Infrainguinal revascularization in end-stage renal disease

Alprostadil treatment of critical limb ischemia in hemodialysis patients : A retrospective single-center analysis

BACKGROUND

Peripheral artery disease and critical limb ischemia are common in patients undergoing chronic hemodialysis treatment and are associated with a high rate of amputation and mortality. The effect of treatment with prostanoids in this specific group of patients is unknown.

METHODS

A retrospective single-center analysis of hemodialysis patients with critical limb ischemia was performed who were treated with the prostanoid analogue alprostadil as an infusion during hemodialysis in the period from 2000 to 2013. The primary study outcome was a combined end-point including amputation and death 1 year after start of alprostadil. Kaplan-Meier curves were used to describe amputation-free survival and overall survival. A multivariable adjusted Cox proportional hazards model was calculated for the primary outcome.

RESULTS

A total of 86 patients (60 males, 69.7%) were studied. The median alprostadil treatment period was 1.8 months. The 1‑year amputation-free survival was 41%. In 36% of patients an amputation was necessary and 35% died. Despite alprostadil treatment, 36% of the study patients additionally underwent an endovascular procedure and 16% had bypass surgery. Men had a significantly higher amputation rate (45%) than women (15%) (P = 0.009). Male sex and dialysis vintage were significantly associated with an increased risk for primary outcome CONCLUSIONS: Despite treatment with alprostadil the mortality, amputation rate and the need for revascularization procedures in hemodialysis patients with critical limb ischemia remained high. The outcome, however, was comparable with that of other treatment, such as endovascular procedures and bypass surgery. The effect of any current treatment strategy on amputation rate or mortality in that patient group remains uncertain.

Editor's Choice - Comparison of Outcomes After Open Surgical and Endovascular Lower Extremity Revascularisation Among End Stage Renal Disease Patients on Dialysis

OBJECTIVES

End stage renal disease (ESRD) patients with peripheral arterial disease (PAD) are at high risk of complications following open surgical revascularisation (OSR). Endovascular revascularisation (ER) is an option, but its role is unclear. This study sought to characterise the outcomes of ER and OSR in ESRD patients treated for claudication or critical limb ischaemia (CLI).

METHODS

The United States Renal Data System was used to investigate outcomes after lower extremity ER and OSR from 2005 to 2011. Primary outcomes were mortality, amputation, and peri-procedural myocardial infarction (MI). Kaplan-Meier (K-M) estimates were generated for mortality and amputation, logistic regression models for 30 day predictors, and proportional hazards models for long-term predictors.

RESULTS

A total of 20,347 patients underwent OSR and ER (20.3% OSR, 79.7% ER). CLI was the indication in 80.8% of ER and 88.4% of OSR. The unadjusted major amputation rate at 30 days was higher after ER compared with OSR (8.8% vs. 6.4%, p < .001). Conversely, the unadjusted mortality rate at 30 days was lower after ER compared with OSR (8.0% vs. 10.5%, p < .001). Multivariable logistic regression models adjusting for medical covariables and CLI versus claudication status demonstrated increased 30 day mortality risk with OSR compared with ER (OR 2.00, 95% CI 1.43-1.79, p < .001), MI (OR 1.38, 1.23-1.54, p < .001), and the combined endpoint of mortality and major amputation (OR 1.57, 1.16-2.12, p = .004), but lower odds of 30 day major amputation alone (OR 0.67, 0.58-0.77, p < .001). Proportional hazards models demonstrated increased long-term mortality risk with OSR compared with ER (HR 1.05, 1.00-1.09, p = .037), without a difference in major amputation (HR 0.99, 0.93-1.05, p = NS).

CONCLUSIONS

In this retrospective analysis of an administrative database, ESRD patients suffer from high mortality and amputation rates following lower extremity revascularisation. Compared with ER, OSR is associated with higher mortality. OSR has better 30 day limb salvage, although long-term outcomes are similar.

Infrainguinal Bypass in Patients with End-stage Renal Disease: Survival and Ambulation

The purpose of this study was to evaluate the outcomes of infrainguinal bypass surgery and ambulatory status in patients with end-stage renal disease (ESRD).

Vascular registry data and the medical records of patients requiring infrainguinal bypass surgery from 1985 through 1995 were reviewed retrospectively. Patients with chronic limb-threatening ischemia requiring maintenance hemodialysis or peritoneal dialysis for ≥ 6 months were compared to a randomly selected group of patients under going foot salvage infrainguinal bypass in the absence of ESRD. Primary outcomes were mortality, amputation, and ambulatory status at 30 days and 1 year. Data were analyzed using Pearson's chi-square methods, Fisher's Exact test, Mann-Whitney U, life table analyses, and Quality of Life-Class (QL-Class) ranking.

There were 57 patients with ESRD who underwent 66 infrainguinal bypass proce dures. Mean age was 65.8 ±9.8 years (41-85 years). The 30-day operative mortality rate was 12.3% (7 patients). The cumulative survival at 1 year was 51.8% ±0.9%, and at 2 years it was 32.8% ± 1.3%. The cumulative limb loss was 29.7% ± 1.1% at 1 year and 36.7% ±2.6% at 2 years. In the comparison group, 46 patients without ESRD underwent 50 infrainguinal bypass procedures. The mean age of these patients was 72.3 ±9.1 years (36-90 years). The cumulative survival for the patients without ESRD was significantly higher (p < 0.001) both at 1 year (91.1% ±0.6%) and 2 years (88.8% ±0.8%). The cumulative limb loss for the comparison group was significantly lower (p < 0.001) at 1 year (4.1% ±0.4%) and at 2 years (6.3% ±0.5%). At both 30 days and 1 year, the QL- Class walking status rating was lower for the group with ESRD compared to patients without ESRD (p < 0.001).

Patients with ESRD have a high mortality rate in the first 24 months after infrain guinal bypass grafting for foot salvage surgery compared with a similar group of patients without ESRD. Although foot salvage can be achieved in some survivors with ESRD, the ambulatory rate is low. These results support a very conservative approach when recom mending infrainguinal bypass grafting for foot salvage surgery for patients with ESRD.

Calciphylaxis: Calcific Angiopathy Resulting in Acral Gangrene

The role and success of peripheral vascular surgery in patients with end-stage renal disease (ESRD) remains controversial. Reduced survival, higher mortality, and lower limb salvage rates have led some authors to advocate primary amputation in this patient population. Until recently, the explanation for high failure and mortality in these patients could not be explained. The authors report five patients with ESRD initially diagnosed with acral gangrene secondary to calciphylaxis. Despite distal gangrene, only three of the five patients had significant peripheral arterial insufficiency. Poor surgical results in ESRD patients developing peripheral vascular disease (PVD) can sometimes be explained on the basis of calciphylaxis.

Predictors of major amputation despite patent bypass grafts

OBJECTIVE

Despite patent vein bypass grafts, some patients with critical limb ischemia (CLI) receive major amputations. We analyzed the predictive factors leading to major amputation in the presence of patent lower extremity bypass (LEB) grafts.

METHODS

Data from the Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III), a large prospective randomized trial of 1404 patients who underwent LEB with vein graft for CLI, were queried for outcomes. The primary outcome was major amputation with patent (PMA) LEB compared with patients with patent LEB who achieved limb salvage (PLS). The population excluded those who received amputation for occluded grafts. A Cox proportional hazard model identified independent predictors.

RESULTS

Of 1404 LEB patients, 162 (11.5%) had major amputation: 89 (6.3%) with patent and 73 (5.2%) with occluded LEB. For PMA, 21 of 89 (23.6%) developed critical stenosis and 11 of 21 (52.4%) were revised. For PLS, 460 of 1242 (37.0%) developed critical stenosis and 351 of 460 (76.3%) were revised. Predictive patient factors included having preoperative gangrene (vs rest pain; hazard ratio [HR], 3.504; 95% confidence interval [CI], 1.533-8.007; P = .0029), diabetes (HR, 1.800; 95% CI, 1.006-3.219; P = .0477), black (vs white) race (HR, 1.779; 95% CI, 1.051-3.011; P = .0321), baseline creatinine clearance <25 mL/min (vs >65 mL/min; HR, 1.759; 95% CI, 1.016-3.048; P = .0439), prior history of coronary artery bypass grafting (HR, 1.702; 95% CI, 1.080-2.683; P = .0221), and lower baseline activity quality of life score (HR, 1.401; 95% CI, 1.105-1.778; P = .0054). Postoperative wound factors included gangrenous changes (HR, 5.830; 95% CI, 1.647-20.635; P = .0063), surgical wound necrosis (HR, 5.319; 95% CI, 1.478-19.146; P = .0105), deep (vs superficial) wound infection (HR, 3.815; 95% CI, 1.220-11.927; P = .0213), and wound healing abnormally (HR, 3.754; 95% CI, 1.061-13.278; P = .0402). Associated postoperative consequences leading to PMA included having recurrent CLI symptoms (HR, 2.915; 95% CI, 1.816-4.681; P < .0001), a severe (vs mild) adverse event (HR, 2.751; 95% CI, 1.391-5.443; P = .0036), fewer percutaneous revisions (HR, 2.425; 95% CI, 1.573-3.740; P < .0001), discharge on low-molecular-weight heparin (HR, 2.087; 95% CI, 1.309-3.326; P = .0020), and decreasing days to critical stenosis/occlusion/revision/amputation (HR, 1.010; 95% CI, 1.007-1.012; P < .0001).

CONCLUSIONS

Whereas a patent vein graft is important to all vascular surgeons, additional factors should be considered in trying to attain limb salvage for patients with CLI. These factors include intervening surgically before CLI has progressed to a state of gangrene or limited activity and optimizing nutrition, diabetes control, cardiac conditions, and activity level. Revision offers hope for clinical improvement but may be delayed when there is no graft lesion identified. The absence of a graft lesion to revise may also portend amputation despite a patent graft because of nongraft-related factors such as infection. Finally, the experience of a severe (vs mild) adverse event may also result in limb loss despite a patent graft. Systematic efforts to reduce severe adverse events among patients may also lead to increased limb salvage.

Surgical Revascularization in Patients with End-Stage Renal Disease: Results Using a New Paradigm in Outcomes Assessment

Studies evaluating the outcome of surgical revascularization (SR) for critical limb ischemia in patients who have end-stage renal disease (ESRD) have differed widely in their findings and conclusions. Differences in definitions of success are largely responsible for the varying outcomes. We developed a method of outcomes assessment that incorporates four all-inclusive end-points to define success. These include primary graft patency to the point of wound healing, postoperative survival of at least 6 months, limb salvage of at least 1 year, and maintenance of ambulatory status of at least 6 months. The purpose of this study was to use this novel method of defining success to determine the outcome of SR in patients with ESRD. From 1998 to 2004, 40 patients (52 limbs) with ESRD and tissue loss underwent SR for limb salvage. Secondary graft patency and limb salvage rates at 36 months were 54.7 per cent and 53 per cent, respectively. When considering each of the four components used to define success separately, success encouragingly ranged between 60 per cent (patent graft until wound healing) and 87.5 per cent (survival for 6 months). However, if all parameters were combined, clinical success was achieved in only 40 per cent (16/40) of patients. Coronary artery disease was the only factor found to significantly reduce success ( P = 0.04). In conclusion, using this multiparameter definition of success, which combines four rather modest outcome milestones, favorable outcome occurred in the minority of cases. This study challenges our current method of analyzing success and questions our therapeutic approach to patients with critical limb ischemia and ESRD.

An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease

BACKGROUND

A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft.

METHODS

Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis.

RESULTS

Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected.

CONCLUSIONS

Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.

Creatinine clearance but not serum creatinine alone predicts long-term postoperative survival after lower extremity revascularization

BACKGROUND

Renal insufficiency is a well-described risk factor for perioperative morbidity and shortened survival after major vascular procedures. Due to the potential inaccuracy of serum creatinine levels alone in measuring kidney function, our aim was to determine whether estimated creatinine clearance more consistently predicted long-term survival.

METHODS

A retrospective review of one institution's vascular registry was performed. Logistic regression analysis was conducted to determine independent predictors of 1-, 2- and 3-year postoperative mortality. Creatinine clearance was estimated as [140 - age (years)] x weight (kg)/72 x serum creatinine (mg/dl), multiplied by 0.85 for women.

RESULTS

A total of 252 consecutive patients underwent infrainguinal bypass procedures between August 1999 and May 2000. Demographics included average age 68 years, 65% male, 74% diabetic, 12% dialysis-dependent, 23% history of congestive heart failure, 12% history of stroke and 20% serum creatinine >2 mg/dl. One-year mortality was 16% (n = 40), 2-year mortality was 25% (n = 64), and 3-year mortality was 35% (n = 88). There was no difference in serum creatinine values between survivors and non-survivors at 1 year (1.8 vs. 1.9, p = 0.80), 2 years (1.8 vs. 2.0, p = 0.62) or 3 years (1.8 vs. 2.0, p = 0.24), and creatinine >2 mg/dl did not predict long-term adverse outcomes. In contrast, reduced creatinine clearance (< or =60 ml/min) was an independent predictor of mortality regardless of dialysis status (1 year: OR = 2.53, p = 0.014; 2 years: OR = 2.46, p = 0.004; 3 years: OR = 2.45, p = 0.001), and creatinine clearance was higher for survivors versus non-survivors at all 3 time points (1 year: 70.2 vs. 49.5, p = 0.003; 2 years: 72.3 vs. 51.2, p < 0.0001; 3 years: 74.7 vs. 52.6, p < 0.0001). Other independent predictors of mortality included a history of stroke (1 year: OR = 3.28, p = 0.008; 2 years: OR = 2.55, p = 0.025; 3 years: OR = 2.35, p = 0.038) and congestive heart failure (1 year: OR = 2.86, p = 0.006; 2 years: OR = 2.54, p = 0.005; 3 years: OR = 2.13, p = 0.017).

CONCLUSIONS

Independent of dialysis status, a decreased creatinine clearance, but not elevated serum creatinine alone, is an independent predictor of mortality after lower extremity arterial reconstruction. Determination of creatinine clearance should replace serum creatinine in the preoperative risk evaluations of patients undergoing major vascular surgical procedures.

Management of peripheral arterial disease in chronic kidney disease

PAD has been overlooked in many epidemiologic studies evaluating cardiovascular risk associated with renal disease. Conversely, CKD has not been evaluated as a potential risk factor in epidemiologic studies of PAD. PAD, however,seems to be more prevalent among patients with even moderate CKD than in the general population and is most common among chronic dialysis patients, one third or more of whom have a low ABI. Patients with CKD also seem to be at increased risk for developing claudication and for requiring surgical intervention for lower extremity PAD. Furthermore, even moderate CKD seems to be a risk factor for postoperative death and complications after both lower extremity amputation and revascularization procedures. Conversely, even asymptomatic PAD seems to be a risk factor for death among dialysis patients. In the general population, statins, antiplatelet agents (particularly clopidogrel), antihypertensive agents, and ACE inhibitors all have a proven benefit in reducing cardiovascular events in patients with PAD and in some instances may also reduce PAD events. Available evidence suggests that patients with CKD also experience cardio-vascular risk reduction with statin and ACE-inhibitor therapy, but these therapies have not been shown to reduce PAD events specifically in patients with CKD. Further studies are needed to identify interventions that can specifically reduce the incidence of PAD complications in patientswith CKD. Although it is clear that mortality and complication rates after both lower extremity amputation and revascularization are increased in patients with even moderate CKD, currently available observational studies do not provide clear guidance for surgical decision making in CKD patients with limb-threatening ischemia. Further studies are needed to evaluate the risksand benefits of amputation over revascularizationamong patients with CKD and to investigatereasons for the high mortality associated with these procedures in this patient group. Further studies are also needed to measure the impact of CKD on care processes for PAD with the goal of identifying target areas for improvement.

Below-the-Knee Angioplasty in Patients With End‐Stage Renal Disease

PURPOSE

To determine clinical efficacy of below-the-knee (BTK) angioplasty in patients with end-stage renal disease (ESRD).

METHODS

Interrogation of a prospectively maintained database containing 2,659 patients treated at a tertiary referral hospital between February 1995 and June 2004 identified 29 ESRD patients (21 men; median age 69 years, IQR 10.12) who had 73 infrapopliteal atherosclerotic lesions treated in 38 ischemic limbs. The indication for treatment was intermittent claudication in 13 (34%) and critical limb ischemia in 25 (66%) limbs. BTK angioplasty was attempted either alone (n=18) or combined with an endovascular inflow procedure (n=20). Primary clinical success was defined as hemodynamic improvement (ABI increase >or=0.1) and/or symptomatic improvement (at least one clinical category). Cumulative rates were calculated according to the Kaplan-Meier estimate.

RESULTS

Primary technical success reached 97%, whereas hemodynamic improvement was obtained in only 50% (19/38) of the limbs treated. The pedal arteries were severely diseased in all, and complete occlusion of the pedal arch was found in 58% (18/31) of limbs on completion angiography. Median follow-up was 5.9 months (IQR 11.5). Primary clinical success was 17%, 11%, 11%, and 11% in patients with BTK angioplasty alone and 53%, 45%, 45%, and 45% in patients with inflow procedures after 3, 6, 9, and 12 months, respectively (p=0.017). Limb salvage was 73% at 12 months. Subgroup analyses showed significantly better clinical results in men (p=0.003) and in patients on hemodialysis compared to peritoneal dialysis (p=0.037).

CONCLUSIONS

Clinical efficacy of BTK angioplasty is limited in patients with ESRD because of the severely diseased pedal arteries. Further studies are warranted to define subgroups of patients likely to experience a more favorable outcome.

Infrapopliteal Angioplasty for Limb Salvage in the Setting of Renal Failure: Do Results Justify Its Use?

Multiple reports advocate the use of infrapopliteal angioplasty for limb salvage; however, its utility in the setting of renal failure is unclear. We performed angioplasty, rather than bypass, for tibial stenoses or occlusions <3 cm on 90 limbs of 79 patients (64.4% male, mean age 67.2 years), all with ischemic ulcer. Seventy (77.8%) had diabetes mellitus and 16 (17.8%) had end-stage renal disease (ESRD). Mean follow-up was 14.3 months (range 0.3-45). Associated femoropopliteal revascularization was required in 28 (31.0%) limbs. Primary angiographic success was achieved in 83 (92.2%) limbs. Residual stenosis or thrombosis occurred in two and five limbs, respectively. Dissection occurred in six limbs, all successfully treated with stent placement. Ulcer healing occurred after initial angioplasty in 41 (55.4%) non-ESRD and four (25%) ESRD limbs. Subsequent revascularization procedures were required in 21 (23.3%) limbs, including six bypasses and 15 repeat angioplasties, of which three underwent subsequent bypasses. Major amputation was required in 11 (14.9%) non-ESRD and seven (43.7%) ESRD limbs. Limb salvage was 84.4% and 80.2% in those without and 52.5% and 52.5% in those with ESRD at 1 and 3 years, respectively (p = 0.01). Thirty-day mortality was 2.2%. Overall actuarial survival was 82.2% and 62.1% at 1 and 3 years, respectively, and did not differ significantly between patients with and without ESRD (p = 0.66). Infrapopliteal angioplasty is a safe technique with low procedural morbidity and mortality. However, the inferior wound-healing and limb-salvage rates observed in patients with renal failure bring to question the utility of infrapopliteal angioplasty in this population.

Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study

Background

Surgical treatment of peripheral vascular disease (PVD) in dialysis patients is controversial.

Methods

We examined the post-operative morbidity and mortality of surgical revascularization or amputation for PVD in a retrospective analysis of United States Renal Data System. Propensity scores for undergoing amputation were derived from a multivariable logistic regression model of amputation.

Results

Of the Medicare patients initiated on dialysis from Jan 1, 1995 to Dec 31, 1999, patients underwent surgical revascularization (n = 1,896) or amputation (n = 2,046) in the first 6 months following initiation of dialysis were studied. In the logistic regression model, compared to claudication, presence of gangrene had a strong association with amputation [odds ratio (OR) 19.0, 95% CI (confidence interval) 13.86–25.95]. The odds of dying within 30 days and within1 year were higher (30 day OR: 1.85, 95% CI: 1.45–2.36; 1 yr OR: 1.46, 95% CI: 1.25–1.71) in the amputation group in logistic regression model adjusted for propensity scores and other baseline factors. Amputation was associated with increased odds of death in patients with low likelihood of amputation (< 33^rd percentile of propensity score) and moderate likelihood of amputation (33^rd to 66^th percentile) but not in high likelihood group (>66^th percentile). The number of hospital days in the amputation and revascularization groups was not different.

Conclusion

Amputation might be associated with higher mortality in dialysis patients. Where feasible, revascularization might be preferable over amputation in dialysis patients.

Influence of renal insufficiency on limb loss and mortality after initial lower extremity surgical revascularization

OBJECTIVE

Limb loss after lower extremity surgical revascularization occurs relatively frequently in patients receiving dialysis. The goal of the present study was to determine whether patients with milder degrees of renal insufficiency are also at risk for this complication.

MATERIAL AND METHODS

This cohort study was carried out at the Department of Veterans Affairs (VA). The study sample consisted of 9932 patients undergoing an initial surgical revascularization procedure between October 1, 1995, and September 30, 2000, recorded by the VA National Surgical Quality Improvement Program (NSQIP). We examined the occurrence of major amputation within 1 year of lower extremity surgical revascularization by level of renal function.

RESULTS

Eleven percent of study patients underwent major lower extremity amputation within 1 year of NSQIP-documented lower extremity revascularization surgery: 10% (739 of 7335) of patients with normal renal function, 11% (251 of 2210) of patients with moderately reduced renal function, 12% (24 of 205) of patients with severe renal insufficiency, and 29% (53 of 182) of patients receiving dialysis. After adjustment for demographic characteristics and comorbid conditions, only patients receiving dialysis were at significantly increased risk for amputation, compared with patients with normal renal function (odds ratio, 2.46; 95% confidence interval, 1.74-3.47; P<.001). Compared with all other veterans undergoing bypass procedures, patients receiving dialysis were more likely to have a wound infection; a diagnostic code for lower extremity gangrene, infection, or ischemic ulceration; an elevated white blood cell count; and preoperative sepsis at the time of initial revascularization. In addition, they were more likely to have a preoperative hospital stay longer than 1 week, undergo concurrent minor amputation, and undergo an outflow (vs inflow) procedure.

CONCLUSION

Only patients receiving dialysis, and not patients with milder degrees of renal insufficiency, appear to be at higher risk for limb loss after revascularization, compared with patients with normal renal function. Further studies are needed to determine why patients receiving dialysis are at a singularly increased risk for limb loss after lower extremity revascularization and whether their more frequent presentation with limb-threatening infection at the time of revascularization reflects late presentation for surgery or a more rapid course of peripheral arterial disease in this patient group.

Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients

BACKGROUND

Peripheral vascular disease (PVD) has become increasingly common in end-stage renal disease (ESRD) patients, leading to an increase in the rate of revascularization and amputation. We studied the prognosis of ESRD patients undergoing their first revascularization procedure.

METHODS

We conducted a longitudinal cohort study of hemodialysis patients enrolled in special studies of the United States Renal Data System. Cox proportional hazards analysis was used to assess the independent effect of type of initial revascularization procedure on lower extremity amputation and all-cause, cardiac, and infectious mortality over 3 years, after adjustment for sociodemographic, clinical, and biologic baseline characteristics.

RESULTS

Eight hundred patients underwent an initial revascularization procedure by surgical bypass or angioplasty. The overall incidence of subsequent amputation was 16.3/100 person-years, 22.6 for bypass, and 5.7 for angioplasty. After adjustment for patient characteristics, the risk of amputation was higher for bypass versus angioplasty [relative hazard (RH) 4.00; 95% CI 2.46 to 6.57], for black versus white patients (RH 1.49; 95% CI 1.04 to 2.15), for uninsured or patients on Medicaid versus patients with private insurance or on Medicare (RH 1.65; 95% CI 1.12 to 2.72), and for patients with diabetes versus no diabetes (RH 2.51; 95% CI 1.67 to 3.76). Compared with patients who underwent angioplasty, the risk of all-cause (RH 1.37; 95% CI 1.10 to 1.70), cardiac (RH 1.50; 95% CI 1.08 to 2.09), and infectious (RH 2.17; 95% CI 1.10 to 4.29) mortality was greater among patients who underwent bypass.

CONCLUSION

Risk of amputation following revascularization procedures was positively associated with type of procedure, black race, uninsured/Medicaid, and diabetes status. Risk of death was also higher following bypass. While this might reflect underlying severity of disease, patient education, screening, and optimal care of lower extremities should be emphasized to detect PVD at an early stage of the disease process.

Infrainguinal revascularization after renal transplantation

BACKGROUND

Although evidence suggests that end-stage renal disease is associated with poor limb salvage and patient survival after arterial revascularization, little is known about the effect of renal transplantation. We analyzed the outcome in patients with renal transplants who underwent infrainguinal bypass procedures.

METHODS

Data prospectively entered into our vascular registry were reviewed for all patients who underwent lower extremity bypass procedures from January 1, 1990, through January 31, 2002. Sixty patients were identified who had a functioning renal allograft at infrainguinal revascularization. Kaplan-Meier survival curves were generated for limb salvage, patency, and patient survival and were compared with the Mantel-Cox log- rank test.

RESULTS

Sixty patients (40 men, 20 women; mean age, 47.1 years) underwent 76 bypass procedures in 71 limbs. Preoperative demographic data included diabetes (59 of 60 patients, 98.3%), coronary artery disease (26 of 60 patients, 43.3%), and preoperative serum creatinine concentration (SCr) greater than 2.0 mg/dL (9 of 60 patients, 11.7%). Mean follow-up was 25.1 months. Overall major complication rate was 11.8%, and 30-day mortality rate was 1.3%. Survival was 93.3% at 1 year and 66.6% at 5 years. Limb salvage was 87% at 1 year and 78% at 5 years. Primary graft patency was 78% at 1 year and 44% at 5 years. Preoperative SCr less than or equal to 2.0 mg/dL was associated with improved overall patient survival (5-year survival, 73.4% vs 37.5%; P =.01, log-rank test). Limb salvage and patency rates were not significantly affected by preoperative SCr greater than 2.0 mg/dL.

CONCLUSIONS

Lower extremity bypass can be performed safely and effectively in patients who have undergone renal transplantation. However, the importance of a well-functioning renal allograft at surgery is demonstrated by marked improvement in patient survival.

Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs' National Surgical Quality Improvement Program

Few data are available on the impact of renal insufficiency on short-term operative outcomes after lower extremity surgical revascularization. We used prospectively collected data from the Department of Veterans Affairs' National Surgical Quality Improvement Program (NSQIP) to explore the association with renal dysfunction of adverse outcomes occurring within 30 d of lower extremity surgical revascularization in a cohort of all patients undergoing at least one lower extremity surgical revascularization from 1/1/94 to 9/30/01 (n = 18,217). Even moderate renal insufficiency (estimated GFR 30-59cc/min/1.73m(2)) was associated with an increased incidence of postoperative death (adjusted odds ratio (OR) 1.44, 95% confidence interval (CI), 1.17 to 1.77, P = 0.001), cardiac arrest (OR 1.43, CI 1.09 to 1.88, P = 0.011), myocardial infarction (OR 1.68, 1.39 to 2.16, P < 0.001), unplanned intubation (OR 1.69, CI 1.39 to 2.07, P < 0.001) and prolonged intubation (OR 1.57, CI 1.28 to 1.94, P < 0.001) within 30 d of lower extremity revascularization. However, the incidence of wound infection and graft failure requiring return to the operating room did not appear to be substantially higher in this group. Our data also show that patients with renal insufficiency undergoing revascularization were more likely to require distal procedures and to present with limb-threatening infection compared to those with normal renal function. Efforts to improve pre-and post-operative care in patients with renal insufficiency undergoing lower extremity revascularization should take into account the increased incidence of postoperative death and cardiopulmonary complications in this group in addition to more traditional concerns about operative site complications. Further studies are needed to explore reasons for the higher rate of limb-threatening infection in patients with renal insufficiency undergoing revascularization.

Infrainguinal arterial reconstruction for limb salvage in patients with end-stage renal disease

OBJECTIVES

to evaluate the efficacy of infrainguinal bypass for limb-threatening ischaemia in patients with end-stage renal disease (ESRD).

MATERIALS AND METHODS

from 1991 through 2000, 28 limbs in 22 patients with ESRD received 33 infrainguinal bypasses, while 65 limbs in 57 patients with functioning kidneys underwent 77 bypasses for limb salvage. The prevalence of diabetes is higher in the ESRD group (p = 0.03).

RESULTS

perioperative mortality and patient survival rate in the follow-up period were significantly poorer in patients with ESRD (18% vs 0%; p = 0.001, and 45% vs 85%, p < 0.001, respectively). Most causes of death were related to atherosclerosis or respiratory diseases. In spite of no significant difference in 2-year primary and secondary graft patency rates and limb salvage between the ESRD and non-ESRD groups (76% vs 83%; p = 0.12, 85% vs 91%; p = 0.06, and 83% vs 93%; p = 0.06, respectively), two cases of early limb loss occurred as a result of uncontrolled infection in the ESRD group. In contrast to autogenous conduits, nonautogenous conduits revealed a poorer outcome in ESRD patients (p = 0.03).

CONCLUSIONS

perioperative mortality and patient survival rate were significantly poorer in the ESRD group. Preoperative full evaluation of myocardial and brain ischaemia, revascularisation with autogenous conduits, appropriate treatment of wound infection, and strict follow-up for accompanying diseases may be needed in these patients.

Lower-extremity peripheral arterial disease among patients with end-stage renal disease

Peripheral arterial occlusive disease (PAOD) accounts for significant morbidity and mortality among end-stage renal disease (ESRD) patients but has not been as extensively studied as other kinds of atherosclerotic disease in this population. The current epidemiology and management of PAOD in ESRD patients is here reviewed and target areas for future research are identified. The prevalence of PAOD appears to be much higher among ESRD patients than in the general population. Risk factors for disease among ESRD patients are not well understood but probably include both conventional and dialysis or uremia-associated risk factors. Standard diagnostic techniques used to identify PAOD in the general population may not be as helpful in ESRD patients because many of these tests are inaccurate in the settings of vascular calcification and small-vessel disease. Despite the fact that this is a common disease in ESRD patients, most of these patients are not screened for PAOD. Interventions that have proven effective in the prevention and treatment of PAOD in the general population, such as smoking cessation, preventive foot care, and exercise, have not been systematically applied to ESRD patients. Furthermore, the optimal management of ischemic ulceration and gangrene in ESRD patients is quite controversial, and better algorithms for the prevention and management of PAOD in ESRD patients are needed. In conclusion, PAOD is common in ESRD patients. Future research should identify risk factors for disease in this population, and efforts should be made to develop strategies for the effective prevention and management of limb ischemia in this population.

A meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease

OBJECTIVES

to determine graft patency, limb salvage, and patient survival following infrainguinal bypass grafting in patients with end-stage renal disease (ESRD).

METHODS

studies published from 1987 through 2000 were identified from the PUBMED database and pertinent original articles. Sixteen studies were found that used survival analysis to report the outcomes of interest. Two investigators independently extracted the data from standard life-tables, survival curves and texts. A new method was developed for meta-analysis of uncontrolled studies that use survival analysis with different follow-up intervals.

RESULTS

random-effects modelling yielded the following summary estimates at one- and two-year follow-up: 79% (95% CI, 70-87%) and 74% (63-85%) for graft patency; 77% (69-84%) and 73% (64-81%) for limb salvage; and 59% and 42% for patient survival.

CONCLUSION

despite a severely limited life span, infrainguinal bypass grafting for the treatment of critical ischaemia is worthwhile in selected patients with ESRD.

Long-term outcomes of revascularization for peripheral vascular disease in end-stage renal disease patients

The occurrence of peripheral vascular disease (PVD) and atraumatic lower-extremity amputations is significantly greater in patients with end-stage renal disease (ESRD) than those with normal renal function. Moreover, the mortality for dialysis patients undergoing atraumatic lower-extremity amputations is far greater. Because PVD requiring amputation is an extreme form of PVD, we tested the hypothesis that mortality and intermediate outcomes for patients with ESRD undergoing lower-extremity revascularization, a less extreme form of PVD, would be equivalent to that for patients without ESRD. This is a retrospective case-control analysis of lower-extremity revascularization in patients with ESRD. Procedures in patients with ESRD were matched with procedures in non-ESRD controls for patient age, sex, race, diabetes mellitus, and hospital setting. Patient survival, graft survival, and limb salvage rates were determined using Kaplan-Meier analysis. Subjective interpretation of functional and symptomatic improvement was determined by telephone interviews with patients or relatives. Thirty-one procedures were performed on 20 patients with ESRD and 64 matched procedures were performed on 57 patients without ESRD. In the ESRD group, median patient survival was 1.72 years compared with 5.17 years for the control group (P < 0.001). Time to 50% limb loss was 1.24 years in the ESRD group and longer than 5.65 years in the control group (P < 0.001). Time to 50% graft patency loss was 0.70 years in the ESRD group and longer than 5.5 years in the control group (P < 0.05). Subjective improvement was less in patients with ESRD. Outcomes of lower-extremity revascularization in patients with ESRD are inferior to those in non-ESRD controls. The mortality rate for patients with ESRD who undergo revascularization is extremely high. Patient-related variables (eg, increased prevalence of hypertension and cardiovascular disease) and/or provider-specific factors (eg, timing of surgery in the course of PVD) may be responsible for poorer outcomes.

Contemporary analysis of outcomes following lower extremity bypass in patients with end-stage renal disease

This study was designed to compare outcomes following infrainguinal bypass between patients with end-stage renal disease (ESRD) and patients with normal renal function (NRF). Sixty-three patients with ESRD undergoing 78 infrainguinal bypasses from 1990 to 1999 were compared with a concurrent group of 132 age-, race-, and gender-matched patients with NRF undergoing 148 bypasses. Limb salvage and survival were calculated using Kaplan-Meier analysis. Markov decision analysis was used to calculate expected quality-adjusted life years (QALY) with intervention. Mean follow-up was 25 months (range 1-116). The results of our study show that infrainguinal bypass in patients with ESRD and tissue necrosis appears to provide a measurable, but marginal, degree of improvement in quality of life.

Peripheral vascular occlusive disease in renal transplant recipients: risk factors and impact on kidney allograft survival

BACKGROUND

This study evaluated the relationship between renal transplantation and the evolution of lower extremity peripheral vascular occlusive disease (PVOD).

METHODS

A total of 664 adult renal allograft recipients from 1985-1995 were retrospectively reviewed for atherosclerotic risk factors and peripheral vascular occlusive disease (PVOD). PVOD events were defined as bypass, major amputation, claudication, or percutaneous angioplasty. Follow-up ranged from 2-12 years.

RESULTS

The cumulative 5- and 10-year incidences of lower extremity PVOD after renal transplantation were 4.2 and 5.9%. Eight of 14 patients (57%) with pretransplant PVOD had additional PVOD events versus de novo appearance of PVOD in 21/650 patients (3.2%; P<0.0001). In a proportional hazards model, age, preoperative PVOD, diabetes, and postoperative smoking were independent risk factors for the development of PVOD after transplantation. Recipients with lower extremity PVOD had significantly lower 10-year patient and graft survival. Increased graft failure was due to an excess of deaths with a functioning graft. A total of 34 major interventions were performed. One- and two-year limb salvage rates were 64.2 and 53.8%.

CONCLUSIONS

Lower extremity PVOD after renal transplantation is associated with diminished patient survival, and affects kidney graft survival via disproportionate patient attrition. Age, preoperative PVOD, diabetes, and postoperative smoking are important risk factors. Transplantation does not appear to either accelerate or retard the progression of disease. An aggressive approach towards limb salvage in properly selected patients is justifiable.

Is lower extremity revascularization worthwhile in patients with end-stage renal disease?

BACKGROUND

The purpose of this study was to review the results of lower extremity revascularization in patients with end-stage renal disease and to determine in these patients the functional benefit and cost of an aggressive approach to limb preservation.

METHODS

During a 5-year period at our institution, 33 bypass operations were performed on 31 limbs of 23 dialysis-dependent patients. Indications for revascularization were limited (18) or extensive (12) tissue loss or ischemia without tissue loss (3). Procedures included aortobifemoral bypass (1), femoropopliteal bypass (10), and femorotibial/pedal bypass (22). A digital or transmetatarsal amputation was performed in 57% of limbs.

RESULTS

The 30-day primary patency was 100%. Cumulative primary and secondary patency rates at 2 years were 65% and 79%, respectively. Limb salvage was 67% and 59% at 1 and 2 years, respectively. Patient survival was poor (47% at 2 years). Peritoneal dialysis was predictive of poor survival (P <.001). Four of 5 patients on peritoneal dialysis died within 3 months of intervention. Extensive tissue loss was predictive of a diminished rate of limb salvage (P =.027). Only 39% of limbs with extensive tissue loss were salvaged at 1 year compared with 78% and 100% of limbs with limited and no tissue loss, respectively. The average hospital cost was $44,308 per year of limb salvage.

CONCLUSIONS

Although revascularization of ischemic limbs in dialysis patients can be achieved with an excellent initial graft patency and reasonable limb salvage, patient survival is poor and costs are high. A selective approach to revascularization in these complicated patients may be indicated. For patients treated with peritoneal dialysis and for those with extensive tissue loss, primary amputation may be the preferred approach.

Autogenous arterial bypass grafts: durable patency and limb salvage in patients with inframalleolar occlusive disease and end-stage renal disease

OBJECTIVE

The purposes of this study were to determine whether autogenous arterial grafts to distal pedal arteries improve the patency of grafts and limb salvage in patients with end-stage renal disease and nonhealing ischemic wounds and to better define the indications for autogenous arterial grafts.

DESIGN

A review of consecutive patients with end-stage renal disease undergoing autogenous arterial grafts from 1994 through 1999 was carried out. The setting was a university hospital. All 11 patients with end-stage renal disease and nonhealing, ischemic wounds (stage IV SVS-ISCVS classification) undergoing autogenous arterial grafting from 1994 to 1999 were evaluated. Noninvasive studies confirmed inadequate perfusion pressures in all patients. Pre-bypass arteriography identified no major arteries patent at the level of the malleolus, with reconstitution of only a distal or branch pedal or plantar vessel less than 1 mm in diameter. Five patients with patent tibial vessels to just above the ankle underwent bypass surgery with autogenous arterial grafts alone. Six patients also had proximal occlusive disease that required grafts longer than the autogenous arterial grafts; in each of these six patients, an autogenous vein graft proximal to the autogenous arterial graft was placed through use of a composite technique. Inflow was from the common femoral artery in one patient, the popliteal artery in five patients, and a tibial artery in five patients. Outflow was to the medial plantar artery in five patients, the distal dorsalis pedis artery in three patients, the lateral plantar artery in two patients, and the superficial arch in one patient. The conduit was the subscapular artery in four patients, the deep inferior epigastric artery in four patients, the superficial inferior epigastric artery in two patients, and the radial artery in one patient. The main outcome measures were assisted primary graft patency and functional limb salvage rate.

RESULTS

Follow-up ranged from 6 to 63 months (mean, 20 months); graft patency was determined by means of duplex scanning. All 11 patients are alive, and nine grafts are patent, including three after revision for graft stenosis. Assisted primary patency was 82% at 3 years. All nine patients with patent grafts remained ambulatory and had healed wounds or limited forefoot amputations.

CONCLUSION

Autogenous arterial grafts were effective in treating limb-threatening ischemia in patients with end-stage renal disease and inframalleolar arterial insufficiency. Graft patency and limb salvage rates were higher than those reported for autogenous vein graft in these patients. Autogenous arterial grafting may therefore prove to be an effective alternative to autogenous vein grafting in selected patients.

Limb amputation on renal replacement therapy

Ten (10) diabetic and 7 non-diabetic patients on renal replacement therapy have undergone limb amputation in the authors' unit in the 1988 to 1996 period. The article examines the course of illness and survival patterns in this distinct and increasing sub-set in the amputee population. Rehabilitation and survival were significantly better in the diabetic group and it is recommended that it would be helpful for both prognosis and analysis if the sub-set of amputees on treatment for chronic renal failure is further divided into diabetic and non-diabetic sub-sets.

Influence of incisional complications on infrainguinal vein bypass graft outcome

Incisional complications following infrainguinal vein bypass remain a formidable challenge to the vascular surgeon. A retrospective analysis of 250 infrainguinal vein bypass grafts (214 patients) was undertaken to identify risk factors for the development of incisional complications and determine the impact of incisional complications on outcome. Incisional complications occurred in 47 (19%) of the bypasses. The mean age was 67.8 years and 155 (62%) of the bypasses were performed in men. The patients were divided into two groups based on the presence or absence of an incisional complication. By univariate analysis, the contributing factors for an incisional complication were: veteran hospital status, dialysis dependence, anemia, obesity, leukocytosis, and hypoalbuminemia (p < 0.05). By multivariate analysis, veteran hospital status, female gender, leukocytosis, and prior ipsilateral bypass were independent risk factors for incisional complications (p < 0.05). The increased incidence of incisional complications in the veteran's hospital group was associated with anemia, leukocytosis, decreased lymphocyte count, and increased incidence of tissue loss (p < 0.05). By life-table analysis, incisional complications did not influence primary patency (p = 0.73), secondary patency (p = 0.91), limb salvage (p = 0.69), or survival (p = 0.92). However, a significant suppurative soft-tissue infection ultimately resulted in a high rate of major amputation.

Realistic expectations for pedal bypass grafts in patients with end-stage renal disease

PURPOSE

Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging clinical problem. Multiple series have shown the inferior limb salvage rate for femoropopliteal or femorotibial bypass grafts in this group. This outcome study is restricted to those patients with ESRD who require pedal bypass grafts for attempted limb salvage.

METHODS

Between December 1, 1990, and December 31, 1997, 34 patients with ESRD underwent pedal bypass grafting on 41 limbs. This review explores the patient and bypass graft outcomes and their relationships to typical risk factors.

RESULTS

The average age in the study was 64 years (range, 39 to 85 years). Twenty patients (59%) were men, 31 (91%) had diabetes, 32 (94%) were hypertensive, and 28 (82%) had coronary artery disease, but only 10 patients (29%) were smokers. All the patients were undergoing dialysis except 2 patients with functioning renal transplants. All bypass grafting procedures were performed for limb salvage. The follow-up periods ranged from 1 to 84 months (average, 13.5 months). With life-table analysis, the cumulative assisted primary patency rate was 62% at 1 year and 62% at 2 years. The limb salvage rate was 56% and 50% at 1 and 2 years, respectively. All the patients who were seen with heel gangrene had early limb loss or died. Seven of the 16 amputations (44%) were performed despite patent bypass grafts. Ten of the 16 amputations (63%) occurred within 3 months of the surgery. The survival rate was 64% at 1 year and 52% at 2 years. After the bypass graft procedure, the mean ankle brachial index and the toe pressure rose from 0.48 to 1.05 and 18 to 86, respectively.

CONCLUSION

Modest success can be expected with pedal bypass grafts in patients with ESRD, with most failures occurring in the first 3 months. Limb salvage rates lag behind graft patency rates because of progressive necrosis despite a hemodynamically functioning bypass graft. Heel gangrene is a strong predictor for a negative outcome. Lastly, overall patient survival rates are poor but comparable with the rates of other patients with ESRD.

Outcome of infrainguinal bypass surgery for critical leg ischaemia in patients with chronic renal failure

OBJECTIVE

To determine whether infrainguinal bypass surgery is worthwhile in patients with critical limb ischaemia (CLI) and chronic renal failure.

DESIGN

Longitudinal observational study.

MATERIALS AND METHODS

Twenty-two patients with moderate renal failure indicated by serum creatinine level above 150 mumol/l, 10 patients with end-stage renal disease requiring dialysis, and three patients with functioning kidney transplant, underwent 39 bypass procedures for critical limb ischaemia.

RESULTS

Six femoropopliteal, 14 femorocrural and 19 femoropedal bypasses were performed. The immediate, 1-month, and 1-year primary patency rates were 97%, 84% and 70%, respectively. The limb salvage was 93% at 1-month and 72% at 1-year follow-up. One-year patency and leg salvage rates were 81% and 79% in non-dialysis patients, and 47% and 37% in dialysis patients. At 1-year follow-up, 55% of surviving patients had salvaged limbs. None of the patients in dialysis was alive with salvaged legs 4 months after revascularisation. Among preoperative risk factors, only serum creatinine showed a statistical significance in predicting leg salvage and survival.

CONCLUSIONS

As the outcome of patients on dialysis is very poor after infrainguinal bypass grafting, revascularisation is seldom indicated. On the contrary, leg salvage can achieve good results in patients not requiring dialysis.

Limb loss after lower extremity bypass

BACKGROUND

Infrainguinal bypass now has a limb salvage rate approaching 90% at 10 years. This study helps elucidate the causes of limb loss despite bypass surgery.

METHODS

A retrospective chart review of all patients undergoing a major lower extremity amputation after attempted bypass surgery.

RESULTS

Between July 1987 and January 1997, 67 major amputations (52 below knee, 15 above knee) followed infrainguinal bypass for limb salvage in 64 patients. Of these patients, 53 (83%) were diabetic and 10 (16%) were on dialysis. The etiology of limb loss included thrombosed bypass (n = 33, 49%), lack of limb salvage despite patent bypass (n = 23, 34%), intraoperative bypass failure (n = 6, 9%), and exposed/infected bypass (n = 5, 8%). The 23 patients with patent grafts required amputations because of hindfoot necrosis (n = 6), persistent forefoot necrosis (n = 6), acute diabetic foot infection (n = 6), and various other reasons (n = 5). Using life-table analysis, survival for the whole group was 56% at 12 months and 17% at 48 months. Patients with limb loss despite a patent bypass fared the worst with survival of 21% at 2 years.

CONCLUSIONS

Bypass thrombosis caused half of the amputations after limb salvage surgery. A patent bypass was functioning at the time of amputation in another third. Survival after failure of limb salvage was abysmal, especially in patients with patent bypasses.

Subcutaneous, video-assisted saphenous vein harvest: report of the first 30 cases

Harvest of the saphenous vein is a commonly performed procedure in cardiovascular surgery. The incision required for its removal is the longest used anywhere. In this report, the authors describe a minimally invasive technique for removal of the vein. This has been used in 30 patients undergoing peripheral arterial bypass (n = 27), venovenous bypass (n = 2), and a saphenopopliteal fistula (n = 1). There were three perioperative complications: skin necrosis over tunnel (one), bulla (one), and saphenous vein injury (one). Harvest time averaged 1.25 h. There was minimal postoperative discomfort in the harvest site and minimal scarring. Endoscopic harvest of the saphenous vein differs from most laparoscopic procedures because of its linear course. Consequently, visualization and dissection is coaxial rather than triangulation. This study demonstrates the technical feasibility of vein harvest. Development of appropriate instrumentation for opening the optical cavity and vein manipulation will reduce operative times.

Failure of foot salvage in patients with end-stage renal disease after surgical revascularization

PURPOSE

This report ascertained factors responsible for for failure of foot salvage in patients with end-stage renal disease (ESRD) after undergoing infrainguinal bypass for critical ischemia.

METHODS

A retrospective review of 69 distal arterial reconstructions performed in 53 patients with ESRD (hemodialysis [n = 37], kidney transplantation [n = 10], peritoneal dialysis [n = 6]) for foot gangrene (n = 28), nonhealing ulcer (n = 25), or ischemic rest pain (n = 16) was conducted. Endpoints of surgical morbidity, limb loss, and graft patency were correlated with extent of preoperative tissue loss and presence of diabetes mellitus.

RESULTS

The 30-day operative mortality rate was 10%, and the patient survival rate at 2 years was 38%. The primary graft patency rate was 96% at 30 days, 72% at 1 year, and 68% at 2 years. Eleven of 22 foot amputations performed during the mean follow-up period of 14 months (range 3 to 96 months) occurred within 2 months of revascularization. Mechanisms responsible for limb loss included graft failure (n = 9), foot ischemia despite a patent bypass (n = 8), and uncontrolled infection (n = 5). Overall, 59% of amputations were performed in limbs with a patent bypass to popliteal or tibial arteries. Healing of forefoot amputations was prolonged, but all limb loss beyond 9 months of revascularization was due to graft failure. The limb salvage rate at 1 year decreased (p = 0.13) from 74% to 51% in patients admitted with gangrene. Only two of seven patients admitted with forefoot gangrene experienced foot salvage.

CONCLUSION

Failure of foot salvage in patients with ESRD and critical ischemia was due to wound healing problems rather than graft thrombosis. Earlier referral for revascularization, before development of extensive tissue ischemia and infection, is recommended. Primary amputation should be considered in patients admitted with forefoot gangrene, particularly if it is complicated by infection.

Factors influencing limb salvage and survival after amputation and revascularization in patients with end-stage renal disease

BACKGROUND

Critical lower-extremity ischemia in patients with end-stage renal disease is associated with high operative mortality and low rates of limb salvage.

PATIENTS AND METHODS

The outcomes of 102 operations for lower-extremity ischemia in 77 patients with end-stage renal disease were analyzed to determine predictors of limb salvage and operative survival.

RESULTS

Patients undergoing amputation (n = 50) and revascularization (n = 52) were similar in age, cause, and duration of renal failure, and prevalence of coronary artery disease. Operative mortality was 13% in revascularized patients and 20% in amputated patients, and was caused by sepsis in 12 of the 17 deaths (71%). Limb salvage in surviving patients was 91% at 30 days and 67% at 1 year. One-year survival was 72% in both groups. Factors associated with limb loss included advanced generalized atherosclerosis, extensive tissue necrosis, failed ipsilateral bypass, and poor cardiac functional status. Overall, factors associated with mortality included failure of limb salvage procedures, hemodynamic instability, and poor cardiac functional status.

CONCLUSIONS

More liberal use of primary amputation for end-stage renal disease patients with critical leg ischemia appears to be an important factor in improving both limb salvage rates and overall operative mortality.