Left Main Revascularization in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Abstract

Introduction/objective: This systematic review and meta-analysis compares percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) as revascularization strategies for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD).

Methods: A comprehensive search of PubMed, Embase, and CENTRAL was conducted, with a pre-registered study protocol registered on PROSPERO (ID: CRD42024496529). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of allcause mortality, myocardial infarction (MI), stroke, or ischemia-driven revascularization. Secondary endpoints included each component of MACCE and 30-day all-cause mortality.

Results: Seven studies were analyzed, including five cohort studies and two subanalyses of randomized clinical trials, encompassing 3,475 patients. PCI was associated with a higher incidence of MACCE (hazard ratio [HR]: 1.50; 95% confidence interval [CI] 1.26-1.79), driven by allcause mortality (HR: 1.38; 95% CI 1.07-1.78), MI (HR: 1.75; 95% CI 1.17-2.62), and ischemiadriven revascularization (HR: 3.22; 95% CI 2.10-4.93). There were no differences in stroke rates (HR: 0.70; 95% CI 0.40-1.22) or 30-day all-cause mortality (odds ratio [OR]: 0.92; 95% CI 0.35-2.41).

Discussion: While previous studies have reported conflicting evidence regarding the noninferiority of PCI to CABG in patients with LMCAD, our pooled analysis demonstrates an increased incidence of MACCE in the PCI group, primarily driven by higher rates of all-cause mortality, myocardial infarction, and ischemia-driven revascularization. The findings suggest that CKD may play a role in clinical outcomes comparable to diabetes in multivessel disease and should be a key factor in revascularization decisions.

Conclusion: CABG is associated with superior long-term outcomes compared to PCI in patients with LMCAD and CKD. However, dedicated randomized controlled trials stratified by CKD stage are essential to guide optimal treatment strategies in this high-risk population.

Keywords: CABG.; Left main coronary artery disease; PCI; chronic kidney disease; mortality; revascularization; systematic review and meta-analysis.