Myocardial revascularization in patients with coronary artery disease and end-stage renal disease

Cardiovascular complications are the leading cause of death in patients with end-stage renal disease (ESRD), In 30-60% of these cases coronary artery disease, mostly multi-vessel disease can be demonstrated by coronary angiography, Because of unspecific clinical symptoms and low sensitivity of non-invasive testing patients are increasingly referred to invasive evaluation of the coronary arteries often followed by revascularization procedures, The results of clinical studies on myocardial revascularization - percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) - in patients with end-stage renal disease are reviewed and therapeutic options are discussed, In this patient group PTCA is associated with a higher periinterventional complication rate, a higher risk for recurring angina pectoris and an increased rate of restenosis when compared to historical controls, For CABG an increased percentage of perioperative deaths (2,6-20%) has been reported, which apart from cardiac causes like myocardial infarction and malignant tachyarrhythmias is caused by bleeding complications and infections. Because of rapid progression of coronary atherosclerosis and low tolerance of ischemic episodes due to diastolic dysfunction in these patients complete revascularisation is warranted in patients with end-stage renal disease, Therefore CABG should be the procedure of choice in all patients with triple-vessel disease and double-vessel disease and impaired systolic function, while PTCA should be considered in the remainder, Regardless of the revascularization procedure choosen angiographic control should be performed regularly for assessment of disease progression.