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Updated: Feb 6, 2026
Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease: EXCEL Trial
Gennaro Giustino1, Roxana Mehran2, Patrick W Serruys3
1The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York. Electronic address: https://twitter.com/g_giustinoMD.
Insights
Patients with chronic kidney disease (CKD) undergoing left main coronary artery disease (LMCAD) revascularization had higher risks of acute renal failure (ARF). Percutaneous coronary intervention (PCI) showed lower ARF rates than coronary artery bypass graft (CABG) surgery, with similar long-term outcomes.
Area of Science:
- Cardiology
- Nephrology
- Interventional Cardiology
Background:
- Optimal revascularization strategy for left main coronary artery disease (LMCAD) in patients with chronic kidney disease (CKD) is not well-defined.
- CKD is associated with increased risks in cardiovascular interventions.
Purpose of the Study:
- To compare the effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery for LMCAD in patients with and without CKD.
- To assess the impact of baseline renal function on outcomes after LMCAD revascularization.
Main Methods:
- Analysis of data from the multicenter randomized EXCEL trial.
- Inclusion of patients with LMCAD and low/intermediate anatomical complexity.
- Definition of CKD as eGFR <60 mL/min/1.73 m² and ARF as a significant creatinine increase or need for dialysis.
Main Results:
- Patients with CKD had higher 3-year rates of death, MI, or stroke compared to those without CKD (20.8% vs. 13.5%).
- Acute renal failure (ARF) occurred more frequently in CKD patients (5.0% vs. 0.8%) and was linked to worse outcomes.
- ARF was less common after PCI than CABG in both CKD and non-CKD groups.
- No significant differences in the primary composite endpoint (death, MI, stroke) were observed between PCI and CABG in patients with or without CKD at 3 years.
Conclusions:
- CKD patients undergoing LMCAD revascularization face higher ARF rates and reduced event-free survival.
- PCI demonstrated a lower incidence of ARF compared to CABG.
- Both PCI and CABG offered similar 3-year outcomes regarding death, stroke, or MI in patients with and without CKD.
Background:
The optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD) remains unclear.
Objectives:
This study investigated the comparative effectiveness of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery in patients with LMCAD and low or intermediate anatomical complexity according to baseline renal function from the multicenter randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial.
Methods:
CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 using the CKD Epidemiology Collaboration equation. Acute renal failure (ARF) was defined as a serum creatinine increase ≥5.0 mg/dl from baseline or a new requirement for dialysis. The primary composite endpoint was the composite of death, myocardial infarction (MI), or stroke at 3-year follow-up.
Results:
CKD was present in 361 of 1,869 randomized patients (19.3%) in whom baseline estimated glomerular filtration rate was available. Patients with CKD had higher 3-year rates of the primary endpoint compared with those without CKD (20.8% vs. 13.5%; hazard ratio [HR]: 1.60; 95% confidence interval [CI]: 1.22 to 2.09; p = 0.0005). ARF within 30 days occurred more commonly in patients with compared with those without CKD (5.0% vs. 0.8%; p < 0.0001), and was strongly associated with the 3-year risk of death, stroke, or MI (50.7% vs. 14.4%; HR: 4.59; 95% CI: 2.73 to 7.73; p < 0.0001). ARF occurred less commonly after revascularization with PCI compared with CABG both in patients with CKD (2.3% vs. 7.7%; HR: 0.28; 95% CI: 0.09 to 0.87) and in those without CKD (0.3% vs. 1.3%; HR: 0.20; 95% CI: 0.04 to 0.90; pinteraction = 0.71). There were no significant differences in the rates of the primary composite endpoint after PCI and CABG in patients with CKD (23.4% vs. 18.1%; HR: 1.25; 95% CI: 0.79 to 1.98) and without CKD (13.4% vs. 13.5%; HR: 0.97; 95% CI: 0.73 to 1.27; pinteraction = 0.38).
Conclusions:
Patients with CKD undergoing revascularization for LMCAD in the EXCEL trial had increased rates of ARF and reduced event-free survival. ARF occurred less frequently after PCI compared with CABG. There were no significant differences between PCI and CABG in terms of death, stroke, or MI at 3 years in patients with and without CKD. (EXCEL Clinical Trial [EXCEL]; NCT01205776).
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