Long-term outcome of dialysis patients in the United States with coronary revascularization procedures

Background. The optimal method of coronary revascularization in dialysis pa tients is controversial, as previous small retrospective studies have repor ted increased cardiac events after percutaneous transluminal coronary angio plasty (PTCA) compared with coronary artery bypass (CAB) surgery. The purpo se of this study was to compare the long-term survival of chronic dialysis patients in the United States following PTCA or CAB surgery. Methods. Dialysis patients hospitalized from 1978 to 1995 for first coronar y revascularization procedure after initiation Of renal replacement therapy were retrospectively identified from the United States Renal Data System d atabase. Survival for the endpoints of all-cause death, cardiac death, myoc ardial infarction, and cardiac death or myocardial infarction was estimated by the life-table method and was compared by the log-rank test. The impact of independent predictors on survival was examined in a Cox regression mod el with comorbidity adjustment. Results. The in-hospital mortality was 5.4% for 6887 PTCA patients and 12.5 % for 7419 CAB patients. The two-year event-free survival (+/-SE) of PTCA p atients was 52.9 +/- 0.7% for all-cause death, 72.5 +/- 0.7% for cardiac de ath, and 62.0 +/- 0.7% for cardiac death or myocardial infarction. in CAB p atients, the comparable survivals were 56.9 +/- 0.6. 75.8 +/- 0.6, and 71.3 +/- 0.6%, respectively (P < 0.02 for PTCA vs. CAB surgery for all endpoint s). After comorbidity adjustment, the relative risk of CAB surgery (vs. PTC A) performed 1990 to 1995 for all-cause death was 0.91 (95% CI, 0.86 to 0.9 7), cardiac death, 0.85 (95% CI, 0.78 to 0.92); myocardial infarction, 0.37 (95% CI, 0.32 to 0.43); and cardiac death or myocardial infarction 0.69 (9 5% CI, 0.64 to 0.74). Conclusions. In this retrospective study, dialysis patients in the United S tates had better survival after CAB surgery compared with PTCA, but our stu dy does not exclude the possibility of more unfavorable coronary anatomy in the PTCA patients at baseline, Our data support the need for prospective t rials of newer percutaneous coronary revascularization procedures in dialys is patients.