Does coronary artery bypass graft surgery improve survival among patients with end-stage renal disease?

Cardiovascular disease remains the most frequent cause of death for patients with end-stage renal disease. To determine the long-term benefit of surgical revascularization in this high-risk population, we studied our patients with ESRD having coronary artery bypass graft surgery (CABG), comparing the results of off-pump to on-pump revascularization. As a baseline reference group, we used dialysis patients with a diagnosis of coronary artery disease who did not have surgical revascularization or percutaneous coronary interventions. The control group data set was obtained from the United States Renal Data System.

From January 1995 through July 2003, 158 patients with end-stage renal disease who were on hemodialysis (excluding those in cardiogenic shock, needing resuscitation, and with emergent or salvage status) underwent CABG. Fifty-nine patients (37.3%) had off-pump revascularization, and 99 patients (62.7%) had bypass grafting utilizing extracorporeal circulation. Preoperative risk factors and operative results were analyzed, and longitudinal survival data obtained.

The mean follow-up time was 39.1 months (median, 33.1) for the on-pump patients and 18.3 months (median, 14.7) for off-pump. The total number of anastomoses per off-pump patient was 2.4 +/- 1.0, and with cardiopulmonary bypass (CPB), it was 3.3 +/- 0.9 (p < 0.001). Patients revascularized off-pump had an operative mortality rate of 1.7%, whereas patients grafted using CPB had an operative mortality of 17.2% (p = 0.003). The predicted risk of mortality for the off-pump group (9.3% +/- 7.4%) was not statistically different from the on-pump cohort (9.1% +/- 7.7%, p = not significant). Logistic regression analysis indicates that CPB use was an independent risk factor for early death (p = 0.01, odds ratio = 13.6, 95% confidence interval: 1.7 to 110). Long-term follow-up demonstrated that the patients revascularized using CPB had improved survival compared with the off-pump patients and the control population.

Off-pump CABG improves early mortality rate when compared with conventional revascularization. Despite a greater operative mortality, however, long-term survival is improved in the patients revascularized with CPB as compared with the off-pump cohort, suggesting possible advantages from a more complete revascularization in this population.