Kumada Yoshitaka, Ishii Hideki, Aoyama Toru, Kamoi Daisuke, Sakakibara Takashi, Umemoto Norio, Ito Ryuta, Takahashi Hiroshi, Murohara Toyoaki
Departments of Cardiovascular Surgery.
Department of Cardiology, Nagoya University Graduate School of Medicine.
Coron Artery Dis. 2018 Sep;29(6):489-494. doi: 10.1097/MCA.0000000000000628.
It remains controversial whether coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) should be optimized to treat coronary artery disease in patients on chronic hemodialysis (HD). Recently, further refinement of drug-eluting stents, such as the everolimus-eluting stent (EES), has led to marked development in this field. We compared long-term clinical outcomes after CABG versus PCI with EES implantation in patients on chronic HD.
We compared 138 patients undergoing CABG and 187 patients treated with EES implantation. The endpoint was major adverse cardiac events (MACE) as a composite outcome, including any revascularization, nonfatal myocardial infarction, or mortality. To reduce the selection bias for the two procedures, propensity score-matching was performed.
During the follow-up period (43 months), 95 (29.2%) MACEs, including 43 (13.2%) revascularizations, 14 (4.3%) nonfatal myocardial infarctions, and 63 (19.4%) deaths, occurred. The freedom rate from MACE and mortality at 5 years were comparable between groups (69.7 vs. 66.7%, P=0.82 and 75.0 vs. 80.6%, P=0.10, respectively); however, those from revascularization at 5 years was higher in the CABG group than the EES group (89.4 vs. 81.0%, P=0.030). In propensity score-matched patients (n=92), the freedom rate from revascularization at 5 years was still higher in the CABG group than in the EES group (93.4 vs. 79.1%, P=0.013). Similarly, the freedom rates from MACE and mortality were comparable (70.0 vs. 66.3%, P=0.69 and 73.8 vs. 79.7%, P=0.30, respectively).
Even in the second-generation drug-eluting stent era, CABG is still superior for preventing revascularization in patients on chronic HD. However, PCI with EES implantation might not have disadvantages compared with CABG in terms of MACE.
对于接受慢性血液透析（HD）的患者，冠状动脉旁路移植术（CABG）或经皮冠状动脉介入治疗（PCI）哪种方法更适合治疗冠状动脉疾病仍存在争议。最近，药物洗脱支架的进一步改进，如依维莫司洗脱支架（EES），使得该领域有了显著发展。我们比较了慢性HD患者接受CABG与植入EES的PCI后的长期临床结局。
我们比较了138例行CABG的患者和187例接受EES植入治疗的患者。终点为主要不良心脏事件（MACE），作为综合结局，包括任何血管重建、非致命性心肌梗死或死亡。为减少两种手术的选择偏倚，进行了倾向评分匹配。
在随访期（43个月）内，发生了95例（29.2%）MACE，包括43例（13.2%）血管重建、14例（4.3%）非致命性心肌梗死和63例（19.4%）死亡。两组间5年时MACE和死亡率的无事件生存率相当（分别为69.7%对66.7%，P = 0.82；75.0%对80.6%，P = 0.10）；然而，CABG组5年时血管重建的无事件生存率高于EES组（89.4%对81.0%，P = 0.030）。在倾向评分匹配的患者（n = 92）中，CABG组5年时血管重建的无事件生存率仍高于EES组（93.4%对79.1%，P = 0.013）。同样，MACE和死亡率的无事件生存率相当（分别为70.0%对66.3%，P = 0.69；73.8%对79.7%，P = 0.30）。
即使在第二代药物洗脱支架时代，CABG在预防慢性HD患者血管重建方面仍更具优势。然而，就MACE而言，植入EES的PCI与CABG相比可能并无劣势。
