Infrainguinal endovascular and bypass surgery for critical leg ischemia in patients on long-term dialysis

Association Between Undernutrition and Mortality and Amputation Outcomes in Chronic Limb Threatening Ischaemia: A Systematic Review

OBJECTIVE

Nutritional status plays a complex role in the pathophysiology and outcomes of chronic limb threatening ischaemia (CLTI). Undernutrition may be a modifiable risk factor. Given the variability in nutritional status concepts in CLTI outcomes studies, a systematic review examining the association between undernutrition and outcomes in patients with CLTI was conducted.

DATA SOURCES

A systematic literature search of nine databases (Allied and Complementary Medicine Database [AMED], CINAHL Complete, Cochrane Library, Google Scholar, Ovid Medline, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection databases) was conducted up to 23 May 2023.

REVIEW METHODS

Inclusion criteria were randomised controlled trials, cohort studies, and case control studies of patients with CLTI conducted after 1982 that reported the effect size for a nutritional status measure and the outcomes of death, amputation, or a composite of the two. Two reviewers independently performed screening, data extraction, and quality assessment, with a third independent reviewer resolving conflicts.

RESULTS

A total of 6 818 citations were screened, with 49 observational studies (31 from Japan) included in the review. The mean patient age ranged from 56.0 - 86.9 years. Most included patients were undergoing revascularisation. Unidimensional indicators of undernutrition (including low serum albumin, low body mass index, and zinc deficiency) as well as multidimensional measures (such as nutritional screening tool scores indicating undernutrition) were found to be associated with a statistically significant increased risk of death, amputation, and composite events in most studies. Effect sizes of the association were generally larger when multidimensional nutritional screening tools were used. However, the quality of evidence was poor, and certainty of evidence very low.

CONCLUSION

Undernutrition is consistently associated with an increased risk of death and amputation in patients with CLTI, regardless of the measure used. Broader efforts to understand the framework of nutritional status and validation of nutritional screening tools in CLTI populations are needed.

Interplay of Diabetes Mellitus and End-Stage Renal Disease in Open Revascularization for Chronic Limb-Threatening Ischemia

BACKGROUND

Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) confers a significant survival disadvantage and is associated with a high major amputation rate. Moreover, diabetes mellitus (DM) is an independent risk factor for developing CLTI. However, the interplay between end-stage renal disease (ESRD) and DM on outcomes after peripheral revascularization for CLTI is not well established. Our goal was to assess the effect of DM on outcomes after an infrainguinal bypass for CLTI in patients with ESRD.

METHODS

Using the Vascular Quality Initiative dataset from January 2003 to March 2020, records for all primary infrainguinal bypasses for CLTI in patients with ESRD were included for analysis. One-year and perioperative outcomes of all-cause mortality, reintervention, amputation-free survival (AFS), and major adverse limb event (MALE) were compared for patients with DM versus those without DM.

RESULTS

Of a total of 1,058 patients (66% male) with ESRD, 726 (69%) patients had DM, and 332 patients did not have DM. The DM group was younger (median age, 65 years vs. 68 years; P = 0.002), with higher proportions of obesity (body-mass index>30 kg/m2; 34% vs. 19%; P < 0.001) and current smokers (26% vs. 19%; P = 0.013). The DM group presented more frequently with tissue loss (76% vs. 66%; P < 0.001). A distal bypass anastomosis to tibial vessels was more frequently performed in the DM group compared to the non-DM group (57% vs. 45%; P < 0.001). DM was independently associated with higher perioperative MALE (OR 1.34; 95% CI, 1.06-1.68; P = 0.013), without increased risks of loss of primary patency and composite outcomes of amputation or death. On the mean follow-up of 11.4 ± 5.5 months, DM patients had a significantly higher rate of one-year MALEs (43% vs. 32%; P = 0.001). However, the one-year primary patency and AFS did not differ significantly. After adjusting for confounders, the risk-adjusted hazards for MALE (HR 1.34; 95% CI, 1.06-1.68; P = 0.013) were significantly increased in patients with DM. However, DM was not associated with increased risk of AFS (HR 1.16; 95% CI, 0.91-1.47; P = 0.238), or loss of primary patency (HR 1.04; 95% CI, 0.79-1.37; P = 0.767).

CONCLUSIONS

DM and ESRD each independently predict early and late major adverse limb events after an infrainguinal bypass in patients presenting with CLTI. However, in the presence of ESRD, DM may increase perioperative adverse events but does not influence primary patency and AFS at one year. The risk profile associated with ESRD appears to supersede that of DM, with no additive effect.

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.

Comparison of open and endovascular procedures in patients with critical limb ischemia on dialysis

OBJECTIVE

Peripheral artery disease is a common comorbidity in patients with end-stage renal disease (ESRD), but there is a paucity of data comparing outcomes of different interventions in this group of patients. In this study, we examined perioperative outcomes of lower extremity endovascular revascularization (ER) and open revascularization (OR) in dialysis patients with critical limb ischemia (CLI).

METHODS

Patients on dialysis and undergoing ER and OR for CLI from 2011 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program dataset. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between ER and OR procedures.

RESULTS

From 2011 to 2015, 1021 lower extremity revascularizations were performed in dialysis patients with CLI. In this group, 535 were ER (53%) and 486 were OR (47%) procedures. Although demographic characteristics such as age and gender were similar between the two groups, there was a higher proportion of Caucasians and African Americans in the OR group. Patients undergoing open and endovascular procedures had similar rates of hypertension, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and bleeding disorders. A minority of procedures (4%) were emergencies, which were distributed equally between the two groups. Preoperative aspirin usage was higher in the ER group (84% vs 78%; P = .024), beta-blocker use was higher in the OR group (79% vs 74%; P = .08), and statin use was similar between the two groups (72% in OR and 70% in ER; P = .54). On risk-adjusted multivariate analysis, OR was associated with a lower rate of major amputation (5.97% vs 11.78%; odds ratio, 0.48; 95% confidence interval [CI], 0.26-0.85), but a higher rate of postoperative bleeding (29.6% vs 8.97%; odds ratio, 2.86; 95% CI, 1.8-4.35) and wound complications (15% vs 3%; odds ratio, 4.5; 95% CI, 2.38-8.3). The 30-day mortality and cardiovascular morbidity were similar between the two groups.

CONCLUSIONS

In patients with ESRD with CLI, OR is associated with a lower risk of major limb amputation but a higher rate of postoperative wound complications and bleeding, compared with ER. Cardiovascular complications, 30-day mortality, reinterventions and readmissions were similar between the two groups. In patients with ESRD with CLI, OR should be considered as an option for limb salvage if feasible. Long-term outcomes comparing the two types of procedures are needed.

Infrainguinal bypass surgery outcomes are worse in hemodialysis patients compared with patients with renal transplants

OBJECTIVE

Studies of infrainguinal bypass surgery (IBS) in patients with end-stage renal disease have focused on hemodialysis (HD) patients. Little is known of the applicability of their outcomes to patients with renal transplants (RTs). In this study, we sought to compare perioperative and long-term outcomes of IBS in a large population-based cohort of HD and RT patients.

METHODS

A retrospective review of all HD and RT patients who underwent IBS between January 2007 and December 2011 in the U.S. Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate 30-day postoperative (graft failure, limb loss, conduit infection, death) and long-term (primary patency [PP], primary assisted patency [PAP], secondary patency [SP], limb salvage, mortality) outcomes.

RESULTS

There were 10,787 IBSs performed in 9739 (90%) HD patients and 1048 (10%) RT patients who presented predominantly with critical limb ischemia (72%). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). Comparing HD vs RT patients, PP, PAP, and SP were 18% vs 33%, 23% vs 38%, and 30% vs 48%, respectively, at 5 years among autogenous conduit recipients (all P < .001) and 20% vs 28% (P = .02), 23% vs 31% (P = .02), and 33% vs 53% (P < .001) among prosthetic conduit recipients. Limb salvage and patient survival were 39% vs 56% and 19% vs 48%, respectively, at 5 years (all P < .001). Risk-adjusted analyses demonstrated higher PP (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 1.20-1.45; P < .001), PAP (aHR, 1.32; 95% CI, 1.19-1.45; P < .001), SP (aHR, 1.47; 95% CI, 1.31-1.65; P < .001), limb salvage (aHR, 1.48; 95% CI, 1.30-1.67; P < .001), and patient survival (aHR, 2.42; 95% CI, 2.17-2.71; P < .001) for RT compared with HD patients.

CONCLUSIONS

The HD-dependent state is associated with elevated bypass and patient-level risks after IBS compared with patients with RTs. These results show that the benefits of renal transplantation likely extend to infrainguinal bypass-specific outcomes. The estimates of risk reported herein should inform the patient's and provider's expectations at the point of care.

Drug-Eluting Balloon Angioplasty for Below the Knee Lesions in End Stage Renal Disease Patients with Critical Limb Ischemia: Midterm Results

BACKGROUND

The 1-year restenosis rate after standard balloon angioplasty (BA) of long lesions in below-the-knee arteries may be as high as 70%. Our aim was to investigate the efficacy and safety of paclitaxel drug-eluting balloon (DEB) for treatment of below the knee lesions in end stage renal disease patients (ESRD) with critical limb ischemia (CLI).

METHODS

Our study is a retrospective, single-center study. Inclusion criteria were ESRD, critical limb ischemia (Rutherford class 4 or higher) and significant stenosis or occlusion of at least 1 below-the-knee vessel. Target vessel restenosis and reocclusion at 1-year follow-up was the primary end point. Major amputation, was the secondary end point.

RESULTS

From July 2012 to February 2015, 50 patients identified with ESRD, with CLI, treated with DEB angioplasty. Six patients were lost to follow-up, leaving 44 patients with 55 vessels (mean age, 58.0 ± 6.9 years; 54.5% male). The mean lesion length was 113.4 ± 55.4 mm. BA confined to the infra-popliteal segment alone in 81.8% of cases. Primary patency was 90.4% at 6 months and 62.2% at 12 months. At a mean follow-up of 13.9 ± 3.5 months all cause mortality was 8.1% (N = 3). The ankle brachial index increased from 0.45 ± 0.04 preoperative to 0.88 ± 0.07 postoperative. There was one major amputation (2.7%) and 5 minor amputations at one year (13.5%).

CONCLUSION

DEB is effective in the treatment of below the knee critical stenosis and occlusions in ESRD patients with critical limb ischemia.

Outcomes of lower extremity revascularization among the hemodialysis-dependent

OBJECTIVE

Optimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention.

METHODS

A regional multicenter registry was queried between 2003 and 2013 for HD patients (N = 689) undergoing open surgical bypass (n = 295) or endovascular intervention (n = 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation.

RESULTS

Among the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb ischemia and 8% for claudication. Overall survival at 1, 2, and 5 years survival remained low at 60%, 43%, and 21%, respectively. Overall 1- and 2-year AFS was 40% and 17%. Mortality accounted for the primary mode of failure for both open bypass (78%) and endovascular interventions (80%) at two years. Survival, AFS, and freedom from major adverse limb event outcomes did not differ significantly between revascularization techniques. At 2 years, endovascular patency was higher than open bypass (76% vs 26%; 95% confidence interval [CI], 0.28-0.71; P = .02). Multivariate analysis identified age ≥80 years (hazard ratio [HR], 1.9; 95% CI, 1.4-2.5; P < .01), indication of rest pain or tissue loss (HR, 1.8; 95% CI, 1.3-2.6; P < .01), preoperative wheelchair/bedridden status (HR, 1.5; 95% CI, 1.1-2.1; P < .01), coronary artery disease (HR, 1.5; 95% CI, 1.2-1.9; P < .01), and chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8; P = .01) as independent predictors of death. The presence of three or more risk factors resulted in predicted 1-year mortality of 64%.

CONCLUSIONS

Overall survival and AFS among HD patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings and justifies a prudent approach to patient selection. Focus for improved results should emphasize predictors of survival to better identify those most likely to benefit from revascularization.

Direct Revascularization With the Angiosome Concept for Lower Limb Ischemia: A Systematic Review and Meta-Analysis

The angiosome concept provides practical information regarding the vascular anatomy of reconstructive and vascular surgery for the treatment of peripheral arterial occlusive disease and, particularly, critical lower limb ischemia.The aim of the study was to confirm the efficacy of direct revascularization with the angiosome concept (DR) for lower limb ischemia.Complementary manual searches were performed through the Pubmed, Cochrane Library, and EMBASE databases.We searched all randomized and nonrandomized studies (NRSs) comparing DR with indirect revascularization (IR) (without the angiosome concept) for lower limb ischemia. Only 9 nonrandomized controlled retrospective cohort studies were found and included. Trials published in any language were included.Primary endpoints were time to limb amputation and time to wound healing. Data extraction and trial quality assessment were performed by two authors independently. A third author was consulted for disagreements settlement and quality assurance.Five NRSs involving 779 lower limbs revealed that DR significantly improved the overall survival of limbs (hazard ratio [HR] 0.61; 95% confidence interval [CI] = 0.46-0.80; P < 0.001; I = 0%). In addition, DR significantly improved time to wound healing (HR 1.38; 95% CI = 1.13-1.69; P = 0.002; I = 0%, in 5 studies including 605 limbs).All included studies were retrospective comparative studies, and no consensus was obtained in describing wound conditions in the included studies.Our results suggested that treatment of lower limb ischemia using DR is more effective in salvaging limbs and healing wounds than IR is. Additional randomized controlled studies are necessary to confirm these results.

Poor late survival after surgical treatment of pleural empyema

BACKGROUND

We have evaluated the outcome of patients who underwent surgical treatment of parapneumonic pleural empyema.

METHODS

This study included 143 consecutive patients older than 18 years who were operated on for parapneumonic pleural empyema.

RESULTS

The overall survival at 30 days, 3 months, 5 years, and 10 years was 97.2, 92.3, 80.6, and 61.9%, respectively. Serum albumin (OR = 0.78, 95% CI = 0.65-0.94), cerebrovascular disease (OR = 30.49, 95% CI = 1.35-689.05), pulmonary embolism (OR = 984.63, 95% CI = 7.81-124206.8), and Thoracoscore (OR = 1.61, 95% CI = 1.10-2.35) were independent predictors of 3-month overall survival. Age (RR = 1.08, 95% CI = 1.03-1.14), serum albumin (RR = 0.89, 95% CI = 0.82-0.98), chronic obstructive pulmonary disease (COPD) (RR = 5.14, 95% CI = 1.3319.84), and cerebrovascular disease (RR = 6.76, 95% CI = 1.33-34.34) were independent predictors of pneumonia/pleural empyema-related death. Twenty-two patients required 33 reinterventions after the primary procedure: 19 patients after primary thoracoscopy and 3 patients after primary thoracotomy. Reintervention did not have any significant impact on 30-day mortality (4.5% vs. 2.5%, p = 0.49), but it affected 3-month mortality (26.1% vs. 4.2%, p < 0.0001). Reoperation was an independent predictor of late overall survival (at 10 years: 35.5% vs. 67.4%, RR = 2.95, 95% CI = 1.33-6.57) and freedom from pneumonia/pleural empyema-related death (at 10 years: 73.9% vs. 91.3%, RR = 4.40, 95% CI = 1.24-15.66).

CONCLUSIONS

Surgical treatment of pleural empyema can be associated with good immediate results, but longer follow-up showed that pneumonia/pleural empyema-related mortality and all-cause mortality are rather poor.

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.

Refinement of survival prediction in patients undergoing lower extremity bypass surgery: stratification by chronic kidney disease classification

OBJECTIVE

End-stage renal disease (ESRD) imparts a significant survival disadvantage to individuals undergoing lower extremity revascularization; however, the influence of lesser degrees of renal impairment remains unclear. This study examined the prognostic significance of the chronic kidney disease (CKD) classification on survival, limb salvage, and graft patency in patients undergoing lower extremity arterial reconstruction.

METHODS

A prospective registry was evaluated for consecutive patients between January 31, 1995, and December 21, 2004, undergoing first-time, lower extremity vein bypass surgery. Glomerular filtration rate (GFR) was estimated with the Modification of Diet in Renal Disease equation using each patient's preoperative creatinine concentration. CKD categories were taken from current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria.

RESULTS

The cohort included 456 subjects, with a mean (+/- SD) age of 68.1 +/- 10.8 years. There were 274 men (60%) and 378 Caucasians (82.5%). Comorbidities included diabetes mellitus in 270 (59.0%), hypertension in 333 (72.7%), coronary artery disease in 242 (52.8%), and dyslipidemia in 203 (44.5%). The surgical indication was critical limb ischemia in 384 (83.8%). Among the variables examined, diabetes and critical ischemia as the indication for bypass were significantly skewed toward higher CKD classifications (P < .001). The 5-year survival rates by CKD class were, CKD 1 and 2, 57%; CKD 3, 46%; CKD 4, 23%; and CKD 5, 9.5%. On univariate analysis, age, coronary artery disease, diabetes mellitus, hypertension, critical ischemia, and CKD were significant predictors of mortality. After adjustment, however, only age (hazard ratio [HR], 1.05, 95% confidence interval [CI], 1.03 to 1.06) and CKD stages 4 (HR, 4.23; 95% CI, 2.04 to 8.75) and 5 (HR, 3.27; 95% CI, 1.96 to 5.45) retained significance. Subjects within the CKD 5 classification were more likely to have a major amputation (P = .018) compared with all other CKD classes. Notably, no relationship was detected between CKD category and graft patency.

CONCLUSION

CKD staging adequately differentiates survival curves and risk for major amputation among patients with renal impairment who are undergoing lower extremity bypass surgery. This may help in clinical decision analysis as well as in the refinement of stratification in future clinical trial design where survival is an end point.

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.

Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: Long-term outcome

OBJECTIVE

To assess long-term outcome and prognostic factors for extreme surgery by vascular and plastic surgical teamwork for leg salvage in patients with critically ischemic large tissue defects.

SUMMARY BACKGROUND DATA

Combined vascular reconstruction and microvascular free-flap transfer has been used to improve distal perfusion and cover large tissue defects caused by the critical limb ischemia (CLI) in few dedicated centers during the past 15 years. Comorbidities compromise the results of these demanding operations, and it is unclear how far this mode of treatment should be extended.

METHODS

During 1989 to 2003, altogether 2157 vascular or endovascular revascularizations for CLI manifested as tissue lesions were performed. These included 81 revascularizations combined with microvascular free flap transfers in 79 patients (37-85 years). All the patients were candidates for major amputation. The patients were followed up at least 2 years or to death (mean follow-up, 62 months; SD, +/-34 months).

RESULTS

One- and 5-year leg salvage rates were 73% and 66%, survival rates 91% and 63%, and amputation-free survival rates of 70% and 41%, respectively. Male gender and American Society of Anesthesiologists score 4 were associated with an increased risk of death, whereas the involvement of the heel mostly with calcaneal osteomyelitis and a large size of defect predicted major amputation.

CONCLUSIONS

A combined vascular reconstruction and free-flap transfer offers an option for advanced limb salvage in a selected group of patients with CLI and a major tissue defect. Poor general condition, the involvement of the heel, and a large defect would indicate an amputation over extreme attempts for limb salvage.

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.

Lower Extremity Bypass Procedures in Diabetic Patients with End-Stage Renal Disease: Is It Worthwhile?

BACKGROUND/AIMS

Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia.

METHODS

A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated.

RESULTS

Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year.

CONCLUSION

Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.

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.