Revascularization Strategies in Chronic Kidney Disease: Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery

Abstract

Chronic kidney disease (CKD) is a highly prevalent condition with rising incidence. CKD is considered a coronary heart disease equivalent and is associated with increased atherosclerotic events and mortality. Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft surgery (CABG) have routinely excluded patients with CKD or included only a small proportion of such patients. Observational studies have demonstrated that coronary revascularization is associated with improved outcomes when compared with no revascularization. However, the optimal approach to revascularization (PCI vs. CABG) remains to be determined. When compared with non-CKD cohorts, patients with CKD have worse short- and long-term outcomes with either PCI or CABG. In patients with multivessel coronary artery disease and CKD, PCI is associated with lower short-term risk of death and stroke but higher long-term mortality and need for repeat revascularization when compared with CABG. However, with improvement in stent technology, the mortality gap between PCI and CABG has reduced thus somewhat leveling the playing field between PCI and CABG. The decision to choose between PCI and CABG for subjects with CKD should be individualized taking into consideration patient comorbidities (including frailty), anatomic complexity, ability to achieve complete revascularization and patient preference. Regardless of the choice of revascularization strategy, all efforts should be made for procedural optimization in this high risk population.