An additional concern regarding patients with advanced CKD and ESRD is the anatomy of their coronary arteries, which are frequently diffusely diseased.44 These issues can raise technical challenges in the delivery of coronary devices during routine PCI, particularly for those with ESRD caused by extensive coronary calcification. Additional strategies such as rotational atherectomy may be required under these circumstances for plaque modification before coronary stent delivery.
After PCI, the presence of CKD and ESRD is also associated with higher rates of major adverse cardiovascular events, including restenosis and repeat target vessel revascularization. In the era before routine stenting, restenosis was a substantial problem, with rates as high as 80% in patients with ESRD. Although the likelihood of these complications has diminished with the availability of newer devices, there still appears to be an increased risk.45,46 For example, Rubenstein and colleagues demonstrated that CKD was independently predictive of worse outcomes, including repeat revascularization, in a cohort of 3334 patients undergoing PCI during a period when coronary stenting and atherectomy were being introduced (Fig. 5-5).46 Within their study population, there also appeared to be no difference between patients with CKD and those with ESRD.46 Although the data are limited, some reports also have suggested that the development of drug-eluting stents may minimize the risk of restenosis even further in patients with CKD and ESRD.47,48 This area requires further investigation.
Another critical issue in these patients is determining the risks and benefits of PCI versus surgical revas-cularization. This is a controversial area, and clinical trials have been unable to directly inform this issue, because most have excluded patients with significant CKD and ESRD. In the absence of adequate clinical trial data, this decision is often individualized and relies on the goals of treatment, the likelihood of technical success with PCI, and the patient's operative risk with bypass surgery.49,50
Finally, it is important for the interventional cardiologist to appropriately select and dose adjunctive drug therapy in patients with CKD and ESRD. The
Figure 5-5. Kaplan-Meier event-free survival for major adverse cardiovascular events, including repeat revascularization, in patients with chronic kidney disease including end-stage renal disease (Renal) versus matched control patients undergoing percutaneous coronary intervention. (From Rubenstein MH, Harrell LC, Sheynberg BV, et al: Are patients with renal failure good candidates for percutaneous coronary revascularization in the new device era? Circulation 2000;102:2966.)
Rights were not granted to include this figure in electronic media Please refer to the printed publication.
risks and benefits of many drugs routinely used as adjunctive therapy in PCI, including glycoprotein IIb/IIIa inhibitors and bivalirudin, need to be carefully weighed in this population because of their diminished renal clearance and potentially increased risk for bleeding.51,52
Patients with CKD often have existing comorbidities that may complicate their procedure and postproce-dure management. As always, developing a systematic approach that incorporates the patient's history, physical examination, and laboratory studies is critical. As described earlier, the clinician needs to pay particular attention to accurate assessment of the degree of CKD at baseline, as well as several clinical risk factors that have been consistently associated with poor outcomes in patients with CKD (e.g., diabetes mellitus, hemodynamic instability). Most of the approaches described here are designed to minimize the risk of contrast-related nephropathy, which is the most likely cause of renal dysfunction after cardiac catheterization and PCI. These approaches are summarized in Table 5-4.
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