) and target lesion revascularization (log-rank, P = 0.003) was markedly higher in CABG.

CONCLUSIONS: Despite the marked progress in PCI technologies and techniques, CABG remains the standard treatment in patients with coronary artery disease complicated by severe renal dysfunction.