Treatment of Coronary Artery Disease in Dialysis Patients with Sirolimus-eluting Stents: 1-year Clinical Follow-up of a Consecut

In this preliminary series, sirolimus-eluting stent implantation appeared safe and effective for the treatment of dialysis patients with coronary artery disease. Dialysis patients are well known to be a high-risk population for cardiovascular morbidity and mortality, especially due to coronary atherosclerotic disease. However, the management of coronary disease in patients with end-stage renal failure is often problematic due to the presence of multiple co-morbidities and frequent limitations to drug prescription.¹ Moreover, these patients have been reported to be at a higher risk for short- and long-term complications after invasive treatment compared to non-dialysis patients.^2,3 The overall impact of invasive coronary treatment in dialysis patients is an ongoing debate. In a recent report, coronary bypass surgery was associated with superior outcomes compared to conventional stenting, with in-stent restenosis being suggested as a possible contributor to the impaired outcomes after percutaneous treatment.⁴ Sirolimus-eluting stents (SES) have been recently shown in randomized studies to markedly decrease neointimal growth and in-stent restenosis in comparison with conventional stents.^5-7 However, all clinical trials conducted to date excluded patients with decreased renal function, and therefore the impact of SES implantation in patients with renal failure is currently unknown. The present study aimed to report on the 1-year clinical outcomes of a consecutive series of patients on chronic dialysis treated with SES. Since April 2002, SES (Cypher; Johnson & Johnson-Cordis unit, Cordis Europa NV, Roden, the Netherlands) have been routinely utilized as the device of choice for all patients treated with percutaneous coronary intervention in our institution.8 During the first 6 months of this policy, SES implantation was performed in ten consecutive patients on chronic dialysis, who comprise the present study population. All patients on either chronic haemodialysis or peritoneal dialysis at the time of the procedure were included. Methods Percutaneous interventions were performed utilizing standard techniques, with the final strategy entirely left at the discretion of the operator aiming to achieve a residual stenosis 2,4,9–22 Although the present study did not include an angiographic re-evaluation, the uneventful late clinical outcomes observed were consistent with a marked reduction in the incidence of restenosis, as seen in non-dialysis patients.^5–7 Coronary surgery has been associated with better clinical outcomes than percutaneous intervention in patients on chronic dialysis.⁴ However, the impact of restenosis as a contributor to the worse outcomes after angioplasty is still to be clarified.⁴ Five out of ten patients in the present series had undergone multivessel SES implantation. In all of these patients, the interventional treatment included stenting of lesions located in the left anterior descending artery or left main coronary, an anatomical scenario typically referred to surgical treatment. Whether SES constitutes an effective therapeutic option for dialysis patients with multivessel disease will have to be determined in further studies incorporating larger number of patients. The SES decrease restenosis by locally delivering the antiproliferative drug, which eventually inhibits neointimal formation and prevents late lumen renarrowing. The interaction between the local administration of sirolimus and the systemic immunosuppression therapy in patients undergoing renal transplantation is currently unclear. In our series, renal transplantation was performed in 4 patients during the follow-up period. None of these patients presented any clinical complication that could be associated with increased drug toxicity. However, importantly, in all cases the transplantation was performed at least 3 months after the coronary procedure and, based on the known drug kinetics of SES, most of the drug should have been released by 1 month after the implantation.

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