coronaryrevascularizationinchronickidneydiseasepatient-230811162145-1e287d5a.pptx

cabg in ckd patients and their management

1. Coronary Revascularization in Chronic Kidney Disease Patient Dr. Nayan Ray MBBS Mymensingh Medical College and Hospital

2. NYN/DMA/BPL Introduction Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease, and for more severe coronary heart disease (CHD). CKD is also associated with adverse outcomes in those with existing cardiovascular disease. This includes increased mortality after an acute coronary syndrome, after percutaneous coronary intervention (PCI) with or without stenting, and after coronary artery bypass. In addition, patients with CKD are more likely to present with atypical symptoms, which may delay diagnosis and adversely affect outcomes. https://www.uptodate.com/contents/chronic-kidney-disease-and-coronary-heart-disease#H4

3. NYN/DMA/BPL ETIOLOGY. As glomerular filtration rate (GFR) declines below w60 to 75 ml/min/1.73 m2, the probability of developing CAD increases linearly and patients with CKD stages G3a to G4 (15-60 ml/min/1.73 m2) have approximately double and triple the CVD mortality risk, respectively, relative to patients without CKD. Sarnak et al. CKD and Coronary Artery Disease: A KDIGO Conference Report J A C C VO L . 7 4 , N O . 1 4 , 2 0 1 9

4. NYN/DMA/BPL Prevalence The prevalence of CHD in 2016 was 42 and 34 percent among patients on hemodialysis and peritoneal dialysis, respectively. When stratified by age, younger patients (22 to 44 years old) had a lower prevalence of CHD than older patients (>45 years old; 15 to 20 versus 33 to 53 percent, respectively). The prevalence of acute myocardial infarction was 14 and 12 percent among hemodialysis and peritoneal dialysis patients, respectively. In 2016, the adjusted mortality rate was 166 per 1000 patient-years for hemodialysis patients and 154 per 1000 patient-years for peritoneal dialysis patients. Cardiac disease accounted for 37 percent of deaths, of which 11 percent were attributed to acute myocardial infarction and CHD and 78 percent to arrhythmia and cardiac arrest. The two-year mortality rate was 34 percent for patients with CHD compared with 18 percent in those without CHD.

5. NYN/DMA/BPL Major causes of cardiovascular death in dialysis patients.

6. Data Source: Special analyses, Medicare 5% sample. Abbreviations: AF, atrial fibrillation; AMI, acute myocardial infarction; CAD, coronary artery disease; CKD, chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; CVD, cardiovascular disease; HF, heart failure; PAD, peripheral arterial disease; SCA/VA, sudden cardiac arrest and ventricular arrhythmias; VHD, valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism Prevalence of common cardiovascular diseases in patients with or without CKD, 2016 NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

7. Prevalence of (a) cardiovascular comorbidities & (b) annual incidence of cardiovascular procedures, by CKD status, age, race, & sex, 2016   (a) Cardiovascular comorbidities # Patients % Patients Overall 66-69 70-74 75-84 85+ White Blk/Af Am Other Male Female Any CVD                       Without CKD 1,086,232 32.4 19.8 27.3 39.2 52.1 33.4 28.7 23.8 36.3 29.5 Any CKD 175,840 64.5 50.0 56.9 66.9 76.5 65.3 62.1 57.3 68.1 61.0 Coronary artery disease (CAD) Without CKD 1,086,232 15.6 10.0 13.9 19.4 22.1 16.2 12.3 11.9 21.2 11.5 Any CKD 175,840 37.9 29.3 34.4 40.2 42.8 38.8 33.2 33.3 45.0 31.1 Acute myocardial infarction (AMI) Without CKD 1,086,232 2.3 1.6 2.1 2.7 3.4 2.4 1.9 1.6 3.1 1.7 Any CKD 175,840 9.3 8.1 8.5 9.5 10.4 9.5 8.2 7.6 11.0 7.6 Heart failure (HF) Without CKD 1,086,232 6.1 3.1 4.3 7.2 13.3 6.2 7.1 4.2 6.5 5.9 Any CKD 175,840 25.9 18.3 20.1 25.7 36.1 25.9 28.4 21.5 25.9 25.9 Valvular heart disease (VHD) Without CKD 1,086,232 5.1 2.6 3.9 6.6 9.3 5.4 3.4 3.5 5.0 5.2 Any CKD 175,840 12.8 7.5 9.3 13.6 18.1 13.4 10.1 10.2 12.8 12.9 Cerebrovascular accident/transient ischemic attack (CVA/TIA)   Without CKD 1,086,232 6.7 3.7 5.5 8.6 11.0 6.8 7.2 4.9 6.9 6.6 Any CKD 175,840 16.1 11.4 13.8 17.5 18.9 15.9 18.6 14.7 16.4 15.8 Peripheral artery disease (PAD) Without CKD 1,086,232 9.7 4.8 7.1 11.6 20.1 9.8 10.6 7.1 10.0 9.4 Any CKD 175,840 25.2 17.4 20.9 26.0 32.8 25.3 26.3 22.2 26.6 24.0 Atrial fibrillation (AF) Without CKD 1,086,232 9.8 4.4 7.0 12.5 19.8 10.5 4.8 5.3 11.2 8.7 Any CKD 175,840 23.8 13.5 17.3 25.3 33.7 25.5 15.0 15.6 26.1 21.6 Cardiac arrest and ventricular arrhythmias (SCA/VA) Without CKD 1,086,232 1.4 1.0 1.4 1.8 1.8 1.5 1.1 0.9 2.0 1.0 Any CKD 175,840 4.1 3.4 3.9 4.4 4.3 4.1 4.5 3.0 5.5 2.8 Venous thromboembolism and pulmonary embolism (VTE/PE) Without CKD 1,086,232 1.2 0.8 1.0 1.3 1.8 1.2 1.3 0.6 1.2 1.1 Any CKD 175,840 3.7 3.3 3.4 3.8 4.2 3.7 5.1 2.2 3.7 3.8 2018 Annual Data Report Volume 1 CKD, Chapter 4 Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2016 with fee-for-service coverage for the entire calendar year. Abbreviations: AF, atrial fibrillation; AMI, acute myocardial infarction; Blk / Af Am, Black African American; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAS/CEA, carotid artery stenting and carotid endarterectomy; CKD, chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; CVD, cardiovascular disease; HF, heart failure; ICD/CRT-D, implantable cardioverter defibrillators/cardiac resynchronization therapy with defibrillator devices; PAD, peripheral arterial disease; PCI, percutaneous coronary interventions; SCA/VA, sudden cardiac arrest and ventricular arrhythmias; VHD, valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism. (a) The denominators for overall prevalence of all cardiovascular comorbidities were Medicare enrollees aged 66+ by CKD status. (b) The denominators for overall prevalence of PCI and CABG were Medicare enrollees aged 66+ with CAD by CKD status. The denominators for overall prevalence of ICD/CRT-D were Medicare enrollees aged 66+ with HF by CKD status. The denominators for overall prevalence of CAS/CEA were Medicare enrollees aged 66+ with CAD, CVA/TIA, or PAD by CKD status

8. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2016 with fee-for-service coverage for the entire calendar year. Abbreviations: AF, atrial fibrillation; AMI, acute myocardial infarction; Blk / Af Am, Black African American; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAS/CEA, carotid artery stenting and carotid endarterectomy; CKD, chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; CVD, cardiovascular disease; HF, heart failure; ICD/CRT-D, implantable cardioverter defibrillators/cardiac resynchronization therapy with defibrillator devices; PAD, peripheral arterial disease; PCI, percutaneous coronary interventions; SCA/VA, sudden cardiac arrest and ventricular arrhythmias; VHD, valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism. (a) The denominators for overall prevalence of all cardiovascular comorbidities were Medicare enrollees aged 66+ by CKD status. (b) The denominators for overall prevalence of PCI and CABG were Medicare enrollees aged 66+ with CAD by CKD status. The denominators for overall prevalence of ICD/CRT-D were Medicare enrollees aged 66+ with HF by CKD status. The denominators for overall prevalence of CAS/CEA were Medicare enrollees aged 66+ with CAD, CVA/TIA, or PAD by CKD status. Prevalence of (a) cardiovascular comorbidities & (b) annual incidence of cardiovascular procedures, by CKD status, age, race, & sex, 2016 (continued) NYN/DMA/BPL   (b) Cardiovascular procedures # Patients % Patients Overall 66-69 70-74 75-84 85+ White Blk/Af Am Other Male Female Revascularization – percutaneous coronary interventions (PCI)           Without CKD 169,959 2.1 3.0 2.5 1.9 1.3 2.1 1.5 2.2 2.2 2.0 Any CKD 66,659 3.1 4.1 3.5 3.4 2.0 3.1 2.9 3.3 3.2 2.9 Revascularization – coronary artery bypass graft (CABG) Without CKD 169,959 1.1 1.8 1.5 1.0 0.2 1.1 0.6 1.3 1.3 0.7 Any CKD 66,659 1.5 2.7 2.4 1.6 0.3 1.6 1.0 1.0 2.0 0.9 Implantable cardioverter defibrillators & cardiac resynchronization therapy with defibrillator (ICD/CRT-D) Without CKD 66,426 0.6 0.6 0.8 0.6 0.3 0.6 0.4 0.6 0.8 0.4 Any CKD 45,552 1.0 1.5 1.4 1.1 0.6 1.0 1.4 1.0 1.4 0.7 Carotid artery stenting and carotid artery endarterectomy (CAS/CEA) Without CKD 268,808 0.5 0.6 0.7 0.6 0.2 0.6 0.3 0.4 0.6 0.4 Any CKD 93,656 0.7 0.8 0.8 0.8 0.4 0.7 0.4 0.6 0.8 0.6 2018 Annual Data Report Volume 1 CKD, Chapter 4

9. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (a) Coronary artery disease (CAD) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

10. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (b) Acute myocardial infarction (AMI) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

11. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (c) Heart failure (HF) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

12. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (d) Valvular heart disease (VHD ) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

13. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (e) Cerebrovascular accident/transient ischemic attack (CVA/TIA) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

14. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (f) Peripheral arterial disease (PAD) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

15. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (g) Atrial fibrillation (AF) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

16. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 (h) Sudden cardiac arrest and ventricular arrhythmias (SCA/VA) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

17. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 ( i ) Venous thromboembolism and pulmonary embolism (VTE/PE) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

18. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2016 with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease. Heart failure in patients with or without CKD, 2016 NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

19. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014 with fee-for-service coverage for the entire calendar year. Survival was adjusted for age, sex, race, diabetic status, and hypertension status. Abbreviation: CKD, chronic kidney disease. Adjusted survival of patients by CKD and heart failure status, 2015-2016 NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

20. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year. Abbreviations: AF, atrial fibrillation; AMI, acute myocardial infarction; CAD, coronary artery disease; CKD, chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; HF, heart failure; PAD, peripheral arterial disease; SCA/VA, sudden cardiac arrest and ventricular arrhythmias; VHD, valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism. Two-year survival of patients with a prevalent cardiovascular disease, by CKD status, adjusted for age and sex, 2015-2016 NYN/DMA/BPL   CKD status Cardiovascular disease No CKD (%) CKD (%) Stages 1 to 2 (%) Stage 3 (%) Stages 4 to 5 (%) CAD 87.4 76.6 81.1 77.6 67.4 AMI 81.7 68.5 74.5 69.0 58.6 HF 75.6 64.6 70.2 65.8 55.7 VHD 86.3 72.1 78.2 72.8 61.1 CVA/TIA 83.3 73.2 76.8 74.6 64.1 PAD 81.3 72.3 76.4 73.6 61.7 AF 82.9 70.0 75.6 71.0 59.6 SCA/VA 86.0 68.8 75.4 68.7 57.9 VTE/PE 81.4 69.6 75.4 71.2 59.3 2018 Annual Data Report Volume 1 CKD, Chapter 4

21. RISK FACTORS Traditional risk factors Diabetes (54 percent), Low serum high-density lipoprotein (HDL) cholesterol (33 percent), Hypertension (96 percent), Left ventricular hypertrophy by electrocardiographic criteria (22 percent), low physical activity (80 percent), and Increased age. NYN/DMA/BPL Risk factors and epidemiology of coronary heart disease in end-stage kidney disease

22. Risk factors unique to chronic kidney disease Chronic kidney disease alone Uremia and renal replacement therapy Disorders of mineral metabolism NYN/DMA/BPL

23. Putative mechanisms of CAD in CKD. NYN/DMA/BPL Clinical and Experimental Nephrology (2019) 23:725–732 https://doi.org/10.1007/s10157-019-01718-5

24. CAC in CKD Vascular calcification is commonly observed in CKD, because, in addition to several classical risk factors, patients with CKD also have certain unconventional risk factors of vascular calcification Among the various risk factors, mineral bone disorder is believed to be the most crucial factor for patients with CKD. The underlying mechanisms include the role of elevated serum phosphate levels, parathyroid hormone levels, and fibroblast growth factor 23 levels as well as decreased active vitamin D and klotho. Although these factors exert a considerable influence on the progression of vascular calcification in CKD, phosphate is the most important factor The supposed mechanisms of vascular calcification involve the transformation of vascular smooth muscle cells into osteoblast-like cells by the uptake of phosphorus into cells through sodium-dependent phosphorus co-transporters and decrease of inhibitors against vascular calcification NYN/DMA/BPL Clinical and Experimental Nephrology (2019) 23:725–732 https://doi.org/10.1007/s10157-019-01718-5

25. Even in the general population, serum phosphate levels are significantly associated with CAC prevalence [36]. Serum phosphate levels are also significantly associated with not only increased CAD, but also increased the other CVD events. Furthermore, the results of a meta-analysis have demonstrated that the presence of vascular calcification is significantly associated with higher CVD events and mortality NYN/DMA/BPL Clinical and Experimental Nephrology (2019) 23:725–732 https://doi.org/10.1007/s10157-019-01718-5

26. Treatment of CAD in CKD In general, aggressive treatment for CAD involves percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). It is very challenging to decide which treatment is better for patients with CKD, and the strategy is controversial. PCI is a treatment for a local vascular lesion, and CABG is a treatment for the total vessel. NYN/DMA/BPL Clinical and Experimental Nephrology (2019) 23:725–732 https://doi.org/10.1007/s10157-019-01718-5

27. Management Algorithm NYN/DMA/BPL

28. Indications for revascularization Stable CAD Persistent angina despite OMT Possible survival benefit (LM disease, 3v CAD, 2v CAD involving proximal LAD) NSTE-ACS Early invasive strategy if refractory angina, hemodynamic instability without comorbidities such as CKD Early invasive strategy not recommended if kidney failure, because risks likely outweigh benefits (Class IIIC recommendation) Invasive strategy reasonable in patients with CKD stages G2 to G3b (Class IIA recommendation) Early invasive strategy for STEMI NYN/DMA/BPL

29. PCI Percutaneous coronary intervention (PCI) in patients with significant renal dysfunction is challenging because of the lesion characteristics and the risk of contrast-induced acute kidney injury (CI-AKI). Indication: An emergency case, Early-to-moderate stage CKD, High risk involved in surgical approach, (4) Short expected life span, and Contraindication for CABG (single-vessel disease or two-vessel disease except for left anterior descending and/or left main trunk). NYN/DMA/BPL Clinical and Experimental Nephrology (2019) 23:725–732 https://doi.org/10.1007/s10157-019-01718-5

30. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on the index date, which was the date of the first procedure claim, with fee-for-service coverage for the entire year prior to this date. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a cardiovascular procedure, by CKD status, adjusted for age and sex, 2014-2016 (a) Percutaneous coronary interventions (PCI) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

31. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on the index date, which was the date of the first procedure claim, with fee-for-service coverage for the entire year prior to this date. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a cardiovascular procedure, by CKD status, adjusted for age and sex, 2014-2016 (b) Coronary artery bypass grafting (CABG) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

32. Study Findings

33. NYN/DMA/BPL Study type: Retrospective Analysis Data Source & Time : 2006–2012 National In patient Sample Database Population Size: 579,747 for NSTE-ACS and 293,950 admissions for STEMI Results: Performance of PCI increased over time among patients presenting with NSTE-ACS and STEMI in the presence of advanced CKD and independently predicted lower in-hospital mortality.

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37. Objective . To assess the safety and short-term outcomes of IVUS-guided zero-contrast PCI in chronic kidney disease (CKD) patients with complex demographics or lesion morphology Results . A total of 15 patients (27 vessels), all men (mean age, 70.0 ± 11.0 years), underwent zero-contrast PCI. )e mean estimated glomerular filtration rate ( eGFR ) and serum creatinine were 30.8 ± 7.3 mL/min/1.73m2 and 2.6 ± 1.3 mg/ dL , respectively. )e mean BMC2 risk for dialysis was 2.1 ± 1.1%, mean SYNTAX score was 20.3 ± 10.3, and mean left ventricular ejection fraction (LVEF) was 42.4 ± 11.6%. Four patients (26.6%) underwent left main coronary artery (LMCA) PCI including one LMCA bifurcation. One patient underwent chronic total occlusion PCI. Technical and procedural success were 100% without any periprocedural complications. No major adverse cardiovascular events (MACE) were reported, and no patient required dialysis within three months of follow-up. NYN/DMA/BPL

38. Methods Study Design and Population : This was a prospective single-center observational study. Clinical and procedural data were obtained from all consecutive patients who underwent zero-contrast PCI at our tertiary care center between November 2019 and May 2020. Percutaneous coronary intervention was planned in patients with significant stenosis (angiographic diameter stenosis ≥70% in non- LMCA and ≥50% in LMCA, IVUS measured minimal luminal area of <6mm2 in LMCA lesions, or flow fraction reserve [FFR] ≤ 0.8) and indication for revascularization. Patients underwent “zero-contrast PCI” if they had met any of the following criteria: (1) eGFR < 30 mL/min/1.73m2; (2) eGFR < 45 mL/min/1.73m2 (Stage 3b, 4, and 5 CKD) among patients aged >75 years or with left ventricular ejection fraction (LVEF) < 35%. NYN/DMA/BPL

39. Procedures A detailed history was collected along with baseline clinical characteristics and laboratory investigations. Baseline echocardiography and electrocardiographic changes were recorded before the procedure to facilitate the detection of changes during the procedure. Standard techniques and catheters were used during the PCI procedure. All procedures were carried out by a single operator with an experience of 200 LMCA PCI and 150 chronic total occlusion (CTO) PCI per year. Procedures were performed via femoral access and 7F guide catheters in all cases, except for one, where a 6F catheter and radial access was used. Stenting strategy (particularly in bifurcation lesions), lesion preparation, the number of stents, and postdilatation were left to the operator’s discretion. NYN/DMA/BPL

40. NYN/DMA/BPL In general, rotational atherectomy was used when IVUS detected calcium arc >180° and calcium length ≥5 mm. Post-dilatation was performed mostly using noncompliant (NC) balloons. Informed consent was obtained from all patients before the procedure. Blood transfusion was planned if postprocedure hemoglobin had reduced to 8 gm%. Boston scientific iLAB ultrasound imaging system with OptiCross 6 coronary imaging catheter (40 MHz) was used for IVUS runs. The study was approved by the institutional review board.

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47. Conclusion IVUS-guided zero-contrast PCI was found to be feasible and safe in CAD patients with moderate-to-severe CKD when done by experts. )is technique can be used safely in patients who are at high risk for CI-AKI, in centers where there is expertise for the performance of complex PCI with intravascular imaging guidance. NYN/DMA/BPL

48. NYN/DMA/BPL 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.

49. 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. NYN/DMA/BPL

50. NYN/DMA/BPL The left y-axis refers to the histogram of the number of patients with estimated glomerular filtration rate ( eGFR ) per 5 ml/min/1.73 m2 increments. The right y-axis refers to the cumulative frequency distribution curve of eGFR values. The median (25%, 75%) eGFR was 79.2 (64.0, 91.3) ml/min/1.73 m2, and the mean SD eGFR was 77.2 +- 19.1 ml/min/1.73 m2 (range 6.5 to 139.2 ml/min/1.73 m2). CKD-EPI ¼ Chronic Kidney Disease Epidemiology Collaboration.

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52. Gennaro Giustino et al. J Am Coll Cardiol 2018; 72:754-765. 3-Year Outcomes for PCI Versus CABG in Patients With or Without CKD

53. 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. NYN/DMA/BPL (EXCEL Clinical Trial [EXCEL]; NCT01205776) (J Am Coll Cardiol 2018;72:754–65)

54. NYN/DMA/BPL Data Source: PubMed and the Cochrane Library database Population: A total of 17 studies with 62,343 patients

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56. Conclusions PCI for patients with CKD and multi-vessel disease (multi-vessel CAD) had advantages over CABG with regard to short-term all-cause death and cerebrovascular accidents, but disadvantages regarding the risk of myocardial death, MI, and RR; there was no significant difference in the risk of long-term all-cause death and MACCE. Large randomized controlled trials are needed to confirm our findings. NYN/DMA/BPL

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58. NYN/DMA/BPL Population Criteria: Cohort of 4,687 adults who underwent cardiac catheterization, had a serum creatinine value measured within 30 days, and had more than one vessel with ≥50% stenosis.

59. Compared with medical management, CABG was associated with a reduced risk of death for patients of any nondialysis CKD severity (HR range 0.43–0.59). There were no significant mortality differences between CABG and PCI, except a decreased death risk in CABG-treated severe CKD patients (HR range 0.54–0.55). Compared with medical management and PCI, CABG was associated with a lower risk of death, MI, or revascularization in non-dialysis CKD patients (HR range 0.41–0.64). There were similar associations between eGFR decrease and mortality increase across all multi-vessel CAD patient treatment groups. When accounting for treatment propensity, surgical revascularization was associated with improved outcomes in patients of all CKD severities NYN/DMA/BPL

60. PCI vs. CABG for multivessel disease in patients with CKD Data from mainly nonrandomized studies Non dialysis CKD patients Short term: higher risk of death, stroke, AKI with CABG vs. PCI Long term: similar risk of death but higher MI and repeat revascularization with PCI when compared with CABG Dialysis patients Short term: higher risk of death and stroke with CABG vs. PCI Long term: higher risk of death, MI, and repeat revascularization with PCI when compared with CABG NYN/DMA/BPL

61. Prevention of AKI in PCI vs. CABG No benefit of bicarbonate and/or NAC on reduction of AKI over normal saline Risk of dialysis-dependent AKI low with ultra-low volume contrast strategies and hydration Risk of AKI considerably higher with CABG than PCI Preservation of residual kidney function by prevention of AKI critical for PD and perhaps for HD patients Recommended strategies to reduce risk include stopping offending drugs (e.g., NSAID, diuretics), hydration, titrating BP to maintain perfusion during surgery, low contrast volumes and/or zero contrast PCI Rates of CI-AKI are low in high-risk patients—should rarely be a reason to withhold needed PCI in CKD patients NYN/DMA/BPL

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64. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on the index date, which was the date of the first procedure claim, with fee-for-service coverage for the entire year prior to this date. Abbreviation: CKD, chronic kidney disease. Probability of survival of patients with a cardiovascular procedure, by CKD status, adjusted for age and sex, 2014-2016 (d) Carotid artery stenting and carotid endarterectomy (CAS/CEA) NYN/DMA/BPL 2018 Annual Data Report Volume 1 CKD, Chapter 4

65. Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on the index date, which was the date of the first procedure claim, with fee-for-service coverage for the entire year prior to this date. Abbreviations: CABG, coronary artery bypass grafting; CAS/CEA, carotid artery stenting and carotid endarterectomy; CKD, chronic kidney disease; ICD/CRT-D, implantable cardioverter defibrillators/cardiac resynchronization therapy with defibrillator devices; PCI, percutaneous coronary interventions. Two-year survival of patients with a cardiovascular procedure, by CKD status, adjusted for age and sex, 2014-2016 NYN/DMA/BPL   CKD status Cardiovascular procedure No CKD (%) CKD (%) Stages 1 to 2 (%) Stage 3 (%) Stages 4 to 5 (%) PCI 83.2 73.0 76.3 74.1 64.3 CABG 89.3 81.8 85.3 82.2 71.8 ICD/CRT-D 79.2 60.3 68.3 60.3 55.1 CAS/CEA 86.4 78.2 78.5 79.0 70.1 2018 Annual Data Report Volume 1 CKD, Chapter 4

66. Conclusion Coronary revascularization decisions for patients with CKD present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. NYN/DMA/BPL J Am Soc Nephrol . 2016 Dec; 27(12): 3521–3529.

67. Compared with percutaneous strategies, surgical revascularization seems to have long–term survival benefit on the basis of observational data but associates with substantially higher short–term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long–term mortality hazard. Off–pump coronary bypass surgery and the newest generation of drug–eluting stent platforms offer no definitive benefits. NYN/DMA/BPL

68. Thank You NYN/DMA/BPL