Zero-Contrast Multivessel Revascularization for Acute Coronary Syndrome in a Patient With Chronic Kidney Disease.
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ABSTRACT:
SUBMITTER: Madhavan MV
PROVIDER: S-EPMC8288793 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Coronary artery disease is a major cause of morbidity and mortality in the kidney transplant population. We compared the long-term outcomes of coronary artery bypass graft (CABG) surgery with percutaneous coronary intervention (PCI) for multivessel coronary disease in a contemporary cohort of US kidney transplant recipients. From the U.S. Renal Data System, we identified all adult kidney transplant patients with ?6 months of Medicare A+B undergoing first recorded multivessel coronary revascularization from 1997 to 2009. The associations of CABG versus PCI with death and the composite of death or myocardial infarction (MI) were compared using proportional hazards regression. Of the 2272 patients included in the study, 1594 underwent CABG and 678 underwent PCI. The estimated 5-year survival rate was 55% [95% confidence interval (CI) 53% to 57%] following coronary revascularization, with no significant association between revascularization type and death [adjusted hazard ratio (aHR) = 1.08; CI 0.94-1.23] or the composite of death or MI (aHR = 1.07; CI 0.96-1.18). Separate propensity score-matched analyses yielded similar results. In this analysis of kidney transplant recipients undergoing multivessel coronary revascularization, we found no difference between CABG and PCI in terms of survival or the composite of death and MI.
| S-EPMC3816637 | biostudies-literature
Project description:Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD).This study evaluated outcomes of PCI versus CABG in patients with CKD.Patients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.Of 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG.In patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI.
| S-EPMC4944845 | biostudies-literature
Project description: Not available
| S-EPMC5179393 | biostudies-literature
Project description: Not available
| S-EPMC6555142 | biostudies-literature
Project description:Coronary artery disease (CAD) has typically been treated either medically, with percutaneous coronary intervention (PCI), or with coronary artery bypass grafting (CABG). As advances in stent technology and minimally invasive surgery have developed, a third option has emerged: hybrid coronary revascularization (HCR). In HCR, minimally invasive CABG and PCI are both employed to treat a single patient, often during the same hospital stay. Patients appropriate for this technique vary widely, from low-risk patients with low SYNTAX lesions outside the left anterior descending artery (LAD), to high-risk patients with multiple comorbidities who are felt by the heart team to benefit most by avoiding a sternotomy. Across both our experience and other series in the literature, mortality with HCR is around 1%. Hospital length of stay is less than one week, and typically less than after conventional CABG, but longer than with isolated PCI. Return to baseline activity is substantially shorter after minimally invasive CABG compared to conventional CABG due to the avoidance of a sternotomy; deep sternal wound infections are entirely avoided. Mid-term need for repeat revascularization may be higher with HCR, though randomized data are lacking. In conclusion, HCR is an evolving method to treat multivessel CAD with favorable early results in high volume centers, though growth in the field is limited by surgical experience and success with minimally invasive techniques.
| S-EPMC6082776 | biostudies-other
Project description:ObjectiveHybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.MethodsThis cohort study used data from New York's cardiac surgery and PCI registries in 2010-2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years.ResultsThere was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67-1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34-0.77)).ConclusionsFor patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.
| S-EPMC8047190 | biostudies-literature
Project description:BACKGROUND:In patients with diabetes and multivessel coronary artery disease (CAD), the FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that, on average, coronary artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI) for major acute cardiovascular events (MACE) and angina reduction. Nonetheless, multivessel PCI remains a common revascularization strategy in the real world. OBJECTIVES:To translate the results of FREEDOM to individual patients in clinical practice, risk models of the heterogeneity of treatment benefit were built. METHODS:Using patient-level data from 1,900 FREEDOM patients, the authors developed models to predict 5-year MACE (all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke) and 1-year angina after CABG and PCI using baseline covariates and treatment interactions. Parsimonious models were created to support clinical use. The models were internally validated using bootstrap resampling, and the MACE model was externally validated in a large real-world registry. RESULTS:The 5-year MACE occurred in 346 (18.2%) patients, and 310 (16.3%) had angina at 1 year. The MACE model included 8 variables and treatment interactions with smoking status (c = 0.67). External validation in stable CAD (c = 0.65) and ACS (c = 0.68) demonstrated comparable performance. The 6-variable angina model included a treatment interaction with SYNTAX score (c = 0.67). PCI was never superior to CABG, and CABG was superior to PCI for MACE in 54.5% of patients and in 100% of patients with history of smoking. CONCLUSIONS:To help disseminate the results of FREEDOM, the authors created a personalized risk prediction tool for patients with diabetes and multivessel CAD that could be used in shared decision-making for CABG versus PCI by estimating each patient's personal outcomes with both treatments.
| S-EPMC7260040 | biostudies-literature
Project description:BACKGROUND:The incidence and prognostic significance of acute kidney injury (AKI) in patients with diabetes mellitus and multivessel coronary artery disease undergoing coronary revascularization is not well known. The current analysis included patients randomized to PCI vs. CABG as part of the FREEDOM trial. We sought to examine the impact of AKI and its predictors in diabetic patients with multivessel coronary artery disease undergoing PCI vs. CABG. METHODS:We conducted a pre-specified subgroup analysis of the FREEDOM trial to examine the incidence, correlates and impact of AKI according to revascularization strategy. AKI predictors were identified using multivariable logistic regression and associations between AKI and outcomes were examined using Cox regression. The primary endpoint was the composite occurrence of all-cause death, stroke or myocardial infarction at 5?years of follow-up. RESULTS:KI occurred more frequently in patients following CABG (15.6%) compared with PCI (9.1%) (p?<?0.001). AKI was associated with a higher risk for major cardiovascular events (MACE) at 5?years (34.6% vs. 20.5%, p?<?0.001), an effect that remained large and significant irrespective of CABG (HR?=?2.18 95% CI 1.44-3.31, p??0.001) or PCI (HR?=?2.08 95% CI 1.35-3.21, p?<?0.0001). There was a non-significant interaction (p-value?=?0.89) between the revascularization method and AKI, supporting that AKI is a significant risk factor in both revascularization methods. CONCLUSIONS:Although risk for AKI was higher in patients undergoing CABG, the impact of AKI on MACE was substantial irrespective of revascularization strategy. Preventive strategies to identify patients at risk for AKI are warranted to mitigate the long-term effects of this complication.
| S-EPMC6710128 | biostudies-literature
Project description:IntroductionPercutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is associated with a high risk of contrast-induced nephropathy and resulting progression of CKD to need for renal replacement therapy. Chronic total occlusions (CTO) PCI is increasingly utilized in the treatment of refractory stable angina and ischaemic heart failure. Recent studies have described the feasibility of 'minimal' or 'zero' contrast PCI by employing intravascular imaging and intra-coronary physiology to guide successful stent implantation with resolution of ischaemia. We extended these techniques to CTO lesions via the retrograde approach.Case presentationTwo patients with estimated glomerular filtration rate ≤15 mL/min who presented with angina symptoms and had subsequent positive stress tests were referred for CTO-PCI. The patients had diagnostic angiography with minimal contrast. After a recovery period, the patients underwent successful retrograde zero contrast CTO-PCI with the use of adjunctive intravascular ultrasound imaging.DiscussionThe described reports are the first two successful attempts at zero contrast retrograde procedures and demonstrate the feasibility of imaging and physiology-guided retrograde PCI without contrast administration in two patients with significant coronary artery disease requiring intervention. When indicated, zero contrast PCI offers the ability to treat obstructive coronary disease without worsening renal function in patients with severe CKD.
| S-EPMC6177013 | biostudies-literature
Project description:Hybrid coronary revascularization (HCR) combines minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. HCR is increasingly used to treat multivessel coronary artery disease that includes stenoses in the proximal left anterior descending artery and at least 1 other vessel, but its effectiveness has not been rigorously evaluated.This National Institutes of Health-funded, multicenter, observational study was conducted to explore the characteristics and outcomes of patients undergoing clinically indicated HCR and multivessel PCI for hybrid-eligible coronary artery disease, to inform the design of a confirmatory comparative effectiveness trial.Over 18 months, 200 HCR and 98 multivessel PCI patients were enrolled at 11 sites. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) (i.e., death, stroke, myocardial infarction, repeat revascularization) within 12 months post-intervention. Cox proportional hazards models were used to model time to first MACCE event. Propensity scores were used to balance the groups.Mean age was 64.2 ± 11.5 years, 25.5% of patients were female, 38.6% were diabetic, and 4.7% had previous stroke. Thirty-eight percent had 3-vessel coronary artery disease, and the mean SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score was 19.7 ± 9.6. Adjusted for baseline risk, MACCE rates were similar between groups within 12 months post-intervention (hazard ratio [HR]: 1.063; p = 0.80) and during a median 17.6 months of follow-up (HR: 0.868; p = 0.53).These observational data from this first multicenter study of HCR suggest that there is no significant difference in MACCE rates over 12 months between patients treated with multivessel PCI or HCR, an emerging modality. A randomized trial with long-term outcomes is needed to definitively compare the effectiveness of these 2 revascularization strategies. (Hybrid Revascularization Observational Study; NCT01121263).
| S-EPMC5142519 | biostudies-literature