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Nakhaei P, Hamouda M, Malas MB. The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease. Ann Vasc Surg 2024:S0890-5096(24)00151-1. [PMID: 38599491 DOI: 10.1016/j.avsg.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages. METHODS This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD. RESULTS CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates. CONCLUSIONS The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.
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Affiliation(s)
- Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mohammed Hamouda
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
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Kamada K, Kokubo T, Nagita H, Namiki Y, Sasajima T. Outcomes of Infrapopliteal Bypass for Chronic Limb-Threatening Ischemia are Worse in Renal Transplant Patients than in Hemodialysis-Dependent Patients. Ann Vasc Surg 2023; 90:181-187. [PMID: 36544294 DOI: 10.1016/j.avsg.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 09/16/2022] [Accepted: 10/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Comparisons of distal bypass outcomes between hemodialysis-dependent (HD) and renal transplant (RT) patients have been reported, but the influences of immunosuppressive therapy on the outcomes remain unclear because of the limited number of RT patients who underwent distal bypass or cohort heterogenicity. We compared outcomes of distal bypass for chronic limb-threatening ischemia (CLTI) with homogenous ischemic limb pathology. METHODS Between January 2014 and December 2019, we performed 334 infrapopliteal bypass procedures using vein grafts for 275 consecutive CLTI patients with tissue loss. Among them, there were 130 HD patients (47.3%) (163 limbs) and 11 RT patients (4%) (15 limbs), and 30-day mortality, 5-year primary and secondary patency (PP and SP), limb salvage (LS), amputation-free survival rates, and wound healing (WH) status were compared between the HD and RT patient groups. RESULTS Nine HD patients died within 30 days after surgery (7%), whereas no deaths were observed among the RT patients. Five-year PP and SP rates in the RT group 39% and 41%, which were significantly worse compared to 64% and 82% in the HD group (P < 0.01). Unsuccessful rate of revision surgery including hemodynamically failed grafts after revision reached over 80% in the RT group, which was technically unfeasible pathology for graft salvage (vs. 3% in the HD group), and WH, and LS rates were significantly worse in the RT group. CONCLUSIONS In comparison with HD patients, RT patients showed a lower LS rate for CLTI. The lower LS rate was associated with a lower SP rate, which was caused by disease progression of distal arteries in the foot.
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Affiliation(s)
- Keisuke Kamada
- Department of Vascular Surgery, Edogawa Hospital, Edogawa-ku, Tokyo, Japan
| | - Taku Kokubo
- Department of Vascular Surgery, Edogawa Hospital, Edogawa-ku, Tokyo, Japan
| | - Hiroyuki Nagita
- Department of Vascular Surgery, Edogawa Hospital, Edogawa-ku, Tokyo, Japan
| | - Yoko Namiki
- Department of Vascular Surgery, Edogawa Hospital, Edogawa-ku, Tokyo, Japan
| | - Tadahiro Sasajima
- Department of Vascular Surgery, Edogawa Hospital, Edogawa-ku, Tokyo, Japan.
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Abu El Hawa AA, Bekeny JC, Dekker PK, Zolper EG, Tirrell AR, Kennedy CJ, Walters ET, Bovill JD, Fan KL, Attinger CE, Steinberg JS, Abrams PL, Evans KK. Surgical Management of Lower Extremity Wounds in the Solid Organ Transplant Patient Population: Surgeon Beware. Adv Wound Care (New Rochelle) 2022; 11:10-18. [PMID: 33487096 PMCID: PMC9831248 DOI: 10.1089/wound.2020.1380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: To evaluate our institutional outcomes of surgical management of lower extremity (LE) wounds in the solid organ transplant recipient population. Approach: An 8-year retrospective review was conducted for all solid organ transplantation (SOT) recipients with LE wounds necessitating surgical management at our tertiary limb salvage center. Outcomes of interest included wound healing, surgical treatment, progression to amputation, and amputation level. Factors contributing to amputation progression were analyzed. The article adheres to the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results: Sixty-four SOT recipients underwent surgical management for their LE wounds between 2010 and 2018. Median number of surgeries per patient was 5 (interquartile range = 2-8); 47 of 64 patients (73.4%) underwent amputation, and 17 of 64 patients (26.6%) underwent nonamputation surgical management. In the amputation group, the majority of primary amputations were minor (42/47, 89.4%); 24 of 42 (57.1%) patients progressed to a higher amputation level, 16 of 42 (38.1%) healed after their index procedure, and 2 of 42 (4.8%) were lost to follow-up (LTFU) after their primary minor amputation. Five of 47 (10.6%) patients undergoing amputations required primary below-knee amputations. In the nonamputation group, 15 of 17 (88.2%) healed, 1 of 17 (5.9%) expired, and 1 of 17 (5.9%) was LTFU. Innovation: To identify the outcomes of patients undergoing surgical management for LE wounds after SOT and elucidate clinical factors that impact the rate of limb salvage. Conclusions: This is the first comprehensive analysis of LE wounds in the transplant population. Our analysis indicates high rates of failed minor amputation, and frequent progression to major amputation in SOT patients. Preexisting comorbidities and immunosuppressive regimens complicate limb salvage; therefore, further research is warranted to optimize surgical LE wound management in this population.
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Affiliation(s)
| | - Jenna C. Bekeny
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Paige K. Dekker
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Elizabeth G. Zolper
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Abigail R. Tirrell
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Christopher J. Kennedy
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Elliot T. Walters
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - John D. Bovill
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Christopher E. Attinger
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - John S. Steinberg
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Peter L. Abrams
- Department of Transplant Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Karen K. Evans
- Department of Plastic and Reconstructive Surgery and MedStar Georgetown University Hospital, Washington, District of Columbia, USA.,Correspondence: Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007, USA .
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Nejim B, Hicks CW, Arhuidese I, Locham S, Dakour-Aridi H, Malas M. Outcomes of Infrainguinal Lower Extremity Bypass Are Superior in Kidney Transplant Recipients Than Patients with Dialysis. Ann Vasc Surg 2019; 63:209-217. [PMID: 31349053 DOI: 10.1016/j.avsg.2019.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/26/2019] [Accepted: 04/12/2019] [Indexed: 11/26/2022]
Abstract
Patients with end-stage renal disease (ESRD) whether on dialysis therapy (DT) or who received a kidney transplant (KT) have previously shown unfavorable surgical outcomes. Little is known about the comparative efficacy and durability of lower extremity bypass (LEB) in those patients. The Vascular Quality Initiative database was explored to identify DT or KT recipients (2003-2016) who had LEB. We included 1,714 bypass procedures; DT: 1,512 (88.2%). Primary patency (PP) at 2 year was comparable between KT and DT groups (PP [95% confidence interval {CI}]: 77.0% [69.7%-82.8%] vs. 80.5% [77.8%-82.9%]; P = 0.212), and the risk-adjusted hazard was similar (adjusted hazard ratio [aHR] [95% CI]: 0.89 [0.61-1.30]; P = 0.540). Amputation-free survival (AFS) at 2 year was more favorable in KT group (AFS [95% CI]: 73.1% [66.3%-78.8%] vs. 48.0% [45.4%-50.6%]; P < 0.001), (aHR [95% CI]: 2.29 [1.62-3.23]; P < 0.001). Patients on DT exhibited a higher risk of mortality than KT recipients (aHR [95% CI]: 2.94 [2.07-4.17]; P < 0.001). This study demonstrated superior limb outcomes in KT recipients than patients on DT after LEB. Despite the comparable PP, the risk of amputation or death was doubled in patients on DT compared with KT recipients. Because both groups were similar in several baseline characteristics, the difference in outcome is likely driven by the positive effect of KT on the physiological milieu of these patients.
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Affiliation(s)
- Besma Nejim
- Division of Vascular Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Isibor Arhuidese
- Division of Vascular Surgery, Department of Surgery, University of South Florida, Tampa, FL
| | - Satinderjit Locham
- Division of Vascular Surgery, University of California San Diego, San Diego, CA
| | - Hanaa Dakour-Aridi
- Division of Vascular Surgery, University of California San Diego, San Diego, CA
| | - Mahmoud Malas
- Division of Vascular Surgery, University of California San Diego, San Diego, CA.
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Outcomes for peripheral vascular intervention and lower extremity bypass in kidney transplant recipients are superior to outcomes of patients remaining on dialysis. J Vasc Surg 2019; 69:1849-1862.e6. [DOI: 10.1016/j.jvs.2018.10.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/02/2018] [Indexed: 11/17/2022]
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