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Optimal Method of Coronary Revascularization in Patients Receiving Dialysis: Systematic Review

Immaculate F. Nevis^*,, Anna Mathew^*, Richard J. Novick, Chirag R. Parikh, Philip J. Devereaux^||,¶, Madhu K. Natarajan^¶, Arthur V. Iansavichus^*, Meaghan S. Cuerden^*,, and Amit X. Garg^*,,||

^* Division of Nephrology and Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada; Section of Nephrology, Yale University, New Haven, Connecticut; ^¶ Division of Cardiology and ^|| Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada

Correspondence: Dr. Amit Garg, London Kidney Clinical Research Unit, Room ELL-101, Westminster Tower, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario N6A 4G5, Canada. Phone: 519-685-8502; Fax: 519-685-8072; E-mail: amit.garg{at}lhsc.on.ca

Background and objectives: Patients receiving dialysis have a high burden of cardiovascular disease. Some receive coronary artery revascularization but the optimal method is controversial.

Design, setting, participants, & measurements: The authors reviewed any randomized controlled trial or cohort study of 10 or more patients receiving maintenance dialysis which compared coronary artery bypass graft (CABG) to percutaneous intervention (PCI) for revascularization of the coronary arteries. The primary outcomes were short-term (30 d or in-hospital) and long-term (at least 1 year) mortality.

Results: Seventeen studies were found. There were no randomized trials: all were retrospective cohort studies from years 1977 to 2002. There were some baseline differences between the groups receiving CABG compared with those receiving PCI, and most studies did not consider results adjusted for such characteristics. Given the variability among studies and their methodological limitations, few definitive conclusions about the optimal method of revascularization could be drawn. In an exploratory meta-analysis, short-term mortality was higher after CABG compared to PCI. A substantial number of patients died over a subsequent 1 to 5 yr, with no difference in mortality after CABG compared to PCI.

Conclusions: Although decisions about the optimal method of coronary artery revascularization in dialysis patients are undertaken routinely, it was surprising to see how few data has been published in this regard. Additional research will help inform physician and patient decisions about coronary artery revascularization.