Long-Term Survival and Repeat Coronary Revascularization in Dialysis Patients Following Surgical and Percutaneous Coronary Revascularization with Drug-Eluting and Bare Metal Stents in the United States
Background—Few published data describe long-term survival of dialysis patients undergoing surgical versus percutaneous coronary revascularization in the era of drug-eluting stents (DES).
Methods and Results—Using United States Renal Data System data, we identified 23,033 dialysis patients who underwent coronary revascularization (6178 coronary artery bypass grafting [CABG], 5011 bare-metal stent [BMS], 11,844 DES), 2004-2009. Revascularization procedures decreased from 4347 in 2004 to 3344 in 2009. DES use decreased by 41% and BMS use increased by 85% 2006-2007. Long-term survival was estimated by the Kaplan-Meier method and independent predictors of mortality examined in a comorbidity-adjusted Cox model. In-hospital mortality for CABG patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28% respectively. In-hospital mortality for DES patients was 2.7%; 1, 2, and 5 year survival was 71%, 53%, and 24% respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes. Survival was significantly higher for CABG patients who received internal mammary grafts (IMG) (HR 0.83, P<0.0001). Probability of repeat revascularization accounting for the competing risk of death was 18% with BMS, 19% with DES, and 6% with CABG at 1 year.
Conclusions—Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after CABG but long-term survival was superior with IMGs. In-hospital mortality was lower for DES patients, but probability of repeat revascularization was higher and comparable to BMS patients. Revascularization decisions for dialysis patients should be individualized.
- Received January 11, 2013.
- Accepted March 29, 2013.