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    • Introduction Coronary artery disease CAD is a major cause

    2018-11-06

    Introduction Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Despite the development of revascularization therapies and refinement of surgical techniques in past decades, the prognosis of patients with ESRD remains poor; the estimated 5-year survival rate after dialysis guanabenz is only approximately 34%. The most crucial cause of mortality in these patients is cardiac disease, accounting for 39–45% of all deaths. Compared with nondialysis patients, patients with ESRD are more likely to have CAD, and most cases are symptomatic multivessel CAD. Moreover, the prevalence and incidence of ESRD are high in Taiwan. Therefore, we conducted this review to determine the survival outcomes and risk factors for mortality following coronary artery bypass grafting (CABG) surgery.
    Revascularization: percutaneous coronary intervention versus CABG The most appropriate method for revascularization is debatable. To date, the optimal treatment for cardiac disease in patients with ESRD remains unknown. According to our research, no randomized controlled trial specifically addressing this debate has been reported. A previous study suggested using CABG over percutaneous coronary intervention (PCI) for complete revascularization because CABG has an extensive atherosclerotic nature and provides a higher chance for renal transplantation in the future. However, in recent decades, the use of PCI has increased, despite evidence of more favorable long-term outcomes in patients with ESRD after CABG compared with those in these patients after medical management or PCI. In other words, an increasing number of patients with ESRD and stable multivessel CAD have undergone PCI as a treatment option. With advancements in technology, a decreased risk of complications and a higher success rate can be achieved, which is crucial given the foreseeable need for repeat revascularization. Advancements in CABG surgery have lowered operative morbidity and mortality rates. In addition, cardiac surgery has become considerably safer for patients with ESRD in recent years; however, their overall prognosis remains poor. The perioperative risks involved in cardiac surgery are higher in patients with ESRD than in the general cardiac patient population, possibly because of multiple extracardiac comorbidities such as ventricular hypertrophy, cerebrovascular and peripheral artery disease, infection, electrolyte disturbance, anemia, cachexia, and increased oxidative stress. Ko et al reported an overall mortality rate of 9% in 296 patients with ESRD who underwent cardiopulmonary bypass (CPB) procedures. According to the American College of Cardiology and American Heart Association guidelines, CABG can be performed in select dialysis patients, with an increased but acceptable risk of perioperative morbidity and mortality.
    Off-pump CABG versus on-pump CABG The increased operative risk in ESRD patients undergoing cardiac surgery is mostly due to preexisting multisystem diseases, generalized atherosclerosis, heavily calcified aorta and coronary arteries, complicated intraoperative and postoperative management, and bleeding tendency. Off-pump coronary artery bypass (OPCAB) seems intuitively simpler and less invasive for hemodialysis (HD)-dependent patients. Manabe et al suggested a physiological basis for supporting OPCAB in HD patients; they reported an improvement in cardiac hemodynamics in terms of a postoperative decrease in the right atrial and pulmonary capillary wedge pressure and postoperative lung oxygenation in patients who underwent OPCAB compared with those who underwent on-pump CABG. Moreover, the application of newly developed surgical equipment, such as stabilizers, has facilitated coronary anastomoses on the beating heart, thus avoiding the need for CPB surgery and preventing subsequent inflammatory responses, fluid overload, electrolyte imbalance, and aggravated bleeding disorders in patients with uremia. In addition, with less manipulation of the ascending aorta, postoperative neurological complications might be decreased.