Coronary Artery Revascularization in Chronic Kidney Disease

Coronary artery revascularization procedures, performed via coronary artery bypass grafting (CABG) or percutaneous (PCI) methods, are among the most commonly performed therapeutic interventions worldwide with >1 million performed annually in the United States alone.1 The relative merits of each approach have been examined in numerous landmark clinical trials that inform practice guidelines and daily clinical decision making.2–5 Although the percutaneous comparator to CABG in early studies usually included balloon angioplasty or bare metal stents, recent studies reflect iterative advances in both stent technology and contemporary medical therapy. Despite this large evidence base, however, routine exclusion of patients with underlying chronic kidney disease (CKD) persists in many clinical trials. In the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI 2D) and Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) studies, for example, patients were excluded with serum creatinine levels exceeding 2 mg/dL and severe renal disease, respectively.2 The public health implication of such systematic under-representation is highlighted by the fact that CKD is present in >40% of all patients undergoing PCI and ≈30% of those receiving CABG.6,7 In addition, renal dysfunction confers a strong, independent, and graded risk for morbidity and mortality after PCI or CABG. The high prevalence of CKD in patients requiring revascularization, coupled with the excess cardiac risk associated with this condition, has motivated consensus statements and clinical investigations examining the impact of PCI and CABG in this high-risk population.8,9See Article by Chan et al It is within the context that Chan et al10 have reported their findings comparing CABG to PCI with drug-eluting stents (DES) in a large cohort …