G Athappan1, T Ponniah. 1. Caritas St Elizabeth Medical Center, Tufts School of Medicine, Brighton, MA 02135, USA. ganeshathappan@gmail.com
Abstract
AIM: Studies on percutaneous transluminal cardiac angioplasty (PTCA) in patients with end stage renal disease (ESRD) on hemodialysis have suggested high rates of procedural complications and restenosis. Bare metal stent percutaneous coronary intervention (PCI) has significantly reduced restenosis and subsequent target lesion revascularization in these patients, although not to the level of non dialysis controls. The introduction of drug-eluting stents (DES) has dramatically reduced restenosis rates compared with bare metal stents (BMS) in patients with various clinical and angiographic characteristics, however their impact on patients with ESRD on dialysis is unclear due to consistent exclusion of this population from major trials. The purpose of this study was therefore to compare the outcomes of PCI with DES and BMS when used for ESRD patients on dialysis, by meta analytical techniques. METHODS: Comparative studies published between January 2002 and January 2009 of DES vs. BMS in ESRD patients on dialysis were identified using an electronic search and reviewed using a random effects model. The primary endpoints of our study were the hard endpoints of mortality, myocardial infarction (MI) and target lesion revascularization (TLR). A secondary endpoint of our analysis was late luminal loss. In hospital mortality and MI were also assessed. Heterogeneity was assessed using Cochrane Q and I(2) statistics. RESULTS: Five reports comprising 641 patients (279 DES, and 362 BMS) were included in the analysis. All the studies were non-randomized comparisons between DES and BMS. The length of follow-up was in the range between 9 and 12 months. In hospital clinical outcomes were similar between the two groups. At follow-up there was a trend towards lower TLR (OR 0.50, CI 0.27-0.93, P=0.011 I(2)=48%) and decreased late luminal loss (WMD -0.34, CI -0.58 -0.10 P=0.09, I(2)=58%) in patients undergoing PCI with implantation of DES. There was no difference in the rates of all cause mortality (OR 0.66, CI 0.40-1.08, P=0.070 I(2)= 0%), and MI (OR 1.35, CI 0.52-3.52, P=0.53, I(2)%) between the two groups. CONCLUSIONS: In ESRD patients on dialysis undergoing PCI, DES are safe and reduce repeat revascularizations. The limited number of patients and limited quality of primary studies included, however need careful interpretation of our results. Further well designed, large randomized controlled trials are required to establish the strategy of management in ESRD patients undergoing PCI.
AIM: Studies on percutaneous transluminal cardiac angioplasty (PTCA) in patients with end stage renal disease (ESRD) on hemodialysis have suggested high rates of procedural complications and restenosis. Bare metal stent percutaneous coronary intervention (PCI) has significantly reduced restenosis and subsequent target lesion revascularization in these patients, although not to the level of non dialysis controls. The introduction of drug-eluting stents (DES) has dramatically reduced restenosis rates compared with bare metal stents (BMS) in patients with various clinical and angiographic characteristics, however their impact on patients with ESRD on dialysis is unclear due to consistent exclusion of this population from major trials. The purpose of this study was therefore to compare the outcomes of PCI with DES and BMS when used for ESRDpatients on dialysis, by meta analytical techniques. METHODS: Comparative studies published between January 2002 and January 2009 of DES vs. BMS in ESRDpatients on dialysis were identified using an electronic search and reviewed using a random effects model. The primary endpoints of our study were the hard endpoints of mortality, myocardial infarction (MI) and target lesion revascularization (TLR). A secondary endpoint of our analysis was late luminal loss. In hospital mortality and MI were also assessed. Heterogeneity was assessed using Cochrane Q and I(2) statistics. RESULTS: Five reports comprising 641 patients (279 DES, and 362 BMS) were included in the analysis. All the studies were non-randomized comparisons between DES and BMS. The length of follow-up was in the range between 9 and 12 months. In hospital clinical outcomes were similar between the two groups. At follow-up there was a trend towards lower TLR (OR 0.50, CI 0.27-0.93, P=0.011 I(2)=48%) and decreased late luminal loss (WMD -0.34, CI -0.58 -0.10 P=0.09, I(2)=58%) in patients undergoing PCI with implantation of DES. There was no difference in the rates of all cause mortality (OR 0.66, CI 0.40-1.08, P=0.070 I(2)= 0%), and MI (OR 1.35, CI 0.52-3.52, P=0.53, I(2)%) between the two groups. CONCLUSIONS: In ESRDpatients on dialysis undergoing PCI, DES are safe and reduce repeat revascularizations. The limited number of patients and limited quality of primary studies included, however need careful interpretation of our results. Further well designed, large randomized controlled trials are required to establish the strategy of management in ESRDpatients undergoing PCI.