Clinical outcome and its predictors in hemodialysis patients with critical limb ischemia undergoing endovascular therapy

Clinical outcomes of endovascular therapy for chronic limb-threatening ischemia in renal transplant recipients

Endovascular treatment (EVT) for peripheral artery disease in patients with chronic limb-threatening ischemia (CLTI) is a common practice in contemporary medicine and its effectiveness is widely acknowledged. However, refractory ulcers can occasionally be encountered, particularly in patients who underwent renal transplantation (RT), even after successful EVT. To date, there have been no data on prognosis reported following EVT for CLTI in RT recipients. We included all RT recipients who underwent EVT in our hospital between 2010 and 2022. We analyzed data from 43 limbs with ischemic ulcerations classified as Rutherford class 5 or 6, which were managed solely with EVT (i.e., no bypass surgery was performed). The primary and secondary outcomes of our study were the incidence of complete wound healing and major adverse limb events (MALE), including clinically driven target vessel revascularization, major amputation, and all-cause death. The median follow-up was 31 months. The mean age of the study population was 64.7 ± 8.7 years, with predominantly male participants (79.1%). The overall wound healing rate was 34.9%. Kaplan-Meier curve revealed that wound healing rates at 1 and 3 years were 33.6% and 40.9%, respectively. The wound healing rates of RT recipients who underwent EVT for CLTI were found to be less than satisfactory.

A scoping review of malnutrition in patients undergoing interventions for peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) is associated with comorbid conditions and frailty. The role of pre-operative nutrition in these patients with PAD is not well characterized. This scoping review sought to describe the prevalence and prognostic implications of pre-operative malnutrition in patients undergoing vascular interventions for claudication or critical limb threatening ischemia (CLTI).

METHODS

Studies were systematically searched across 6 databases from inception to August 2021. Studies focusing on patients with claudication or CLTI undergoing open or endovascular procedures were included if pre-operative nutrition was measured and correlated with a clinical outcome.

RESULTS

Of 4186 records identified, 24 studies addressed the prevalence or prognostic impact of malnutrition in patients undergoing interventions for PAD. The proportion of women included in these studies ranged from 6% to 58%. The prevalence of pre-operative malnutrition ranged from 14.6% to 72%, and notably 7 different malnutrition assessments were used in these studies. Across all scales, pre-operative malnutrition was associated with at least one of the following outcomes: mortality, post-operative complications, length of stay, readmission rates, as well as delayed wound healing.

CONCLUSION

There are a variety of tools used to measure malnutrition in patients undergoing interventions for PAD. Our findings suggest that pre-operative malnutrition is associated with adverse clinical outcomes in patients undergoing open and endovascular procedures for claudication or CLTI, and there is lack of consensus on which tool to use. Clinicians and surgeons should be sensitized to the importance of assessing malnutrition preoperatively in adults undergoing interventions for PAD.

Systematic review and meta-analysis of outcomes of lower extremity peripheral arterial interventions in patients with and without chronic kidney disease or end-stage renal disease

OBJECTIVE

Patients with chronic kidney disease (CKD) have a greater risk of peripheral arterial disease (PAD). Although individual studies have documented an association between CKD and/or end-stage renal disease (ESRD) and adverse outcomes in patients undergoing PAD interventions in an era of technological advances in peripheral revascularization, the magnitude of the effect size is unknown. Therefore, we performed a meta-analysis to compare the outcomes of PAD interventions for patients with CKD/ESRD with those patients with normal renal function, stratified by intervention type (endovascular vs surgical), reflecting contemporary practice.

METHODS

Five databases were analyzed from January 2000 to June 2019 for studies that had compared the outcomes of lower extremity PAD interventions for patients with CKD/ESRD vs normal renal function. We included both endovascular and open interventions, with an indication of either claudication or critical limb ischemia. We analyzed the pooled odds ratios (ORs) across studies with 95% confidence intervals (CIs) using a random effects model. Funnel plot and exclusion sensitivity analyses were used for bias assessment.

RESULTS

Seventeen observational studies with 13,140 patients were included. All included studies, except for two, had accounted for unmeasured confounding using either multivariable regression analysis or case-control matching. The maximum follow-up period was 114 months (range, 0.5-114 months). The incidence of target lesion revascularization (TLR) was greater in those with CKD/ESRD than in those with normal renal function (OR, 1.68; 95% CI, 1.25-2.27; P = .001). The incidence of major amputations (OR, 1.97; 95% CI, 1.37-2.83; P < .001) and long-term mortality (OR, 2.28; 95% CI, 1.45-3.58; P < .001) was greater in those with CKD/ESRD. The greater TLR rates with CKD/ESRD vs normal renal function were only seen with endovascular interventions, with no differences for surgical interventions. The differences in rates of major amputations and long-term mortality between the CKD/ESRD and normal renal function groups were statistically significant, regardless of the intervention type.

CONCLUSIONS

Patients with CKD/ESRD who have undergone lower extremity PAD interventions had worse outcomes than those of patients with normal renal function. When stratifying our results by intervention (endovascular vs open surgery), greater rates of TLR for CKD/ESRD were only seen with endovascular and not with open surgical approaches. Major amputations and all-cause mortality were greater in the CKD/ESRD group, irrespective of the indication. Evidence-based strategies to manage this at-risk population who require PAD interventions are essential.

Nutritional status and outcomes of superficial femoral artery stenting due to intermittent claudication

BACKGROUND

The pathogenesis of in-stent restenosis is still not clear. The aim of this study was to determine the nutritional status of patients with lower limb ischemia and the risk of target lesion revascularization (TLR) after superficial femoral artery (SFA) stenting.

METHODS

Numerous parameters of nutritional status assessment were compared between 70 patients undergoing SFA endovascular intervention with a self-expandable plane stent due to life-limiting intermittent claudication and 40 patients undergoing carotid artery stenting (CAS). All subjects were followed up for at least 1 year in relation to outcomes such as clinically driven TLR occurrence.

RESULTS

Patients undergoing SFA stenting had a lower prevalence of overweight and obesity than those who underwent CAS (51.43% vs. 72.50%; P=0.031). An increase in Ankle-Brachial Index of >0.15 after SFA stenting (early end-point) was positively associated with greater handgrip strength (HGS), fat-free mass, skeletal muscle mass and waist-to-hip ratio. Freedom from TLR (late end-point) was significantly related to a higher waist-to-height ratio (WHtR), HGS and Geriatric Nutritional Risk Index (GNRI) Score. The 1-year risk of TLR for patients with a WHtR of ≥61.39 amounted to odds ratio; 95% confidence interval: 0.21; 0.05-0.25; P=0.021.

CONCLUSIONS

Parameters of nutritional status assessment were associated with early and late outcomes of SFA stenting in patients with intermittent claudication. Abdominal fat distribution and higher HGS and GNRI scores lowered the 1-year risk of TLR. Further study is needed to determine the pathomechanism of the obesity paradox, sarcopenia and undernutrition in relation to outcomes of endovascular interventions.

Outcomes of severe limb ischemia with tissue loss and impact of revascularization in haemodialysis patients with wound, ischemia, and foot infection (WIfI) stage 3 or 4

Summary. Background: With growing prevalence, end-stage renal disease (ESRD) as well as critical limb ischemia (CLI) are both conditions associated with high morbidity and mortality rates. Patients and methods: A retrospective single-centre study provided data of a German interdisciplinary vascular centre. Seventy-seven consecutive haemodialysis (HD) inpatients (median age, 73.6 years) with 91 threatened limbs with Wound, Ischemia, and foot Infection (WIfI) clinical stage 3 or 4 were evaluated for in-hospital treatment of peripheral arterial disease, limb salvage rates, major amputation (MA)-free and overall survival. Results: The 1-year MA-free limb salvage rate was 82 %. On multivariate analysis, a higher WIfI clinical stage (hazard ratio [HR], 7.54; p = 0.008) indicated a higher risk of MA, while at least one-vessel run-off to the foot after revascularization of any kind was associated with a lower risk of MA (HR, 0.17; p = 0.001). In the composite endpoint analysis, the 1-year MA-free overall survival rate was 65 %. Patients with limbs in WIfI clinical stage 4 versus stage 3 carried a more than two-fold increased hazard of death or MA (HR, 2.63; p = 0.028), while revascularization was associated with reduced risk (HR, 0.40; p = 0.021). One-year overall survival (78 %) was not associated with WIfI stage or revascularization but was worse in patients with previous symptomatic coronary artery disease (HR, 3.25; p = 0.039). During long-term follow-up over 12 years, MA-free survival probability was significantly lower in the WIfI stage 4 versus WIfI stage 3 group (HR, 1.58; p = 0.048) without significant differences in overall survival (HR, 1.10; p = 0.696). Conclusions: Lower-extremity CLI with tissue loss in HD patients is associated with high morbidity and mortality rates. WIfI clinical stage was predictive of 1-year MA-free survival, while revascularization significantly reduced MA risk but did not influence overall survival.

Poor survival of dialysis patients with unhealed wounds because of critical limb ischemia: Limb salvage and survival requires wound healing

Maintenance of blood flow in the wound area is required to heal wounds of critical limb ischemia (CLI) in dialysis patients. However, many dialysis patients have both a stenotic lesion in below-knee blood vessels and a cardiovascular event as complications, and thus, it may be difficult to ensure sufficient blood flow. Therefore, many deaths occur because of problems with wound healing. The aim of this study is to identify the optimal treatment, including revascularisation and amputation, from the perspective of wound healing by analysing the survival of hemodialysis patients with CLI who had healed or unhealed wounds in a lower extremity. The subjects were 52 patients who received maintenance dialysis at our clinic, including 27 with healed CLI wounds and 25 with unhealed CLI wounds. The Kaplan-Meier method was used to compare survival between the two groups. Multivariate analysis was conducted to examine the effect of an unhealed wound on mortality. The mean follow-up period was 1.7 ± 1.1 years. In the unhealed wound group, the 1-, 2-, and 3-year survival rates were 48%, 20%, and 12%, respectively. The overall survival rate was significantly lower in the unhealed wound group compared with the healed wound group (12% vs 63%, P = .0002 by log-rank test). In multivariate analysis, unhealed CLI wounds had a significant independent association with mortality (hazard ratio 3.32; 95% confidence interval [CI]: 1.41-8.77, P = .0054). In this study, the 3-year survival rate suggested a significantly poorer prognosis of hemodialysis patients with unhealed CLI wounds compared with those with healed wounds. An unhealed wound is an independent risk factor for mortality in hemodialysis patients with CLI.