Renal insufficiency and severe coronary artery disease: should coronary artery bypass grafting, off-pump coronary artery bypass grafting or percutaneous coronary intervention be performed?

Chronic kidney disease (CKD) is an important determinant of long-term survival. However, the optimal revascularization strategy for patients with CKD is still controversial. Herein we review the impact of different treatment modalities on the outcomes of patients with CKD. CABG could confer better long-term outcomes than PCI in patients with CKD, irrespective of CKD severity. CABG as compared with PCI may be associated with improved long-term survival albeit higher short-term risk. Off-pump as compared with on-pump CABG may be associated with better short-term outcomes but no demonstrable long-term benefit. In CKD patients who are treated with PCI, the use of drug-eluting stents may be associated with better intermediate-term outcomes than bare metal stents. There is insufficient evidence to inform the optimal revascularization strategy for patients with CKD and severe coronary artery disease. CABG as compared with PCI confers greater long-term benefit but higher upfront risk. A multidisciplinary, team-based evaluation based on individual patient comorbidity, frailty and anatomical disease burden, is recommended when making treatment decisions.