Long-term mortality after coronary revascularization in Swedish dialysis patients with three-vessel disease: a nationwide retrospective cohort study

Introduction

Cardiovascular diseases (CVDs) cause 44% of all mortality in patients undergoing chronic dialysis (1). Moreover, coronary artery disease (CAD) is one of the leading causes of morbidity and mortality among patients with end-stage renal disease (ESRD) requiring chronic dialysis. CAD is present in about 50% of the dialysis population ≥65 years of age (2,3). Among patients undergoing haemodialysis, the prevalence of CVD and CAD is estimated at 70% and 42%, respectively (4).

The cardiovascular risk in dialysis patients is associated with traditional CVD risk factors such as diabetes, hypertension, and hypercholesterolemia as well as non-traditional risk factors; the latter include uraemia-related factors such as mineral and bone disease abnormalities (related to abnormal calcium-phosphorus metabolism), anaemia, inflammation, and oxidative stress, and dialysis-related factors such as type and frequency of dialysis and dialysate composition (5). These factors contribute to the development of fibrocalcific lesions and play a key role in the progression of CVD as glomerular filtration rate (GFR) declines. The risk of CAD increases progressively with decreasing GFR, and patients with GFR <60 mL/min/1.73 m² have a two-to-threefold higher risk of CVD mortality compared with those without ESRD (5). Dialysis patients have more extensive coronary calcification, involving both intimal and medial layers, leading to more aggressive disease (6). The underlying mechanisms include elevated serum phosphate, parathyroid hormone, and fibroblast growth factor 23, along with reduced levels of active vitamin D and klotho, an anti-aging protein expressed most prominently in the kidney. Although several of these factors contribute to the progression of vascular calcification in dialysis patients, phosphate appears to play a central role (7).

The development of coronary stent technology, particularly the introduction of drug-eluting stents (DES), has improved PCI outcomes by reducing restenosis, stent thrombosis, and the need for repeat revascularization. However, the impact on long-term survival remains dependent on patient characteristics and clinical presentation (8). The SYNTAX study, which compared percutaneous coronary intervention (PCI) using first-generation paclitaxel-eluting stents with coronary artery bypass grafting (CABG) in patients with de-novo three-vessel without dialysis, is the only study addressing the issue of survival benefit in patients with three-vessel disease (9). To our knowledge, no study has analysed the survival benefit in dialysis patients with three-vessel disease. The optimal revascularization strategy for patients with ESRD requiring dialysis remains uncertain. Current guidelines on myocardial revascularization favour CABG in patients with a life expectancy exceeding 1 year; however, no specific recommendation is provided for this high-risk population (10). Moreover, no prospective randomized trials have compared CABG with PCI among patients with ESRD requiring dialysis, and existing observational studies have yielded conflicting results (11-15).

The aim of this nationwide retrospective cohort study was therefore to assess short- and long-term all-cause mortality in dialysis patients with ESRD and three-vessel CAD who have undergone CABG or PCI, and to explore differences in risk between the two interventional groups. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0332/rc) (16).

Methods

Study design

This Swedish nationwide retrospective cohort study included 611 patients (412 PCI patients and 199 CABG patients), ≥18 years old, with ESRD requiring chronic dialysis and three-vessel CAD, who underwent a first-time isolated CABG or PCI during 2006–2020. Stenosis was considered significant when it involved ≥50% of the vessel lumen. No patient was lost to follow-up. A flow diagram describing patient selection is given in Figure S1.

Data sources

The study population was identified in the Swedish Cardiac Surgery Registry, which is a part of the SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) (17). The Cardiac Surgery Registry has collected information about patient characteristics, comorbidity including ESRD requiring dialysis, operative data, and early complications for all open-heart surgery procedures in Sweden since 1992.

Additional information about comorbidities, not captured in the Swedish Cardiac Surgery Registry, was collected from the National Patient Register (NPR). Registration in the NPR is mandatory for all hospitals in Sweden. The register records the diagnoses from all hospital admissions in Sweden, and has a complete national coverage from 1987 for all diagnoses and an overall validity of 85–95% for cardiovascular diagnoses (18). Diagnoses in the NPR are based on International Classification of Diseases (ICD) codes: the 9^th revision (ICD-9) from 1987 to 1997, and the 10^th revision (ICD-10) from 1997 to 2020. These codes were used to identify patients with dialysis at the time of surgery, comorbidities, and events during follow-up (Table S1). The Swedish Cause of Death Register was used to obtain mortality data according to ICD codes. This register has been updated annually since 1997 (19). Individual patient data from these three national registers were linked together through a personal 10-digit social security number, unique for all Swedish citizens (20).

Statistical analysis

Continuous variables are described as mean and standard deviation (SD) or median and range as appropriate, and categorical variables as frequency and percentage. For comparison between groups, Fisher’s exact test was used for dichotomous variables and the two-sample t-test or Mann-Whitney U test was used for continuous variables. Incidence rates were calculated as number of events divided by the number of follow-up years per respective study group, expressed in terms of 100 person-years, and described from the day of surgery to 30 days postoperatively and from the day of surgery to the end of follow-up for all-cause mortality. The 95% confidence intervals (CIs) were estimated using exact Poisson limits. Time to all-cause mortality was depicted by cumulative incidence curves and described at 30 days and 1, 2, 5, and 10 years after surgery.

To estimate the risk of all-cause mortality, Cox regression was used for the short-term (day of surgery to 30 days postoperatively) and long-term (day of surgery to end of follow-up) periods. All analyses were adjusted for age and sex in a first model, and for age, body mass index (<18.5, 18.5 to <25, 25 to <30, ≥30 kg/m², and unknown), years on dialysis, sex, diabetes, heart failure, peripheral vascular disease, hyperlipidaemia, hypertension, stroke, atrial fibrillation, myocardial infarction, malignancy, chronic respiratory disease, and acute coronary syndrome in a second model. For the outcome of all-cause mortality, patients were censored at the time of kidney transplant [25 (6.1%) and 28 (14.1%) patients in the PCI and CABG group, respectively]. The proportional hazards assumption was checked by adding an interaction term between the intervention and log(time) in the Cox regression model.

To ensure robustness, we performed a sensitivity analysis where all analyses were repeated using propensity score matching (PSM). A 1:1 matched group was created on the basis of all baseline characteristics, using CABG as the main treatment and PCI as the reference/control. The matching algorithm used 1:1 nearest neighbour matching, with an optimal calliper width of 0.2 of the standard deviation of the logit of the propensity score. To validate the performance of the matching procedure, the distribution of the propensity scores and baseline characteristics and years on dialysis was compared between the groups and described by standardized differences (Figure S2). No power calculation was performed, as all eligible patients with preoperative dialysis and three-vessel disease who underwent first-time PCI or CABG in Sweden during 2006–2020 were included. All analyses were performed in version 9.4 of SAS (SAS Institute Inc., Cary, NC, USA).

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Results

Patients’ characteristics

The study included 611 CABG and PCI patients (23% women) with three-vessel CAD and ESRD requiring chronic dialysis before the intervention. Of these, 412 (67%) underwent PCI and 199 (33%) underwent CABG. Median follow-up was 1.7 (range, 0.7–3.7) years in the PCI group and 2.5 (range, 1.1–5.0) years in the CABG group. The proportion of patients who underwent PCI and CABG by year is shown in Figure S3. Patient characteristics for the two study groups are presented in Table 1. Patients in the PCI group were older, had been on dialysis for longer, and a higher proportion had history of cancer compared to the CABG group. Previous myocardial infarction, hyperlipidaemia, and atrial fibrillation were more common in the CABG group. No differences between the groups were observed for body mass index, acute coronary syndrome 6 weeks before intervention, diabetes, heart failure, peripheral vascular disease, previous stroke, hypertension, or chronic obstructive pulmonary disease. Baseline characteristics of the patients included in the PSM sensitivity analysis (165 well-balanced pairs of PCI and CABG patients) are shown in Table S2.

Short-term mortality

The crude 30-day mortality was 6.8% (n=28) in the PCI group and 4.5% (n=9) in the CABG group (Table 2). Cumulative mortality at 30 days after PCI and CABG showed no significant differences between the groups: 6.8% in the PCI group vs. 4.5% in the CABG group (P=0.34; Figure 1A). Event rate per 100 person-years, age- and sex-adjusted hazard ratios (HRs), and multi-adjusted HRs for the 30-day mortality risk in the PCI and CABG groups are shown in Table 2. No difference in the 30-day mortality risk was observed between the CABG group and the PCI group, either in the age- and sex-adjusted model (HR: 0.78; 95% CI: 0.36–1.67; P=0.52) or in the multi-adjusted model (HR: 0.70; 95% CI: 0.31–1.61; P=0.40). The PSM sensitivity analysis supported the main analysis, with no significant differences between the PCI and the CABG groups in cumulative mortality at 30 days (6.7% vs. 4.8%; multi-adjusted HR: 0.72; 95% CI: 0.29–1.80; P=0.49; Figure 1B, Table 3).

Figure 1 Cumulative incidence of mortality at 30 days. (A) Cumulative incidence of 30-day all-cause mortality among dialysis patients with three-vessel disease who were treated with CABG or PCI. (B) Cumulative incidence of 30-day all-cause mortality in a propensity score analysis of dialysis patients with three-vessel disease who were treated with CABG or PCI. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention.

Long-term mortality

From the day of surgery to the end of the study, deaths occurred in 263 of 412 (63.8%) patients in the PCI group and 109 of 199 (54.8%) patients in the CABG group (Table 2). In the PCI group, 30.8% (n=81) of the deaths were attributed to ischemic heart disease and 42.2% (n=111) to CVD, while the corresponding figures in the CABG group were 21.1% (n=23) and 34.9% (n=38) respectively (Table S3). The cumulative incidence for death attributed to ischemic heart disease and CVD and other deaths in CABG and PCI patients is shown in Figure S4. Cumulative mortality in the CABG group was lower than in the PCI group at 1 year (14.4% vs. 26.8%), 5 years (51.3% vs. 67.2%), and 10 years (76.3% vs. 88.9%) (P<0.001; Figure 2A).

Figure 2 Cumulative incidence of mortality at 10 years. (A) Cumulative incidence of 10-year all-cause mortality among dialysis patients with three-vessel disease who were treated with CABG or PCI. (B) Cumulative incidence of 10-year all-cause mortality in a propensity score analysis of dialysis patients with three-vessel disease who were treated with CABG or PCI. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention.

Table 2 shows the event rate per 100 person-years, age- and sex-adjusted HR, and multi-adjusted HR for the risk of mortality from the day of surgery to the end of follow-up in the PCI and CABG groups. In both the age- and sex-adjusted model and the multi-adjusted model, CABG was associated with a lower risk of long-term mortality compared to PCI (age- and sex-adjusted HR: 0.72; 95% CI: 0.57–0.91; P=0.005; multi-adjusted HR: 0.70; 95% CI: 0.55–0.89; P=0.004). Similar results, with a higher cumulative mortality in the PCI group compared to the CABG group, were also shown in the PSM sensitivity analysis. Cumulative mortality in the CABG and PCI groups was 16.2% vs. 24.2% at 1 year, 49.6% vs. 65.0% at 5 years, and 77.2% vs. 86.4% at 10 years (P=0.009; Figure 2B). The PSM analysis was in line with the main analysis, showing that CABG was associated with lower risk of long-term mortality compared to PCI (multi-adjusted HR: 0.68; 95% CI: 0.51–0.91; Table 3).

Discussion

The main findings of this population-based cohort study are as follows. Patients with three-vessel CAD and ESRD requiring chronic dialysis undergoing CABG or PCI had high early mortality and poor long-term survival. There was no significant difference in short-term mortality between patients treated with CABG and those treated with PCI. Patients who underwent CABG had a favourable long-term survival compared to patients who underwent PCI. These results were confirmed in a sensitivity analysis using PSM.

Comparative studies assessing the risk of mortality after CABG or PCI in patients on chronic dialysis are rare, and the results are inconsistent. A meta-analysis by Grazioli et al. (21) reported that CABG was associated with higher 30-day mortality and an increased incidence of long-term strokes, but CABG was more effective than PCI as it led to a greater reduction in major adverse cardiovascular and cerebrovascular events, particularly in repeat revascularization and new myocardial infarctions due to restenosis.

Tasoudis et al. showed that in patients on dialysis, CABG was associated with favourable long-term survival, while PCI was associated with lower mortality in the immediate postoperative period but a higher risk of repeated revascularization (11). Other studies have also shown a better long-term outcome for patients undergoing CABG (12,13,15). In contrast, Bangalore et al. showed a higher rate of short-term mortality in CABG patients compared to PCI patients, but long-term mortality was similar between the two modes of intervention (14). Furthermore, Doulamis et al. could not demonstrate any differences in all-cause mortality for dialysis patients treated with PCI using a DES vs. patients who underwent CABG (22).

In contrast to our data, Tasoudis et al. reported that PCI had an advantage in the early follow-up compared to CABG (11). Our data revealed further that CABG was associated with lower long-term mortality risk than PCI. This finding is in accordance with previous studies in dialysis patients treated with revascularization, which have also reported better survival for patients who underwent CABG compared to PCI (11-13). Moreover, our results are analogous to those reported in the SYNTAX study, where patients who underwent CABG for three-vessel disease without dialysis showed a survival benefit compared to PCI at 10 years (9).

Previous studies from our research group have shown that preoperative treatment with dialysis has a markedly negative impact on survival in patients undergoing surgical aortic valve replacement (23). Similar findings were shown in the present study, with a high incidence of mortality in both the CABG and PCI patients with ongoing dialysis and three-vessel CAD. Our results are in accordance with previous studies showing that CABG and PCI are associated with high operative mortality and poor long-term survival in patients with ESRD requiring chronic dialysis (24,25). In the present study, we did not have access to a control group of patients with ESRD requiring chronic dialysis who had not undergone CABG or PCI, and so we were not able to compare the mortality risk with controls. However, patients with ESRD requiring chronic dialysis are inherently at high risk of mortality (26,27). Flythe et al. concluded that the general 5-year survival rate after initiation of maintenance dialysis is approximately 40% (28).

The better long-term outcome after CABG compared to PCI in patients with three-vessel disease is in line with previous studies (9,29,30). CABG has been specifically shown to be advantageous in high-risk populations (i.e., patients with diabetes and ischemic cardiomyopathy), and the present study implies that this also might be applicable for patients with ESRD requiring chronic dialysis (30). However, the unfavourable outcome for both CABG and PCI patients on dialysis may be attributed not only to the high burden of risk factors such as diabetes, heart failure, hypertension, and peripheral vascular disease, but also to the accelerated atherosclerosis which leads to more severe and diffuse cardiac and peripheral vascular complications (31).

Stents and bypass grafts both provide revascularization to vascular territories that are affected by flow-limiting stenoses. However, only CABG provides protection against proximal vessel occlusions, because the majority of bypass graft insertions are performed distal to the plaque location. CABG thus provides a “collateralization effect” that protects against new myocardial infarctions (11,32). These specific aspects of the revascularization provided by the surgical technique can be considered as an explanation for the more favourable outcome of the CABG patients vs. the PCI patients.

This study has both strengths and limitations. Strengths include the large study population of patients with three-vessel disease and ongoing dialysis treatment, and the use of high-quality registers that provide comprehensive information on patient demographics, comorbidities, and outcomes with complete follow-up for an extended period. Limitations include those inherent in an observational study, such as selection bias and residual confounding. The sample size for the 30-day endpoint is an additional limitation, as the observed event rates and group sizes were insufficient to achieve 80% statistical power. This indicates that a substantially larger cohort would be required to reliably detect differences between PCI and CABG at this early time point. Since the patients were enrolled over a 15-year period, the choice of interventional method may, in some cases, have been determined by the treating physician rather than a multidisciplinary heart team. This may have introduced selection bias. The substantial baseline differences may also reflect treatment selection bias. Patients undergoing PCI were older, had been on dialysis for a longer duration, and had a higher prevalence of previous malignancy. This may indicate that some patients were considered too frail to undergo CABG at the time of the revascularization decision. We also did not have data on the frailty or functional status of patients at the time of revascularization, nor did we have access to a validated risk score to predict mortality and guide clinical decision-making. Moreover, owing to limitations in the registry, we were unable to conduct analyses stratified by dialysis modality (haemodialysis or peritoneal dialysis) or laboratory markers, which may represent a significant source of potential residual confounding. We performed a sensitivity analysis with PSM, which showed similar results to the main analysis, demonstrating that results in the main analysis were not sensitive to the chosen statistical analytical method.

Data on emergency revascularization were unavailable. It is plausible that, in cases of acute myocardial infarction requiring urgent intervention, clinicians favoured PCI over CABG to achieve faster revascularization and recovery while minimizing surgical delays and the physiological impact of extracorporeal circulation. However, the groups did not differ significantly regarding the number of patients presenting with acute coronary syndrome, defined as myocardial ischemia within 6 weeks pre-intervention. This suggests that the patients were not selected preoperatively for the choice of revascularization procedure based on their clinical presentation.

All patients included in the study were diagnosed with three-vessel CAD, but data on how many of the patients underwent complete revascularization were not available. Complete revascularization has been shown to reduce 1-year mortality in patients with myocardial reinfarction and multivessel coronary disease compared to an incomplete strategy (33), and should therefore always be favoured in this patient population.

Another limitation is that some patients in the PCI group were treated with bare metal stents and first-generation DES, which does not reflect the contemporary practice of using only second-generation DES (10). Second-generation stents, which have been available since 2010, make it possible to reduce the duration of dual antiplatelet therapy after PCI. This factor may reduce mortality and morbidity due to bleeding events (34).

Pan et al. (34) showed that all-cause mortality was significantly higher among patients who underwent CABG than among those who underwent PCI with DES at every time point examined up to 5 years from the time of revascularization, and that survival was significantly higher in patients receiving PCI with DES. Although this shows the efficacy of DES in patients with one- and two-vessel disease (10), no such results have been demonstrated in a study population including multivessel disease.

In our material, no information was available on the stent and graft types, and so we were unable to determine whether these factors influenced mortality in the PCI and CABG groups. However, we did not observe significant interaction between treatment group and calendar year, suggesting that the treatment effects were consistent throughout the study period.

Despite its limitations, this study is the first to report nationwide experience of coronary revascularization in patients with ESRD requiring chronic dialysis and three-vessel CAD, with long-term follow-up comparing CABG and PCI. It provides unique information on outcomes in this highly vulnerable patient group. Improved understanding of differences in long-term outcomes between revascularization strategies is essential to guide clinical decision-making. At the individual level, this knowledge may support more effective treatment selection, reduce rehospitalization, and improve quality of life.

Conclusions

Mortality risk is high in dialysis patients with three-vessel CAD undergoing revascularization. Patients who underwent CABG had a lower adjusted long-term mortality risk compared to patients undergoing PCI, while no difference in early mortality risk was observed. The combination of chronic kidney disease and CAD is associated with poor outcomes, and poses a great challenge to the treating physician. Treatment decisions should be tailored individually to each patient following a multi-disciplinary discussion and consideration of relevant risks and benefits as well as patient preference.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0332/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0332/prf

Funding: This work was supported by the Swedish state under the agreement between the Swedish government and the county councils concerning economic support of research and education of doctors (ALF agreement; No. ALFGBG-942665, to S.J.N.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0332/coif). S.J.N. reports support from the Swedish state under the agreement between the Swedish government and the county councils for research and education of doctors. E.B. reports travel and accommodation support from Medtronic (bifurcation stenting course, Copenhagen, March 2026) and Philips (intravascular ultrasound course, Stockholm, November 2025), all unrelated to the present work. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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