Does Coronary Artery Bypass Graft Surgery
Improve Survival Among Patients With End-Stage
Renal Disease?
Todd M. Dewey, MD, Morley A. Herbert, PhD, Syma L. Prince, RN,
Carrie L. Robbins, RN, Christina M. Worley, RN, Mitchell J. Magee, MD, and
Michael J. Mack, MD
Cardiopulmonary Research Science and Technology Institute and Medical City Dallas Hospital, Dallas, Texas
Background. Cardiovascular disease remains the most
frequent cause of death for patients with end-stage renal
disease. To determine the long-term benefit of surgical
revascularization in this high-risk population, we stud-
ied our patients with ESRD having coronary artery by-
pass graft surgery (CABG), comparing the results of
off-pump to on-pump revascularization. As a baseline
reference group, we used dialysis patients with a diag-
nosis of coronary artery disease who did not have surgi-
cal revascularization or percutaneous coronary interven-
tions. The control group data set was obtained from the
United States Renal Data System.
Methods. From January 1995 through July 2003, 158
patients with end-stage renal disease who were on he-
modialysis (excluding those in cardiogenic shock, need-
ing resuscitation, and with emergent or salvage status)
underwent CABG. Fifty-nine patients (37.3%) had off-
pump revascularization, and 99 patients (62.7%) had
bypass grafting utilizing extracorporeal circulation. Pre-
operative risk factors and operative results were ana-
lyzed, and longitudinal survival data obtained.
Results. The mean follow-up time was 39.1 months
(median, 33.1) for the on-pump patients and 18.3 months
(median, 14.7) for off-pump. The total number of anasto-
C ardiac disease remains the most frequent cause of
death for patients with end-stage renal disease
(ESRD) on long-term dialysis. Forty-four percent of all-
cause mortality within this high-risk population can be
directly related to cardiac disease, with approximately
20% of deaths attributed to acute myocardial infarction
(AMI) [1]. Patients with ESRD sustaining AMI have
notoriously poor long-term survival. The 2-year mortality
after AMI between the years 1990 and 1995 was 74% [2].
In the year 2000, there were approximately 281,000
patients on dialysis in the United States, and current
projections show that number reaching to more than
Accepted for publication Aug 25, 2005.
Presented at the Fiftieth Annual Meeting of the Southern Thoracic
Surgical Association, Bonita Springs, FL, Nov 1315, 2003.
Address correspondence to Dr Dewey, 7777 Forest Lane, Suite A323,
Dallas, TX 75230; e-mail: tdewey@csant.com.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CARDIOVASCULAR
moses per off-pump patient was 2.4 1.0, and with
cardiopulmonary bypass (CPB), it was 3.3 0.9 (p <
0.001). Patients revascularized off-pump had an operative
mortality rate of 1.7%, whereas patients grafted using
CPB had an operative mortality of 17.2% (p 0.003). The
predicted risk of mortality for the off-pump group (9.3%
7.4%) was not statistically different from the on-pump
cohort (9.1% 7.7%, p not significant). Logistic regres-
sion analysis indicates that CPB use was an independent
risk factor for early death (p 0.01, odds ratio 13.6, 95%
confidence interval: 1.7 to 110). Long-term follow-up
demonstrated that the patients revascularized using CPB
had improved survival compared with the off-pump
patients and the control population.
Conclusions. Off-pump CABG improves early mortal-
ity rate when compared with conventional revasculariza-
tion. Despite a greater operative mortality, however,
long-term survival is improved in the patients revascu-
larized with CPB as compared with the off-pump cohort,
suggesting possible advantages from a more complete
revascularization in this population.
(Ann Thorac Surg 2006;81:591 8)
2006 by The Society of Thoracic Surgeons
500,000 patients by the year 2010 [1]. Increasingly these
patients are referred for surgical revascularization owing
to symptoms of angina or hemodynamic instability while
on dialysis. Additionally, coronary artery disease may be
identified in asymptomatic patients undergoing evalua-
tion and work-up for renal transplantation. In approxi-
mately two thirds of patients with chronic renal failure,
the inciting etiology is either diabetes mellitus or long-
standing hypertension. As such, these patients fre-
quently present with an aggressive atherosclerotic pro-
cess characterized by diffuse coronary artery disease as
well as a virulent vasculopathic condition involving the
entire body.
Numerous reports have described the increased mor-
tality and morbidity faced by these patients as compared
with nondialysis patients while undergoing coronary
artery bypass graft surgery (CABG) [3 6]. However, little
is known regarding whether off-pump CABG (OPCABG)
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.08.048
 592 DEWEY ET AL
CABG IN END-STAGE RENAL DISEASE
can decrease this mortality, and provide long-term re-
sults equivalent with conventional CABG. Furthermore,
to elucidate whether revascularization improves the sur-
vival of these high-risk patients, a comparison with a
CARDIOVASCULAR
population of patients on dialysis with coronary artery
disease but who have not had documented surgical
revascularization or percutaneous coronary intervention
must be performed.
The goal of this retrospective study was to compare
early and long-term results of coronary revascularization
using the alternative techniques of conventional revas-
cularization with cardiopulmonary bypass (CPB) and
off-pump bypass grafting. Additionally, the long-term
survival of our surgical patients was judged against a
cohort of patients identified from the United States Renal
Data System (USRDS) database as having coronary ar-
tery disease but no interventions, either surgical or
catheter based, to determine whether the natural history
of this population can be significantly altered by coronary
revascularization.
Material and Methods
Data Set
The Cardiopulmonary Research Science and Technology
Institute (CRSTI) maintains a Society of Thoracic Sur-
geons (STS) approved database for an 18-hospital, 22-
surgeon practice, collecting data on all patients undergo-
ing cardiac surgery. Since 1985, data have been collected
on more than 32,000 patients. The current data collection
form contains more than 300 data elements prospectively
recorded on all patients undergoing cardiovascular pro-
cedures. In 2000, the field previously named chronic
obstructive pulmonary disease (COPD) was renamed as
chronic lung disease (CLD). Whereas COPD was a binary
response variable (yes/no), CLD is now an ordinal vari-
able (none/mild/moderate/severe). To be able to com-
bine the data before 2000 with the current data, the CLD
value was collapsed into a binary yes/no value and has
been named COPD also.
Institutional Review Board approval was obtained to
identify 174 patients who had renal failure and were on
dialysis at the time of CABG between January 1, 1995,
and July 31, 2003. Patient identification was strictly con-
trolled in accordance with the Health Insurance Portabil-
ity and Accountability Act of 1996 regulations. Sixteen
patients were excluded from the study population for
cardiogenic shock and active resuscitation at the time of
CABG, and for procedures classified as salvage/
emergent in nature. Patient follow-up involved collecting
data from the Social Security Death Index and phone
calls to the patient or their family. Changes in status such
as death or kidney transplant were noted and the date of
the occurrence recorded; the data were then combined
with the patient records from the STS database.
The control data set was obtained from the USRDS
2002 core and hospital data sets. This data set, derived
from Medicare claims part A (hospitalization) and part B
(physician/provider), contains information on approxi-
Ann Thorac Surg
2006;81:591 8
mately 1.2 million patients with ESRD on dialysis. The
accuracy of these data has previously been validated by
the National Institutes of Health [7]. Using the master
data set, patients having a diagnosis of coronary disease
(atherosclerosis or myocardial infarction) were extracted.
Patients whose records showed that they had undergone
CABG, percutaneous coronary intervention, or kidney
transplant were then excluded. The resulting data set
consisted of 340,037 patients with date of death or last
follow-up records. Data were current as of October 2001.
Statistics
Chi-square statistics were used to test for differences in
categorical variables between patient groups. When
small numbers of values were observed, Fishers exact
test was utilized. Continuous variables were tested using
a Student t test, while differences in medians were
compared using the Wilcoxon rank sum test. In all cases,
statistical significance required a p value of 0.05 or less.
Survival curves were calculated using the Kaplan-
Meier technique, with the survival distribution function
plotted against the length of follow-up. The measured
endpoint was death; patients alive at last follow-up were
included as right censored values. Curves were com-
pared using log-rank statistics, emphasizing the longer
follow-up results. Using the CRSTI dataset, a Cox pro-
portional hazards model was used to assess the impact of
independent predictors on patient survival over time.
Results
One hundred and fifty-eight patients were identified as
meeting entrance criteria, with 59 having off-pump and 99
on-pump CABG. None of these patients underwent renal
transplantation during the follow-up period. Despite the
nonrandomized nature of this review, an analysis of 26
categorical preoperative risk factors showed few significant
statistical differences between the off-pump and the on-
pump groups (Table 1). The on-pump group had a greater
number of patients with a diagnosis of COPD, 30.3%, versus
the off-pump group, 12.1% (p 0.009). Additionally, the
on-pump cohort as compared with the off-pump group had
a greater percentage of patients with previous myocardial
infarctions: 61.6% versus 32.2% (p 0.001). Patients in the
off-pump group had a greater incidence of preoperative
inotrope use as compared with the on-pump patients: 6.8%
versus 1.0% (p 0.05). There were no differences between
the groups in regard to the percentage of women in each
cohort, or the incidence of diabetes, hypertension, periph-
eral vascular disease, cerebral vascular accident, left main
disease greater than 50%, or symptoms of congestive heart
failure.
Analysis of continuous variables showed that average
age, ejection fraction, and the STS predicted risk of
mortality also were not statistically different between the
two groups (Table 1). The incidence of reported angina
was equal in the on-pump group (88.9%) and off-pump
group (86.4%). Of those 64 patients with unstable angina,
however, 76.6% were operated on using CPB (p 0.003).
The perioperative outcomes are noted in Table 2. The
Ann Thorac Surg DEWEY ET AL 593
2006;81:591 8 CABG IN END-STAGE RENAL DISEASE

Table 1. Preoperative Risk Factors

Off-Pump (59) On-Pump (99)
Chi-Square
Variable Count % Count % p Value

CARDIOVASCULAR
Female 29 49.2 34 34.3 ns (0.066)
Current smoker 11 18.6 15 15.2 ns
Diabetes mellitus 38 64.4 61 61.6 ns
Angina 51 86.4 88 88.9 ns
Unstable angina (of those with angina) 15 29.4 49 55.7 0.003
Hypertension 48 81.4 82 82.8 ns
Cerebral vascular accident 9 15.3 12 12.1 ns
Recent 1 11.1 1 8.3 ns
Remote 8 88.9 11 91.7
Chronic obstructive pulmonary disease 7 12.1 30 30.3 0.009
Peripheral vascular disease 20 33.9 32 32.3 ns
Previous coronary artery bypass graft 4 6.8 4 4.0 ns
Myocardial infarction (MI) 19 32.2 61 61.6 0.001
Never 40 67.8 38 38.4 0.002
New ( 7 days) 7 11.9 20 20.2
Old ( 7 days) 12 20.3 41 41.4
Congestive heart failure 19 32.2 44 44.4 ns
Inotropes 4 6.8 1 1.0 0.05
Left main disease 50% 16 27.1 27 27.3 ns
Intra-aortic balloon pump 2 3.4 9 9.1 ns
Intraoperative 0 0.0 3 33.3 ns
Postoperative 0 0.0 1 11.1
Preoperative 2 100.0 5 55.6
Continuous variables (mean SD)
Age 62.0 13.0 63.3 11.0 ns
Ejection fraction (%) 46.9 14.9 46.8 12.7 ns
STS predicted risk of mortality 0.093 0.074 0.091 0.077 ns

ns not significant; STS The Society of Thoracic Surgeons.

overall mortality was 18 of 158 (11.4%), with the on-pump
group having a significantly increased operative mortal-
ity as compared with the off-pump cohort, 17.2% versus
1.7% (p 0.003). (Data were available on the cause of
death for 15 of 18 patients: 7 [46.7%] were listed as
cardiac; 2 each [13.3%] from infection, neurologic, and
other causes; and 1 each [6.7%] in pulmonary and renal
categories. For reference, we looked at our data on all 391
CABG patients who had renal disease, but were not on
dialysis. In this group, 33 of 391 [8.4%] died periopera-
tively, with 8 (24.2%) listed as from a cardiac cause, 7
(21.2%) as neurologic, 6 (18.2%) as renal or other, and 3
(9.1%) as from infection or pulmonary causes.)
Additionally, the on-pump patients were significantly
more likely to have prolonged periods of ventilation
postoperatively (namely, more than 24 hours), 28.3%
versus 6.8% (p 0.001), and to require transfusion of
blood products, 86.6% versus 49.2% (p 0.001). There
were no differences between the two groups regarding
the need for reoperation for bleeding, or the incidence of
stroke, sternal wound infection, perioperative myocardial
infarction, or readmission to the hospital. Additionally,
no patients required conversion from an off-pump ap-
proach to CPB-supported revascularization.
The patients having revascularization with CPB had
significantly more grafts than the off-pump patients: 3.3
0.9 versus 2.4 1.0 (p 0.001). However, the off-pump
patients had a greater number of arterial grafts than the
on-pump bypass group: 0.9 0.5 versus 0.7 0.6 (p
0.03). While the on-pump group spent a greater number
of days in the intensive care unit than the beating-heart
patients, 5.2 6.7 versus 2.7 2.6 (p 0.002), the longer
overall length of stay of 11.9 10.9 days for on-pump
patients was not statistically significantly different from
the 9.3 7.9 days observed for the off-pump patients.
Logistic regression analysis demonstrated that female
sex, need for a preoperative intra-aortic balloon pump,
and use of cardiopulmonary bypass were independent
risk factors for operative death (Table 3).
Long-term follow-up data were then collected on all
patients that survived the perioperative period by direct
calls to the patient or their family, and by review of the
Social Security Death Index. Mean follow-up times ranged
from 39.1 months (median, 33.1) for the on-pump group to
18.3 months (median, 14.7) for the off-pump cohort. Survival
curves were calculated using the Kaplan-Meier technique
and plotting the survival distribution function against time
of follow-up (Fig 1). A control group was identified from the
 594 DEWEY ET AL Ann Thorac Surg
CABG IN END-STAGE RENAL DISEASE 2006;81:591 8

Table 2. Perioperative Outcomes

Off-Pump (59) On-Pump (99)
Chi-Square
Variable Count % Count % p Value
CARDIOVASCULAR

Operative mortality 1 1.7 17 17.2 0.003

Reoperation for bleeding 0 0.0 2 2.0 ns
Perioperative myocardial infarction 0 0.0 0 0.0 ns
Deep sternal infection 1 1.7 1 1.0 ns
Septicemia 0 0.0 5 5.1 ns
Stroke, permanent 0 0.0 2 2.0 ns
Stroke, transient 2 3.4 3 3.0 ns
Prolonged ventilation 4 6.8 28 28.3 0.001
Pneumonia 2 3.4 5 5.1 ns
Cardiac arrest 0 0.0 5 5.1 ns
Tamponade 0 0.0 4 4.0 ns
Gastrointestinal complications 1 1.7 5 5.1 ns
Multisystem failure 0 0.0 3 3.0 ns
Atrial fibrillation 8 13.6 19 19.2 ns
Readmission to hospital 8 17.4 7 8.0 ns
Blood products used 29 49.2 84 86.6 0.001
Continuous variables (mean SD)
Length of stay, days 9.3 7.9 11.9 10.9 ns
Median 7 8 0.04
Total number of grafts 2.4 1.0 3.3 0.9 0.001
Number of distal arteries 0.9 0.5 0.7 0.6 0.03
Number of distal veins 1.5 1.0 2.5 1.1 0.001
Intensive care unit, days 2.7 2.6 5.2 6.7 0.002

ns not significant.

USRDS database consisting of dialysis patients with a
diagnosis of coronary artery disease and no history of any
coronary interventions or surgery.
Survival in the on-pump group dropped rapidly during
the first month, with a higher rate of perioperative mortal-
ity. The patients then showed better survival than the
control or off-pump groups over the rest of the follow-up
period. Off-pump patients showed the same survival as the
USRDS controls for the first 10 to 12 months, then began
dropping more rapidly. Comparison of the curves using
log-rank statistics showed the differences between the off-
pump patients and the USRDS control group, as well as the
on-pump to off-pump differences, to be statistically signif-
icant (p 0.03). (The early crossing of the curves that results
from perioperative mortality may make the statistical prob-
ability less reliable.) Calculated over a 4-year period, this is
an annual death rate of 38.1% for the off-pump group, 22.9%
Table 3. Logistic Regression for Perioperative Mortality
Odds Ratio
(95% Confidence
Variable Interval)
Sex (female/male) 4.4 (1.215.5)
Pump status (on/off-pump) 13.6 (1.7109.8)
IABP use (Preoperative use/ 17.6 (2.5124.3)
never used)
IABP intra-aortic balloon pump.
per year for the control group and 19.0% per year for the
on-pump patients.
Comparing just nondiabetic patients (Fig 2), the patients
revascularized with CPB had a survival advantage over the
control population (p 0.5, nonsignificant) and the off-
pump group (p 0.03). (The early crossing of the curves
that results from perioperative mortality may make the
statistical probability less reliable. After the curves cross,
the on-pump data lie above the USRDS curve at all points.)
The available data show the survival curve for the off-pump
nondiabetic patients falling faster than either the on-pump
patients (p 0.03) or the control diabetic patients (p 0.01).
Comparing only patients with diabetes (Fig 3), the off-
pump diabetic patients are very close in survival to the
control group, whereas the on-pump curve lies above the
other two except for the short initial perioperative period.
The differences are not statistically significant, with small
numbers of patients in the on- and off-pump groups.
A Cox proportional hazards model was used to identify
variables affecting the rate of death. The risk of death
p increased with age (p 0.042; hazard ratio [HR] 1.02;
Value 95% confidence limits [CL]: 1.00 to 1.04) and decreased
with increasing body surface area (p 0.017, HR 0.35,
0.02
95% CL: 0.15 to 0.83); increasing ejection fraction also
0.01
decreased the risk slightly (p 0.026; HR 0.98; 95% CL:
0.01
0.97 to 1.00). Pump as a factor had a hazard ratio of 0.64
(95% CL: 0.40 to 1.02) comparing on-pump to off-pump
groups, indicating approximately a 35% reduction in risk
Ann Thorac Surg
2006;81:591 8
when the patient is done on pump (p 0.058). Analysis of
the data starting at 12 months shows the significance of
the pump as a factor in long-term survival, with p 0.003
and a hazard ratio of 0.38 (95% CL: 0.20 to 0.71).
To determine if the high perioperative mortality in the
on-pump patients biased the survival comparison by
eliminating the sickest patients from this group, we again
contrasted the factors used to estimate preoperative risk
for the patients in both cohorts who survived the periop-
erative period (Table 4). There were no significant differ-
ences between the two groups in regard to age, ejection
fraction, incidence of diabetes or hypertension, or pe-
ripheral and cerebral vascular disease. Additionally,
there was no statistical difference in the STS predicted
risk of mortality between these two groups. Clinical
differences between the groups included slightly more
female patients remaining in the off-pump group than
the on-pump, 48.3% versus 31.7% (p 0.05), and a higher
frequency of COPD, 30.5% versus 12.3% (p 0.01), and
previous myocardial infarction, 61% versus 32.8% (p
0.001), in the CPB patients.
A Cox proportional hazards model was then used to
identify independent predictors of death in these groups.
The risk of death (excluding perioperative mortality)
decreased 64% when the procedure was performed using
DEWEY ET AL 595
CABG IN END-STAGE RENAL DISEASE
Fig 1. End-stage renal disease Kaplan-Meier
survival curve for all patients. (USRDS
United States Renal Data System.)
CARDIOVASCULAR
CPB (p 0.001, relative risk [RR] 0.36, 95% confidence
interval [CI]: 0.21 to 0.63). Additionally, female patients
had a 44% decreased risk of death compared with males
(p 0.03, RR 0.56, 95% CI: 0.33 to 0.96). Other factors
associated with improved survival were increasing ejec-
tion fraction (p 0.001, RR 0.97, 95% CI: 0.95 to 0.99)
and body surface area (p 0.006, RR 0.164, 95% CI:
0.057 to 0.474).
Comment
Coronary artery disease remains a major cause of death
among patients with ESRD. In addition to coronary
atherosclerosis, left ventricular hypertrophy, diastolic
dysfunction, congestive heart failure, and complex ven-
tricular arrhythmias leading to sudden death develop in
patients with ESRD on dialysis [8]. The reported 2-year
cumulative survival rate for patients with ESRD and
congestive heart failure is as low as 33% [9]. ESRD
patients also suffer from ventricular dysfunction caused
by toxic waste byproducts [10] and diffuse coronary
artery disease, the result of elevated calcium levels [11].
In this study, patients revascularized using CPB demon-
strated a strikingly increased operative mortality compared
with the off-pump patients, 17.2% versus 1.7%, despite
Fig 2. End-stage renal disease Kaplan-Meier
survival curve for nondiabetic patients.
(USRDS United States Renal Data
System.)
 596 DEWEY ET AL Ann Thorac Surg
CABG IN END-STAGE RENAL DISEASE 2006;81:591 8

Fig 3. End-stage renal disease Kaplan-Meier

survival curve for diabetic patients. (USRDS
United States Renal Data System.)
CARDIOVASCULAR

having nearly the same STS predicted risk of mortality. The
observed on-pump mortality rate falls within the wide
range of previously reported mortality rates of 11.4%
(Franga and colleagues [12]), 15% (Blum and coworkers
[13]), and 20% (Rostand and coworkers [14] and Batiuk and
associates [15]). Previous reports have shown a correlation
between New York Heart Association class and operative
mortality [13, 16], as well as a strong association between a
recent preoperative myocardial infarction and operative
death [15]. Our on-pump cohort had a higher frequency of
new (less than 7 days) myocardial infarction than the
off-pump group, 20.2% versus 11.9% (p 0.002), but an

Table 4. Demographics of Patients Surviving the Perioperative Period

Off-Pump (58) On-Pump (82)
Chi-Square
Variable Count % Count % p Value

Female 28 48.3 26 31.7 0.05

Current smoker 10 17.2 13 15.9 ns
Diabetes mellitus 37 63.8 50 61.0 ns
Diabetes control
Diet 1 2.7 1 2.0 ns
Insulin 28 75.7 35 70.0
Oral 7 18.9 12 24.0
Hypertension 48 82.8 67 81.7 ns
Cerebral vascular accident 8 13.8 11 13.4 ns
Recent 1 12.5 1 9.1 ns
Remote 7 87.5 10 90.9
Chronic obstructive pulmonary disease 7 12.8 25 30.4 0.01
Peripheral vascular disease 19 32.8 26 31.7 ns
Previous coronary artery bypass graft 4 6.9 2 2.4 ns
Myocardial infarction 19 32.8 50 61.0 0.001
Never 39 67.2 32 39.0 0.004
New ( 7 days) 7 12.1 16 19.5
Old ( 7 days) 12 20.7 34 41.5
Congestive heart failure 19 32.8 37 45.1 ns
Inotropes 4 6.9 1 1.2 ns
Left main disease 50% 16 27.6 18 22.0 ns
Intra-aortic balloon pump 2 3.4 4 4.9 ns
Intraoperative 0 0.0 2 50.0 ns
Postoperative 0 0.0 0 0.0
Preoperative 2 100.0 2 50.0
Continuous variables (mean SD)
Age 62.1 13.1 62.3 11.1 ns
Ejection fraction (%) 46.8 15.0 46.3 12.4 ns
STS predicted risk of mortality 0.093 0.075 0.078 0.059 ns

ns not significant; STS The Society of Thoracic Surgeons.

Ann Thorac Surg
2006;81:591 8
equivalent percentage of patients with symptoms of con-
gestive heart failure.
Logistic regression analysis identified pump use as an
independent predictor of mortality. Potential difficulties
associated with the use of extracorporeal circulation
include maintaining fluid and electrolyte balance, sus-
taining adequate hemoglobin levels, and restoring hemo-
stasis at the conclusion of the procedure. These problems
were realized in that our on-pump group required sig-
nificantly more blood product administration and had
longer postoperative ventilatory times than did the off-
pump cohort. The off-pump approach resulted in notice-
ably better outcomes in the perioperative period than did
the use of CPB for revascularization. Similar results have
been described in much smaller series when comparing
off-pump to on-pump outcomes in dialysis-dependent
patients and other high-risk populations [17, 18].
Remarkably, this perioperative mortality benefit did not
translate into equivalent or better survival on long-term
follow-up. For off-pump patients, longevity was signifi-
cantly worse than for the on-pump patients who survived
the perioperative period. In fact, the off-pump group did
not demonstrate improved survival over a control group
with coronary artery disease who did not have revascular-
ization. A possible explanation may relate to there being
significantly fewer grafts performed in the off-pump group,
despite a considerable beating-heart surgery experience in
our practice. Many reports in the literature comparing the
two methods also demonstrate fewer grafts in off-pump
than in on-pump patients. Whether the reduced number
seen means incomplete revascularization and whether that
leads to long-term sequelae have been a concern with
off-pump bypass surgery. Early studies demonstrating de-
creased perioperative and long-term survival with incom-
plete revascularization were performed in patients with
arrested hearts on CPB [22]. Despite this, most studies show
improved perioperative results in off-pump compared with
on-pump patients, especially for high-risk patients [19 21].
Long-term follow-up may suggest that any effect from the
reduced graft numbers may be observed after the initial
perioperative period.
Improved perioperative survival of off-pump patients
may be explained by the reduced ischemic burden placed
on these patients. Because a period of global cardiac isch-
emia is induced in arrested-heart surgery, a greater penalty
is paid, usually in the form of increased early mortality, for
incomplete revascularization. Conversely, since off-pump
bypass grafting causes only intermittent periods of regional
ischemia, incomplete revascularization may be better toler-
ated and not show any consequences in the perioperative
period. However, long-term survival and freedom from
repeat surgical or percutaneous intervention would con-
tinue to be adversely affected.
The use of arterial grafts for revascularization has been
shown to increase survival in both dialysis and nondialysis
patients [23, 24]. Additionally, internal mammary artery
patency has been found to be superior to saphenous vein in
patients with ESRD owing to its resistance to atherosclerotic
change [25]. In this study, the off-pump patients demon-
strated worse long-term survival even though more arterial
DEWEY ET AL 597
CABG IN END-STAGE RENAL DISEASE
grafts were used per patient than in the on-pump group.
Once more, fewer grafts overall may play a role in the
survival of the patients in the beating-heart group.
It is recognized that diabetes mellitus is an indepen-
CARDIOVASCULAR
dent predictor of adverse long-term outcomes in patients
undergoing CABG [19, 26]. Subgroup analysis of our data
showed that the long-term survival of off-pump patients
was still worse than that of on-pump patients or controls,
although the effect was largest in the nondiabetic group.
This association was also confirmed by the Cox propor-
tional hazard model, which showed that the use of CPB
was a predictor of survival.
To determine if the sickest or weakest patients were
dying during the perioperative period, we looked at
those surviving beyond the operative mortality period.
The off-pump group only decreased by 1 patient while 17
on-pump patients had died. In the remaining patients,
there was no significant change in the risk factors, with
the exception of a decrease in the STS predicted risk of
mortality for the on-pump survivors that dropped by
about 11%. Statistically, it was not different from the
off-pump value, but may suggest that the stress of sur-
gery was worse when done on pump.
This study remains limited in that no information was
collected regarding the duration of dialysis before CABG,
which could affect the survival curves if a disproportion-
ate number of patients with a long history of dialysis
were in one group. Additionally, no assessment regard-
ing the quality of the target vessels, vessel size, or lesion
characteristics were collected on the STS database.
We conclude that off-pump revascularization in patients
with ESRD on hemodialysis demonstrates superior periop-
erative morbidity and mortality compared with conven-
tional surgery with CPB. However, long-term survival is
significantly better in the on-pump patients, possibly be-
cause of incomplete revascularization in the off-pump co-
hort. Surgical revascularization using CPB does appear to
increase the life expectancy of patients with ESRD and
coronary artery disease compared with patients who had no
interventions. The increased operative mortality among
these patients emphasizes the importance of patient selec-
tion and surgical approach when offering CABG to this
high-risk group. Finally, these findings stress the need for
follow-up of all patients who have undergone off-pump
bypass grafting to ensure that the benefits seen in the
perioperative period, translate into long-term results equiv-
alent to conventional revascularization.
The data used to create a control population for this manuscript
were supplied by the United States Renal Data System, a section
of the National Institutes of Health. The interpretation and
reporting of these data were the responsibility of the authors,
and in no way should be seen as an official policy or interpre-
tation of the United States government.
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 598 DEWEY ET AL
CABG IN END-STAGE RENAL DISEASE
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DISCUSSION
DR KEVIN D. ACCOLA (Orlando, FL): In your conclusions you
differentiated between off-pump and on-pump results. I was curi-
ous how you selected which patients you were going to do off
pump and which patients you were going to do on pump. Was this
merely a surgical decision at the time of the procedure or do you
have some type of decision-making process with this?
DR DEWEY: Much of the selection was surgeon bias. Up until
the late 1990s, most of these patients were done on bypass, but
since approximately mid 1998, our approach has been to do
off-pump bypass surgery because we felt that perioperative
morbidity and mortality were reduced with that approach.
DR ALAA Y. AFIFI (Albany, NY): I enjoyed your paper. These
are certainly a very sick group of people. You have made it clear
that in the long term, people with complete revascularization do
better than those who have had incomplete revascularization.
You have demonstrated that you have better results in your
on-pump group versus the off-pump group. The big concern,
though, is why is there a 10-fold increment in operative mortal-
ity in patients that you do on pump versus off pump?
We certainly have seen similar concerns with some of these very
sick patients. The way we have handled them on many occasions,
is by going on pump, cooling them down to 25C, and giving one
dose of cold blood high potassium cardioplegia, and then through-
Ann Thorac Surg
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out the remainder of the procedure we just give cold blood in a
retrograde manner with a goal of performing complete revascular-
ization . So the question becomes, how do you approach myocar-
dial protection while you are on pump? And, once again, why do
you think you have a 10-fold mortality difference in your on-pump
versus off-pump group? Thank you.
DR DEWEY: I think renal failure patients are a difficult group in
which to perform bypass grafting, and the problems associated
with cardiopulmonary bypass are primarily electrolyte or fluid
in nature. Additionally, one can have problems maintaining
hemoglobin levels because these patients typically are anemic.
Furthermore, there can be problems with hemostasis as evi-
denced by greater need for transfusions not only red cells but
also platelets and other clotting factors to control bleeding. Some
of the perioperative deaths can be attributed to multiorgan
failure, secondary to volume overload, leading to increased
ventilator time, and some of the deaths are due to delayed
tamponade in the intensive care unit.
The problem with doing these patients on bypass is that the
vasodilatory effects of the pump are vastly accentuated over pa-
tients who do not have renal disease. Our standard on-pump
approach is to use blood cardioplegia, and dialyze these patients
intraoperatively, then not dialyze them again until either the first or
second postoperative day.