Komiya Tatsuhiko, Ueno Go, Kadota Kazushige, Mitsudo Kazuaki, Okabayashi Hitoshi, Nishiwaki Noboru, Hanyu Michiya, Kimura Takeshi, Tanaka Shiro, Marui Akira, Sakata Ryuzo
Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan.
Eur J Cardiothorac Surg. 2015 Aug;48(2):293-300. doi: 10.1093/ejcts/ezu426. Epub 2014 Nov 21.
The optimal strategy for coronary revascularization in patients with renal dysfunction remains undefined. As coronary artery bypass grafting (CABG) may be associated with higher mortality, less invasive percutaneous coronary intervention (PCI) may be preferred. To date, only limited information has been published regarding the effects of severe renal dysfunction on the outcome after CABG and PCI. To address this limitation, we analysed the clinical outcomes after CABG or PCI in patients with severe renal dysfunction not on chronic haemodialysis (HD).
Among patients enrolled in the CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) Registry (a multicentre PCI/CABG registry in Japan), we identified 374 patients with multivessel disease and an estimated glomerular filtration rate <30 ml min(-1)1.73 m(-2) (PCI: n = 229, CABG: n = 145). Patients with acute myocardial infarction (n = 221) were excluded. Then, 77 pairs were selected for further analysis using propensity score matching. The median follow-up was 2.5 years.
In-hospital deaths following CABG (2, 2.6%) and PCI (4, 5.2%) did not differ significantly between groups (P = 0.46). Deterioration of renal function during hospitalization occurred in 9 and 5% of the CABG and PCI groups, respectively (P = 0.35). The rate of early introduction of HD did not differ between groups: CABG, 8%; PCI, 9%. Long-term survival was not different between CABG and PCI. However, freedom from major adverse cardiac and cerebrovascular events (log-rank, P = 0.003) and target lesion revascularization (log-rank, P = 0.003) was markedly higher in CABG.
Despite the marked progress in PCI technologies and techniques, CABG remains the standard treatment in patients with coronary artery disease complicated by severe renal dysfunction.
肾功能不全患者的冠状动脉血运重建最佳策略仍不明确。由于冠状动脉旁路移植术（CABG）可能与较高死亡率相关，因此可能更倾向于采用侵入性较小的经皮冠状动脉介入治疗（PCI）。迄今为止，关于严重肾功能不全对CABG和PCI术后结局的影响，仅有有限的信息发表。为解决这一局限性，我们分析了未接受慢性血液透析（HD）的严重肾功能不全患者接受CABG或PCI后的临床结局。
在参与CREDO - 京都（京都冠状动脉血运重建结局研究）注册研究（日本一项多中心PCI/CABG注册研究）的患者中，我们确定了374例多支血管病变且估算肾小球滤过率<30 ml·min⁻¹·1.73 m⁻²的患者（PCI组：n = 229，CABG组：n = 145）。排除急性心肌梗死患者（n = 221）。然后，使用倾向评分匹配法选择77对患者进行进一步分析。中位随访时间为2.5年。
CABG组（2例 [2.6%]）和PCI组（4例 [5.2%]）的住院死亡在两组间无显著差异（P = 0.46）。CABG组和PCI组分别有9%和5%的患者在住院期间肾功能恶化（P = 0.35）。两组早期开始HD的比例无差异：CABG组为8%，PCI组为9%。CABG组和PCI组的长期生存率无差异。然而，CABG组无主要不良心脑血管事件（对数秩检验，P = 0.003）和靶病变血运重建（对数秩检验，P = 0.003）的发生率显著更高。
尽管PCI技术和技巧取得了显著进展，但CABG仍然是合并严重肾功能不全的冠心病患者的标准治疗方法。
