Karkhanis Reena, Tam Derrick Y, Fremes Stephen E
Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
Curr Opin Cardiol. 2018 Sep;33(5):546-550. doi: 10.1097/HCO.0000000000000539.
Coronary artery disease is common in patients with end-stage renal disease (ESRD) on hemodialysis. ESRD patients are prone to atherosclerosis and are likely to present with advanced CAD requiring coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI).
Individual observational studies and aggregated results comparing PCI to CABG have shown an increased risk of early postoperative mortality in the CABG group followed by a decrease in late mortality and cardiovascular events. Drug eluting stents are preferred to bare metal stents in patients undergoing PCI. Bilateral versus single internal thoracic arterial grafting strategies showed no difference in survival, freedom from cardiac death or freedom from cardiac events. There was no clear survival advantage to off-pump CABG over on-pump CABG in ESRD patients. Evidence to support either CABG or PCI was limited to retrospective observational studies that were at risk for treatment allocation bias.
CABG carries an upfront risk of increased perioperative mortality while demonstrating late survival benefit compared with PCI. Thus, in the context of balancing these competing risks and benefits, deciding on the most appropriate treatment in this high-risk cohort is challenging. Comprehensive patient evaluation by a multidisciplinary team is strongly recommended.
冠状动脉疾病在接受血液透析的终末期肾病（ESRD）患者中很常见。ESRD患者易患动脉粥样硬化，很可能出现需要冠状动脉旁路移植术（CABG）或经皮冠状动脉介入治疗（PCI）的晚期冠心病。
比较PCI与CABG的个体观察性研究及汇总结果显示，CABG组术后早期死亡率增加，随后晚期死亡率和心血管事件减少。接受PCI的患者中，药物洗脱支架优于裸金属支架。双侧与单支胸廓内动脉移植策略在生存率、无心脏死亡或无心脏事件方面无差异。在ESRD患者中，非体外循环CABG与体外循环CABG相比，没有明显的生存优势。支持CABG或PCI的证据仅限于存在治疗分配偏倚风险的回顾性观察性研究。
CABG围手术期死亡率有前期增加的风险，而与PCI相比有晚期生存获益。因此，在平衡这些相互竞争的风险和获益的背景下，在这个高危人群中决定最合适的治疗方法具有挑战性。强烈建议由多学科团队对患者进行全面评估。
