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Published on: November 19, 2019
Arterial Grafting Survival Benefit in Patients With End-Stage Renal Disease Undergoing Coronary Artery Bypass
Christine Yang1, Sameer Singh1, Takuya Ogami2
1Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
Insights
For end-stage renal disease patients undergoing coronary artery bypass grafting, left internal mammary artery grafting offers an early survival benefit over SVG-only in non-transplanted individuals. Multi-arterial grafting showed no significant survival advantage.
Area of Science:
- Cardiovascular Surgery
- Nephrology
- Transplantation Medicine
Background:
- End-stage renal disease (ESRD) significantly increases risks for patients undergoing coronary artery bypass grafting (CABG).
- The survival advantage of arterial grafting versus saphenous vein graft (SVG)-only in ESRD patients remains uncertain.
- Kidney transplantation dramatically impacts long-term survival in ESRD patients.
Purpose of the Study:
- To compare hospital and long-term survival outcomes.
- To evaluate arterial grafting strategies (LIMA+SVG, MAG, SVG-only) in ESRD patients undergoing CABG.
- To assess outcomes in both transplanted and non-transplanted ESRD patient cohorts.
Main Methods:
- Utilized the United States Renal Data System (USRDS) for data from 2015-2021.
- Analyzed isolated CABG patients with subsequent transplant status.
- Employed Inverse Probability of Treatment Weighting (IPTW) to balance baseline characteristics.
Main Results:
- Left internal mammary artery (LIMA) grafting demonstrated a 5-year survival benefit over SVG-only in non-transplanted ESRD patients (31.6% vs. 26.6%; p < 0.001).
- This LIMA benefit diminished after 4 years in landmark analysis.
- Multi-arterial grafting (MAG) did not show a significant 5-year survival benefit compared to LIMA in either transplanted or non-transplanted ESRD patients.
Conclusions:
- An early survival benefit exists for LIMA grafting in non-transplanted ESRD patients undergoing CABG.
- Limited evidence suggests MAG does not offer a survival advantage over LIMA in ESRD patients, irrespective of transplant status.
- Arterial grafting strategies warrant careful consideration in ESRD patients undergoing CABG.
Background:
End-stage renal disease (ESRD) is associated with increased morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG); however, the survival benefit of arterial grafting in this population remains unclear. Given the dramatic impact that transplantation can have on long-term survival in patients with ESRD, this study compared hospital and long-term survival for arterial graft vs saphenous vein graft (SVG) only in patients with ESRD who did or did not undergo transplantation.
Methods:
With use of the United States Renal Data System, data were collected on all isolated CABG patients along with subsequent transplant status from 2015 to 2021. CABG patterns were divided as left internal mammary artery (LIMA) plus SVG, SVG only, and multiarterial grafting (MAG). Inverse probability of treatment weighting (IPTW) was used to adjust for baseline differences.
Results:
In total, there were 14,917 (89.8%) patients in LIMA, 512 (3.1%) patients in MAG, and 1187 (7.1%) patients in SVG only. After IPTW, comparison groups were well balanced. In IPTW-adjusted cohorts, LIMA showed a 5-year survival benefit compared with SVG only in patients not receiving transplants (31.6% vs 26.6%; P < .001); however, in landmark analysis, this difference diminished after 4 years. MAG grafting did not show a 5-year survival benefit over LIMA in either patients who did not undergo transplantation (31.7% vs 31.6%; P = .21) or patients who received transplants (80.5% vs 84.8%; P = .65).
Conclusion:
Despite diminished life expectancy for patients with ESRD, there remains an early survival benefit for LIMA grafting in patients who do not undergo transplantation. Limited data did not demonstrate a significant survival benefit for MAG vs LIMA in patients with ESRD regardless of subsequent transplantation status.
