Outcomes of lower extremity revascularization among the hemodialysis-dependent

Poor Limb Prognosis of Patients with Chronic Limb-Threatening Ischemia on Hemodialysis: A Retrospective Observational Study Based on the Global Limb Anatomic Staging System

BACKGROUND

The Global Limb Anatomic Staging System (GLASS) has been widely used to evaluate patients with chronic limb-threatening ischemia (CLTI). As end-stage kidney disease (ESKD) is a well-known CLTI risk factor, we aimed to determine whether patients on hemodialysis (HD) have a worse limb prognosis than those without ESKD, considering the same GLASS background.

METHODS

The data of 445 patients who underwent surgical and/or endovascular revascularization procedures for lower extremity ischemia were retrospectively collected in our division between 2005 and 2018. The major amputation rate and amputation-free survival (AFS) were compared between HD and non-HD patients.

RESULTS

Among the 215 (48%) patients receiving HD, 58 limbs required major amputation (27% limb loss rate). Among the non-HD group, the limb loss rate was 13% (P < 0.0001). The overall AFS was significantly worse in patients receiving HD than those not (P < 0.0001). The AFS was significantly worse in HD patients when comparing GLASS-standardized subgroups.

CONCLUSIONS

Patients with CLTI who were receiving HD had a worse limb prognosis than those not receiving, even when considering the same GLASS classification. Furthermore, there is a need for an ideal guideline focused on ESKD-directed peripheral artery disease.

Comparison of mortality and amputation after lower extremity bypass versus peripheral vascular intervention in patients with chronic limb-threatening ischemia and comorbid chronic kidney disease

OBJECTIVE

Comorbid chronic kidney disease (CKD) is associated with worse outcomes for patients with chronic limb-threatening ischemia (CLTI). However, comparative effectiveness data are limited for lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) in patients with CLTI and CKD. We aimed to evaluate (1) 30-day all-cause mortality and amputation and (2) 5-year all-cause mortality and amputation for LEB vs PVI in patients with comorbid CKD.

METHODS

Individuals who underwent LEB and PVI were queried from the Vascular Quality Initiative with Medicare claims-linked outcomes data. Propensity scores were calculated using 13 variables, and a 1:1 matching method was used. The mortality risk at 30 days and 5 years in LEB vs PVI by CKD was assessed using Kaplan-Meier and Cox proportional hazards models, with interaction terms added for CKD. For amputation, cumulative incidence functions and Fine-Gray models were used to account for the competing risk of death, with interaction terms for CKD added.

RESULTS

Of 4084 patients (2042 per group), the mean age was 71.0 ± 10.8 years, and 69.0% were male. Irrespective of CKD status, 30-day mortality (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.63-1.42, P = .78) was similar for LEB vs PVI, but LEB was associated with a lower risk of 30-day amputation (sub-HR [sHR]: 0.66, 95% CI: 0.44-0.97, P = .04). CKD status, however, did not modify these results. Similarly, LEB vs PVI was associated with a lower risk of 5-year mortality (HR: 0.79, 95% CI: 0.71-0.88, P < .001) but no difference in 5-year amputation (sHR: 1.03, 95% CI: 0.89-1.20, P = .67). CKD status did not modify these results.

CONCLUSIONS

Regardless of CKD status, patients had a lower risk of 5-year all-cause mortality and 30-day amputation with LEB vs PVI. Results may help inform preference-sensitive treatment decisions on LEB vs PVI for patients with CLTI and CKD, who may commonly be deemed too high risk for surgery.

Chronic Kidney Disease Predicts Adverse Major Cardiovascular Events and Adverse Limb Events in Patients With Diabetes and Peripheral Arterial Disease

This study aims to explore the effect in each stage of chronic kidney disease (CKD) on the major adverse cardiovascular events (MACE) in diabetes mellitus (DM) patients with peripheral arterial disease (PAD). A total of 246 DM patients with diagnosed PAD were enrolled in this study. Of these, 86 patients (35%) died and 34 patients had non-fatal cardiovascular events occurred at the last 7 years follow-up. The baseline eGFR obtained from the first quantified eGFR value within 6 months from the date of enrollment estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Then, based on eGFR at entry, we defined CKD as an eGFR < 60 mL/min/1.73 m2, and stratified all patients into four groups: eGFR-1, normal eGFR (≥90 mL/min/1.73 m2); eGFR-2, mildly decreased eGFR (60-89 mL/min/1.73 m2); eGFR-3, moderately decreased eGFR (30-59 mL/min/1.73 m2); and eGFR-4, severely decreased eGFR (<30 mL/min/1.73 m2). The mean eGFR was 54.4 ± 28.9 mL/min/1.73m2, and more than 30% of all patients had CKD (eGFR <60 mL/min/1.73m2). The seven-year cumulative incidence of MACE was 29.8% (95% confident interval [95% CI] 15.5-35.7) for eGFR-1 group, 40.4% (95% CI 27.4-45.2) for eGFR-2group, 66.2% (95% CI 47.6-71.4) for eGFR-3 group, and 94% (95% CI 75.0-99.0) for eGFR-4 group. In addition, after adjustment, hazard ratio (HR) for MACE was 2.36 (95% CI 1.26-4.40) in the eGFR-3 group and 7.62 (95% CI 3.71-15.66) in the eGFR-4 group. Restricted mean survival time (RMST) for survival analysis was consistent with HR in this study. After adjusting confounders, relative to eGFR-1 group, an association between the eGFR group and MACE outcome was found only in eGFR-3 group and eGFR-4 group. The moderate to severe reduction in eGFR, was an independent risk factor for MACE among DM patients with PAD throughout a 7-year follow-up duration. Thus, early CKD screening might be essential in the management of diabetic patients with PAD.

Association between readmission care fragmentation and outcomes after interventions for peripheral arterial disease

OBJECTIVE

Lower extremity revascularization (LER) for peripheral artery disease is complicated by the frequent need for readmission. However, it is unclear if readmission to a nonindex LER facility (ie, a facility different from the one where the LER was performed) compared with the index LER facility is associated with worse outcomes.

METHODS

This was a national cohort study of older adults who underwent open, endovascular, or hybrid LER for peripheral artery disease (January 1, 2010, to December 31, 2018) in the Vascular Quality Initiative who were readmitted within 90 days of their vascular procedure. This dataset was linked to Medicare claims and the American Hospital Association Annual Survey. The primary outcome was 90-day mortality and the secondary outcome was major amputation at 90 days after LER. The primary exposure was the location of the first readmission after LER (categorized as occurring at the index LER facility vs a nonindex LER facility). Generalized estimating equations logistic regression models were used to assess the association between readmission location and 90-day mortality and amputation.

RESULTS

Among 42,429 patients who underwent LER, 33.0% were readmitted within 90 days. Of those who were readmitted, 27.3% were readmitted to a nonindex LER facility, and 42.2% of all readmissions were associated with procedure-related complications. Compared with patients readmitted to the index LER facility, those readmitted to a nonindex facility had a lower proportion of procedure-related reasons for readmission (21.5% vs 50.1%; P < .001). Most of the patients readmitted to a nonindex LER facility lived further than 31 miles from the index LER facility (39.2% vs 19.6%; P < .001) and were readmitted to a facility with a total bed size of <250 (60.1% vs 11.9%; P < .001). Readmission to a nonindex LER facility was not associated with 90-day mortality or 90-day amputation. However, readmission for a procedure-related complication was associated with major amputation (90-day amputation: adjusted odds ratio, 3.33; 95% confidence interval, 2.89-3.82).

CONCLUSIONS

Readmission after LER for a procedure-related complication is associated with subsequent amputation. This finding suggests that quality improvement efforts should focus on understanding various types of procedure-related failure after LER and its role in limb salvage.

The Effect of Chronic and End Stage Renal Disease on Long-term Outcomes after Infrainguinal Bypass

OBJECTIVES

Patients undergoing infrainguinal bypass for chronic limb threatening ischemia (CLTI) with renal dysfunction are at an increased risk for perioperative and long-term morbidity and mortality. Our goal was to examine perioperative and 3-year outcomes after lower extremity bypass for CLTI stratified by kidney function.

METHODS

A retrospective, single-center analysis of lower extremity bypass for CLTI was performed between 2008 and 2019. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60ml/min/1.73m²), chronic kidney disease (CKD) (eGFR15-59ml/min/1.73m²), and end stage renal disease (ESRD) (eGFR<15ml/min/1.73m²). Kaplan-Meier and multivariable analysis were performed.

RESULTS

There were 221 infrainguinal bypasses performed for CLTI. Patients were classified by renal function as normal (59.7%), CKD (24.4%), and ESRD (15.8%). Average age was 66 years and 65% were male. Overall, 77% had tissue loss with 9%, 45%, 24%, and 22% being Wound, Ischemia, and foot Infection (WIfI) stages 1-4, respectively. The majority (58%) of bypass targets were infrapopliteal and 58% used ipsilateral greater saphenous vein. The 90-day mortality and readmission rates were 2.7% and 49.8%, respectively. ESRD, compared to CKD and normal renal function, respectively, had the highest 90-day mortality (11.4% vs. 1.9% vs. .8%, P=.002) and 90-day readmission (69% vs. 55% vs. 43%, P=.017). On multivariable analysis, ESRD, but not CKD, was associated with higher 90-day mortality (OR 16.9, 95% CI 1.83-156.6, P=.013) and 90-day readmission (OR 3.02, 95% CI 1.2-7.58, P=.019). Kaplan Meier 3-year analysis showed no difference between groups for primary patency or major amputation, however ESRD, compared to CKD and normal renal function, respectively, had worse primary-assisted patency (60% vs. 76% vs. 84%, P=.03) and survival (72% vs. 96% vs. 94%, P=.001). On multivariable analysis, ESRD and CKD were not associated with 3-year primary patency loss/death, but ESRD was associated with higher primary-assisted patency loss (HR 2.61, 95% CI 1.23-5.53, P=.012). ESRD and CKD were not associated with 3-year major amputation/death. ESRD was associated with higher 3-year mortality (HR 4.95, 95% CI 1.52-16.2, P=.008) while CKD was not.

CONCLUSION

ESRD, but not CKD, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary-assisted patency, there were no differences in loss of primary patency or major amputation.

Differences in major limb outcomes by indication for lower extremity endovascular revascularization in patients receiving hemodialysis

The incidence of lower extremity artery disease (LEAD) in patient receiving hemodialysis is remarkably higher than the general population. The treatment strategy and prognosis for LEAD patients differs depending on whether a patient has intermittent claudication (IC) or critical limb-threatening ischemia (CLTI). However, the distinction between the prognosis in HD-dependent patients with IC and CLTI has not been fully elucidated. This study is to determine whether indication of PAD has a distinct impact on major adverse cardiovascular and cerebrovascular events (MACCE) and limb events in patients receiving hemodialysis. The current study included 2321 prospectively enrolled patients from the Tokyo taMA peripheral vascular intervention research ComraDE registry (UMIN-CTR no. UMIN000015100) between September 2014 and December 2016. Out of the enrolled patients, 1644 were not receiving hemodialysis (non-HD patients) and 603 were receiving hemodialysis (HD patients). A composite of all-cause death, myocardial infarction, and stroke events defined as MACCE; while limb events were defined as a composite of unscheduled major amputation, unscheduled major lower limb surgery, acute limb ischemia, unscheduled endovascular treatment, and target lesion revascularization. Propensity score matching was applied among the non-HD and HD patients, in whole group, IC subgroup, and CLTI subgroup. Kaplan-Meier analysis was used for the analysis of outcomes for the whole group, IC subgroup, and the CLTI subgroup. CLTI accounted for 75.5% of the HD patients, whereas IC was 63.4% in the non-HD patients. The HD patients exhibited more frequent below-the-knee lesions than those in the non-HD patients in both IC (p = 0.01) and CLTI (p < 0.001) subgroups. Overall, HD patients exhibited a significantly higher rate of MACCE at 24 months. This trend was similar for limb events in whole group and CLTI subgroup. In contrast, no significant differences in outcomes for limb events were found in IC subgroup. Although, prognosis after EVT in HD patients were significantly worse than non-HD patients, comparable outcome with non-HD patients was observed in the patients treated for IC. Clinical trial registration: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR No. UMIN000015100).

TcPO2 Value Can Predict Wound Healing Time in Clinical Practice of CLTI Patients

BACKGROUND

Transcutaneous oxygen pressure (TcPO2) is a noninvasive, nonradiological test to measure local oxygen released from capillaries through the skin. Since it reflects the metabolic state of the lower limb, it can predict wound healing in patients with critical limb threatening ischemia (CLTI). The purpose of this study was to determine the effectiveness of TcPO2 test in evaluating wound healing potential of patients with CLTI.

METHODS

This was a retrospective, single-center, nonrandomized, and observational study. A prospectively registered database of patients who visited Vascular Surgery Department of St. Mary's Hospital for CLTI and underwent TcPO2 tests from October 1, 2015 to July 1, 2021 was reviewed. Patients were divided into 2 groups: (1) those who had amputation only; and (2) those who underwent revascularization procedures. Patients whose wound healing status could not be determined were excluded. The clinical characteristics of patients, patient characteristics related to lower TcPO2 value, treatment success rate, and time for the wound to be healed were analyzed.

RESULTS

A total of 84 patients were included in this study. There was no difference in background patient characteristics between the 2 groups despite better survival within 12 months and shorter healing time in the revascularization group. A total of 76 patients survived 12 months after surgery, and 63 patients were healed. Higher HbA1c, higher serum creatinine, history of stroke, and history of coronary artery disease were related to lower TcPO2 value on multiple linear regression. The cutoff value of TcPO2 was determined to be 40 mm Hg for predicting wound healing. This value was similar to those of previous studies. In addition, there was a negative correlation between TcPO2 and wound healing time. Correlations among the anklebrachial index (ABI), toe-brachial index (TBI), and TcPO2 were not determined because ABI and TBI for some patients could not be obtained due to wound condition.

CONCLUSIONS

The TcPO2 value can predict the wound healing process of ischemic lower extremity injury.

National Treatment Patterns and Outcomes for Hospitalized Patients with Chronic Limb-Threatening Ischemia and End-Stage Kidney Disease

Background

Chronic limb-threatening ischemia (CLTI) can be associated with dismal outcomes but there are limited real-world data to further define the impact of end-stage kidney disease (ESKD) on outcomes nationally in this subset of patients. We sought to characterize national patterns of inpatient treatment of CLTI and compare outcomes in patients without ESKD.

Methods

The National Inpatient Sample was queried from 2015-2018 for all hospital admissions including treatment for CLTI. Mixed-effects linear and logistic regression models were used to estimate the effect of ESKD on outcomes and treatment choice.

Results

We identified 11 652 hospital admissions with CLTI alone and 2705 with CLTI + ESKD. Hospital admissions with CLTI + ESKD patients included patients who were younger (66 vs 69 years, P < .0001), less likely to be white (39% vs 63%, P < .0001), and more likely to reside in lower income large metropolitan areas. Admissions for CLTI + ESKD patients had a lower likelihood of open arterial reconstruction (OR .40, P < .0001) and a higher likelihood of endovascular revascularization or major limb amputation (OR 1.70, P < .0001). Admissions for CLTI + ESKD also had a 4.5- and 1.5-fold higher odds of in-hospital death and complications. These findings were associated with a longer LOS ( P < .0001), increased probability of discharge to rehabilitation facility (50% vs 41%, P < .0001), and greater hospital charges (median, $107 K vs $85 K, P < .0001).

Conclusions

Compared to hospital admissions for patients without ESKD, admissions for patients with CLTI + ESKD demonstrated distinctive demographic characteristics, a lower likelihood of open revascularization and a higher likelihood of endovascular revascularization and major limb amputation. Chronic limb-threatening ischemia + ESKD hospital admissions showed worse overall outcomes and greater resource utilization compared to CLTI admissions without ESKD.

Applicability of the Vascular Quality Initiative (VQI) mortality prediction model for infrainguinal revascularization in a tertiary limb preservation center population

OBJECTIVE

Patients undergoing revascularization for chronic limb-threatening ischemia (CLTI) are at elevated risk for both mortality and limb loss. To facilitate therapeutic decision-making, a mortality prediction model derived from the Vascular Quality Initiative (VQI) database has stratified patients into low, medium, and high risk, defined by 30-day mortality estimated of ≤3%, 3-5%, or >5% and 2-year mortality estimates of ≤30%, 30-50%, or ≥50%, respectively. The purpose of this study was to compare expected mortality risk derived from this model with observed outcomes in a tertiary center.

METHODS

Consecutive patients treated at a single center between 2016 and 2019 were analyzed. Baseline demographics, approach, and mortality events were reviewed. Observed mortality was obtained using life-table methods and compared using a log-rank test with the expected mortality risk which was calculated using the VQI model.

RESULTS

This study cohort consisted of 195 revascularization procedures in 169 unique patients stratified into 128 (66%) low, 50 (26%) medium, and 17 (8%) high-risk cases based on the VQI model. 90% of revascularizations were performed for tissue loss. Compared with the VQI population, comorbidities were prevalent and included unstable angina or myocardial infarction within 6 months (6% vs. 2.4% in VQI; p<0.001), congestive heart failure (30% vs. 23%; p<0.001), and dialysis dependence (14% vs. 0.9%; p<0.001). Patients were also older (31% vs. 21% ≥80 years old; p<0.001) and more likely to be frail (45% vs. 64% independent; p<0.001). High-risk patients were more prevalent in the endovascular group (11% of 132 endovascular interventions vs. 3% of 63 bypasses; p=0.056). 30-day observed mortality exceeded expected VQI prediction model mortality in all groups, although was not statistically significant. The VQI model adequately stratified the studied population into risk groups (p<0.001). Low risk CLTI patients (65% of the overall cohort) experienced 2- year mortality of 18.9%. However, observed mortality for medium and high-risk VQI strata were similar. After a median follow-up of 28 months, medium-risk patients incurred a significantly higher mortality than predicted (53.5%±2.1% vs. 36.8%±1.1%; p=0.016).

CONCLUSIONS

The VQI mortality prediction model discriminates mortality risk after limb revascularization in CLTI, accurately identifying a majority subgroup of patients who are suitable for either open or endovascular intervention. However, it may underestimate mortality in a tertiary referral population with high comorbidity burden and was not well calibrated for the medium-risk group. It may be more appropriate to dichotomize CLTI patients who are candidates for limb salvage into an average risk and high-risk group.

Rheopheresis for severe peripheral arterial disease in hemodialysis patients: A clinical series

BACKGROUND

Rheopheresis is a double-filtration plasmapheresis that removes high-molecular-weight molecules from the plasma and thereby lowers blood viscosity. This treatment has been proposed in hemodialysis (HD) patients for chronic limb-threatening ischemia (CLTI), but very few studies have evaluated the usefulness of this technique.

PRINCIPAL OBJECTIVE

To assess 1-year amputation-free survival (AFS) of HD patients suffering from CLTI treated by rheopheresis.

MATERIAL AND METHOD

We conducted a retrospective study of 28 consecutive HD patients treated by rheopheresis in three French dialysis centers between 1 February 2017 and 30 April 2019 in two indications resulting from CLTI, namely chronic ulceration or recent minor amputation with delayed healing.

RESULTS

One-year AFS rate reached 53.6 (-19.8; +16.3)%. One-year overall survival rate reached 67.9 (-20.5; +13.1)%. Main causes of death were infections and related to palliative care implying reduction or withdrawal of regular dialysis treatment. Hypotension episodes were the main rheopheresis adverse events with a prevalence rate of 13.5%. Rheopheresis sessions significantly reduced fibrinogen, C-reactive protein, α2-macroglobulin, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, IgM, and estimated plasma viscosity (P < .0001).

CONCLUSION

Rheopheresis may improve clinical outcomes of CLTI in HD patients. The assessment of rheopheresis effectiveness needs to be confirmed by a multicenter randomized controlled trial, such as the ongoing project in France (RHEO-PAD, NCT: 03975946).

Bypass surgery versus endovascular intervention for lower extremity revascularization in patients with chronic renal disease or end-stage renal disease: a systematic review and meta-analysis

BACKGROUND

Endovascular revascularization (ER) and open revascularization (OR) are recognized treatment modalities for peripheral artery disease, but whether one technique provides better outcomes than the other is unclear, especially in patients with chronic or end-stage renal disease.

METHODS

We conducted a systematic literature search on the PubMed, Scopus, and Google scholar databases. We considered randomized-controlled trials, and retrospective record-based and prospective studies for inclusion. All included studies compared patient outcomes between the two management modalities and reported adjusted effect sizes.

RESULTS

We found the risks of in-hospital mortality (OR 0.52; 95% CI 0.30-0.92) and 30-day mortality (OR 0.63; 95% CI 0.49-0.80) during the post-operative period to be significantly lower in patients undergoing ER than in those undergoing OR. The pooled odds of amputation within 30 days of the post-operative period suggested a significantly higher risk of amputation in patients undergoing ER (OR 1.51; 95% CI 1.32-1.73) than in the others. Compared to patients undergoing OR, those undergoing ER had higher odds of being discharged to home (OR 2.30; 95% CI 1.58-3.36), lower odds of wound complications within 24 months of the post-operative period (OR 0.34; 95% CI 0.15-0.79), and a reduced length of hospital stay (WMD - 5.9; 95% CI - 10.8 to - 1.00).

CONCLUSIONS

For elderly patients with ESRD and chronic limb ischemia, ER may be the best choice due to its lower risk of mortality, lower odds of wound complications, reduced length of hospital stay, and reduced risk of re-intervention requirement when compared to OR. However, OR should be considered as an option when limb salvage is preferred.

Chronic Kidney Disease and Cerebrovascular Disease: Consensus and Guidance From a KDIGO Controversies Conference

The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.

Periprocedural Outcomes of Popliteal vs Upper Extremity Access in the Treatment of Superficial Femoral Artery Occlusive Disease

PURPOSE

Percutaneous lower extremity revascularization is being performed via upper extremity, pedal, or popliteal access with increasing frequency. This study aimed to compare periprocedural outcomes of popliteal (POA) and upper extremity (UEA) access for the treatment of isolated superficial femoral artery (SFA) occlusive disease.

MATERIALS AND METHODS

A retrospective cohort study compared the outcomes of patients undergoing primary percutaneous intervention of SFA occlusive disease with POA or UEA using the Vascular Quality Initiative database from December 2010 to June 2019. Our primary endpoint was technical success. Secondary endpoints included factors associated with perioperative complications.

RESULTS

A total of 349 patients underwent isolated SFA intervention through the popliteal, radial, or brachial artery. UEA was performed in 188 (53.9%) patients and POA in 161 (46.1%). Technical success with TASC A lesions was 95.8% and with TASC D lesions, 65.0%. POA had a higher proportion of TASC D lesions (24.8% vs 10.6%, p<0.001), and larger (≥7 Fr) sheath size (14.3% vs 2.7%, p<0.001). UEA had a higher proportion of no calcification (27.1% vs 11.2%, p<0.001), and smaller (4-5 Fr) sheath size (46.8% vs 34.8%, p=0.023). There was no difference in technical success between UEA and POA (88.8% vs 84.5%, p=0.230), which was also seen on multivariable analysis (p=0.985). Univariate analysis revealed technical failure was associated with TASC D lesions (45.7% vs 12.9%, p<0.001) and the presence of severe calcifications (39.1% vs 17.5%, p=0.002). Multivariable analysis confirmed technical failure was associated with degree of calcification (OR, 2.4; 95% CI, 1.18 to 4.89; p=0.016) and TASC D lesions (OR, 5.01; 95% CI, 2.45 to 10.24; p<0.001). Postoperative complications were associated with UEA on univariate (p=0.041) and multivariate analysis (OR, 2.08; 95% CI, 0.80 to 5.37; p=0.016). Access site complications were also associated with UEA compared to POA (4.3% vs 0.0%, p=0.027).

CONCLUSIONS

There is no difference in technical success between UEA and POA when treating isolated SFA occlusive disease, and UEA is associated with a higher complication rate. Technical success is dependent on calcification and TASC II classification. Based on similar technical success rates and low complication rates, POA should be considered as a viable alternative to UEA when planning endovascular interventions.

A prognostic risk score for major amputation in dialysis patients with chronic limb-threatening ischemia after endovascular revascularization

BACKGROUND

Almost 38% of all patients with end-stage chronic kidney disease (CKD) have peripheral arterial disease of the lower limbs that can lead to chronic limb threatening ischemia (CLTI). The aim of this study was to assess the impact of several factors to conduct a stratification of the amputation risk in CKD patients with CLTI receiving endovascular revascularization.

METHODS

Observational, retrospective, single-center study of patients treated from 2010 to 2016. The primary endpoint was the major amputation. The study included adult CKD dialysis patients affected by CLTI (rest pain and/or trophic lesions) with indication to endovascular revascularization and excluded for open repair.

RESULTS

A total of 82 patients were considered (58 men [70.7%], 24 women [29.3%] mean age 70.4±15.0 years). The number of major amputations was 28 (34.1%). The arterial lesion severity (TASC II-classification) and the trophic lesions extension (WIfI classification) were significantly associated with major amputation (OR and 95%CI, 1.20 [1.07-1.34], P=0.001; 2.65 [1.49-4.72], P=0.001; respectively). Based on the above-mentioned characteristics, a prognostic score was proposed to predict the major amputation risk. A score ≥23 was associated with a 67.6% probability of amputation in the following 12 months.

CONCLUSIONS

The CLTI revascularization is associated with poor outcomes in CKD patients. The present clinical score provided a pragmatic tool to calculate the major amputation risk. An elevated score could facilitate the decision-making process in order to perform an endovascular treatment vs. conservative approach.

Outcomes of Lower Extremity Endovascular Revascularization: Potential Predictors and Prevention Strategies

Peripheral artery disease (PAD) is a manifestation of atherosclerosis, which may affect arteries of the lower extremities. The most dangerous PAD complication is chronic limb-threatening ischemia (CLTI). Without revascularization, CLTI often causes limb loss. However, neither open surgical revascularization nor endovascular treatment (EVT) ensure long-term success and freedom from restenosis and revascularization failure. In recent years, EVT has gained growing acceptance among all vascular specialties, becoming the primary approach of revascularization in patients with CLTI. In clinical practice, different clinical outcomes after EVT in patients with similar comorbidities undergoing the same procedure (in terms of revascularization technique and localization of the disease) cause unsolved issues that need to be addressed. Nowadays, risk management of revascularization failure is one of the major challenges in the vascular field. The aim of this literature review is to identify potential predictors for lower extremity endovascular revascularization outcomes and possible prevention strategies.

Early outcomes of patients with chronic kidney disease after revascularization for critical limb ischemia

BACKGROUND

The aim of this study was to report early outcomes of patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) after revascularization for critical limb-threatening ischemia (CLTI).

METHODS

Perioperative data of patients from the CRITISCH (critical limb ischemia) Registry, who also had NDD-CKD (stages 3 and 4), were compared to their counterparts with normal renal function (NRF) or mild renal insufficiency (stages 1 and 2). Patient characteristics and type of first-line treatment were assessed. Amputation-free survival was the primary composite endpoint. Secondary endpoints included major adverse cardiovascular and cerebral events (MACCE) and hemodynamic failure of revascularization. Multivariable logistic regression determined risk factors for the endpoints.

RESULTS

424 patients with NDD-CKD were identified. Endovascular revascularization (ER) was performed in 251 patients (59.2%). Eighty-six patients (20.3%) underwent bypass surgery (BS) and 29 patients (6.8%) femoral artery patchplasty (FAP). Conservative treatment (CT) was offered to 46 patients (10.9%); 12 patients (2.8%) underwent primary major amputation (PMA). Logistic regression analysis showed an increased early risk for amputation/death (OR=1.92, 95% CI: 1.09-3.40), death (OR=5.53, 95% CI: 1.92-15.90) and hemodynamic failure of the revascularization (OR=1.80, 95% CI: 1.19-2.72) compared to patients with NRF. Patients with NDD-CKD also seem to carry a higher risk for MACCE (OR=1.82, 95% CI: 0.99-3.36). NDD-CKD was not a risk factor for limb loss alone (OR=1.05, 95% CI: 0.49-2.22).

CONCLUSIONS

NDD-CKD was an independent risk factor for early postoperative mortality, morbidity and reduced patency, but not for limb loss. Robust follow-up is necessary to monitor for such events, as well as to prevent readmission.

Implications of Renal Disease in Patients Undergoing Peripheral Arterial Interventions

Since the first peripheral endovascular intervention (PVI) in 1964, the procedure's technical aspects and indications have advanced significantly. Today, endovascular procedures span the spectrum of presentations from acute limb ischemia to critical limb ischemia and symptomatic limiting claudication. Goals of PVI remain restoring limb perfusion, minimizing rates of amputation and mortality, and sparing the need for the high-risk bypass surgery. Unfortunately, there are no large randomized controlled trials that address the optimal approach to peripheral arterial disease revascularization in chronic kidney disease (CKD) patients.

Influence of end-stage renal disease on long-term survival after major amputation

Background: To analyze long-term outcomes and possible influencing factors in patients with endstage renal disease (ESRD) and critical limb ischemia (CLI) after major amputation compared to patients with normal renal function and non-dialysis-dependent chronic kidney disease. Patients and methods: Abstraction of single-center medical records of patients undergoing above knee (AKA) and below knee (BKA) amputation over a 10 years period (n = 436; 2009-2018). Excluded were amputations due to trauma or tumor. Patients were subdivided according to renal function in three categories: ESRD patients (n = 98), non-dialysis dependent chronic kidney disease (CKD, n = 98) and normal renal function (NF, n = 240). Predefined endpoints were survival and postoperative complications. Cox-regression models were built to analyze independent risk factors for outcome parameters. Results: In total, 298 AKA, 133 BKA and 5 knee joint exarticulations were performed. ESRD patients showed inferior in-hospital results as to death (ESRD 36.7 % vs. CKD 19.4 % and NF 20.0 %, P = .002). Similarly, long-term survival rates (6 months: ESRD 55.0 % vs. CKD 69.4 %, NF 67.9 % 1 year: ESRD 48.6 %, CKD 60.2 %, NF 60.8 % 5 years: ESRD 9.9 %, CKD 31.8 %, NF 37.1 %, P < .001) were significantly decreased for ESRD patients. Median postoperative survival was 10 months in ERSD, and 22 months in CKD and NF, respectively. Analysis of postoperative surgical complications revealed no differences between groups (ESRD 19.4 %, CKD 17.3 %, NF 17.0 %; P = 0.433). Cox regression analysis indicated that dialysis (HR 1.63; 95 % CI 1.22-2.16; P = .001), hypertension (HR 1.59; 95 % CI 0.99-2.54) and smoking (HR 1.22; 95 % CI 1.03-1.44; P = .022) was associated with increased risk of death during follow-up. Conclusions: Mortality after limb amputation in ERSD patients remains high. Survival of ERSD patients is lower in relation to chronic kidney disease and patients with normal renal function. Due to poor in hospital outcomes and absent long-term survival, benefit of primary amputation in ERSD seems scarce.

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.

Intradialytic hypotension is an important risk factor for critical limb ischemia in patients on hemodialysis

BACKGROUND

Critical limb ischemia (CLI) and intradialytic hypotension (IDH) are common complications in patients on hemodialysis (HD). However, limited data are available on whether IDH is related to CLI in these patients. The aim of this retrospective study was to evaluate whether IDH is a risk factor for CLI in HD patients.

METHODS

We examined the frequency of IDH in 147 patients who received HD between January 1 and June 30, 2012. Blood pressure was measured during HD every 30 min and IDH was defined as a ≥ 20 mmHg fall in systolic blood pressure compared to 30 min before and a nadir intradialytic systolic blood pressure < 90 mmHg. The primary study outcome was newly developed CLI requiring revascularization treatment or CLI-related death. We assessed the association of IDH with outcome using a multivariable subdistribution hazard model with adjustment for male, age, smoking and history of cardiovascular disease.

RESULTS

The median follow-up period was 24.5 months. Fifty patients (34%) had episodes of IDH in the study entry period. During follow-up, 14 patients received endovascular treatment and CLI-related death occurred in 1 patient. Factors associated with incident CLI in univariate analysis were age, smoking, diabetes mellitus, peripheral arterial disease, history of cardiovascular disease, and IDH. IDH was significantly associated with the outcome with the subdistribution hazard ratio of 3.13 [95% confidence interval, 1.05-9.37].

CONCLUSIONS

IDH was an independent risk factor for incident CLI in patients on HD.

In-hospital outcome of peripheral vascular intervention in dialysis-dependent end-stage renal disease patients

BACKGROUND

The impact of end-stage renal disease (ESRD) on peripheral vascular intervention (PVI) outcome remains incompletely elucidated.

OBJECTIVES

We sought to compare the outcome of PVI in dialysis patients with those with normal kidney function.

METHODS

Using weighted data from the National Inpatient Sample database between 2002 and 2014, we identified all peripheral artery disease (PAD) patients aged ≥18 years that underwent PVI. Multivariate logistic regression analysis was performed to examine in-hospital outcomes.

RESULTS

Of 1,186,192 patients who underwent PVI, 1,066,830 had normal kidney function (89.9%) and 119,362 had ESRD requiring dialysis (10.1%). Critical limb ischemia was more prevalent in dialysis patients (63.2 vs. 34.0%, p < .001). Compared with normal kidney function group, ESRD requiring dialysis was associated with higher in-hospital mortality (1.5 vs. 4.2%, adjusted OR: 2.13 [95% CI: 2.04-2.23]) and longer length of hospital stay (median 3 days, Interquartile range [IQR] (0-6) vs. 7 days, IQR (4-18); p < .001). Dialysis patients had higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke; 14.3 vs. 9.8%, p < .001) and net adverse cardiovascular events (composite of MACE, major bleeding, or vascular complications; 40.8 vs. 29.1%, p < .001). ESRD patients less frequently underwent open bypass (5.6 vs. 8.5%, p < .001) and more frequently had major amputation (10.3 vs. 3.0%, p < .001) compared with normal kidney function group.

CONCLUSION

PAD patients on dialysis who underwent PVI have higher rates of mortality and adverse outcomes as compared to those with normal kidney function.

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.

Outcomes of Infrainguinal Lower Extremity Bypass Are Superior in Kidney Transplant Recipients Than Patients with Dialysis

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.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

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.

Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

BACKGROUND

Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation.

METHODS

We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD.

RESULTS

Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services.

CONCLUSIONS

Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.

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.

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.

Open Versus Endovascular Revascularization of Below-Knee Arteries in Patients With End-Stage Renal Disease and Critical Limb Ischemia

Background:

Evaluation of below-the-knee open revascularization (OR) versus endovascular revascularization (EVT) in patients with end-stage renal disease and critical limb ischemia (CLI) was performed.

Patients and Methods:

Seventy-seven dialysis patients with CLI and infrapopliteal involvement from 2007 to 2017 were included. Thirty-five patients received OR and 42 patients were treated with EVT. Survival, amputation-free survival (AFS) and wound-healing were evaluated. Furthermore, both groups were analyzed for differences as to anatomic (lesion length, runoff, pedal arch classification) and clinical (VSG risk score, WIfI score) characteristics.

Results:

Amputation-free survival (1-year AFS: OR 54.5% vs 47.6% in EVT, 2-year AFS OR 38.3% vs 23.9% EVT, P = .201) did not significantly differ between OR and EVT nor did the wound healing rate (29% OR vs 31% EVT, P = .532). Overall survival was noticeably poor (1-year survival: 66.7% in OR and 49% in EVT, 2-year survival OR 47.4% vs EVT 27.7%; P = .088); evaluation of peripheral runoff (Rutherford score 6.9 OR vs 7.1 EVT, P = .499) and pedal arch classification as well as WIfI or VSG risk score (9.8 OR vs 9.6 EVT, P = .673) could not detect significant differences as to both the groups. Treated median lesion length was significantly increased in OR patients (OR 26 cm vs EVT 7 cm, P < .001), whereas the incidence of major adverse cardiac events was higher in EVT patients (67% in EVT vs 40% OR, P = .023).

Conclusion:

OR and EVT showed comparable outcomes as to AFS and wound healing. Poor overall survival remains the determining factor in patients with ESRD having CLI. Both groups differ in terms of anatomic features as lesion length and severity of comorbidities; considering the comparable long-term outcomes, decision-making should be based on these premises; individually applied, each method can contribute to limb salvage, although the overall survival remains limited.

Design Strategies for Global Clinical Trials of Endovascular Devices for Critical Limb Ischemia (CLI) - A Joint USA-Japanese Perspective

For more than 10 years, the Harmonization by Doing (HBD) program, a joint effort by members from academia, industry and regulators from the United States of America (USA) and Japan, has been working to increase timely regulatory approval for cardiovascular devices through the development of practical global clinical trial paradigms. Consistent with this mission and in recognition of the increasing global public health effects of critical limb ischemia (CLI), academic and government experts from the USA and Japan have developed a basic framework of global clinical trials for endovascular devices for CLI. Despite differences in medical and regulatory environments and complex patient populations in both countries, we developed a pathway for the effective design and conduct of global CLI device studies by utilizing common study design elements such as patients' characteristics and study endpoints, and minimizing the effect of important clinical differences. Some of the key recommendations for conducting global CLI device studies are: including patients on dialysis; using a composite primary endpoint for effectiveness that includes 6-month post-procedure therapeutic success and target vessel patency; and using a 30-day primary safety endpoint of perioperative death and major adverse limb events. The proposed approach will be uniquely beneficial in facilitating both the initiation and interpretation of CLI studies and accelerating worldwide CLI device development and innovation.

Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures

BACKGROUND

Hemodialysis (HD) has been shown to be an independent predictor of poor outcomes after femoropopliteal revascularization procedures in patients with chronic limb-threatening ischemia. However, HD patients tend to have isolated infrageniculate disease, an anatomic risk factor for inferior patency. We aimed to compare outcomes for HD versus non-HD patients after infrageniculate open lower extremity bypass (LEB) and endovascular peripheral vascular interventions (PVIs).

METHODS

Data from the Society for Vascular Surgery Vascular Quality Initiative database (2008-2014) were analyzed. All patients undergoing infrageniculate LEB or PVI for rest pain or tissue loss were included. One-year primary patency (PP), secondary patency (SP), and major amputation outcomes were analyzed for HD versus non-HD patients stratified by treatment approach using both univariable and multivariable analyses.

RESULTS

A total of 1688 patients were included, including 348 patients undergoing LEB (HD = 44 versus non-HD = 304) and 1340 patients undergoing PVI (HD = 223 versus non-HD = 1117). Patients on HD more frequently underwent revascularization for tissue loss (89% versus 77%, P < 0.001) and had ≥2 comorbidities (91% versus 76%, P < 0.001). Among patients undergoing LEB, 1-y PP (66% versus 69%) and SP (71% versus 78%) were similar for HD versus non-HD (P ≥ 0.25) groups, but major amputations occurred more frequently in the HD group (27% versus 14%; P = 0.03). Among patients undergoing PVI, 1-y PP (70% versus 78%) and SP (82% versus 90%) were lower and the frequency of major amputations was higher (27% versus 10%) for HD patients (all, P ≤ 0.02). After correcting for baseline differences between the groups, outcomes were similar for HD versus non-HD patients undergoing LEB (P ≥ 0.21) but persistently worse for HD patients undergoing PVI (all, P ≤ 0.006).

CONCLUSIONS

HD is an independent predictor of poor patency and higher risk of major amputation after infrageniculate endovascular revascularization procedures for the treatment of chronic limb-threatening ischemia. The use of endovascular interventions in these higher risk patients is not associated with improved limb salvage outcomes and may be an inappropriate use of healthcare resources.

Long-term outcomes after autogenous versus synthetic lower extremity bypass in patients on hemodialysis

BACKGROUND

Hemodialysis dependence confers unique physiologic conditions. Prior reports of outcomes after infrainguinal open bypass operations in patients on hemodialysis have been based on relatively small sample institutional series. In this study, we evaluate long-term outcomes after open bypass operations in a large contemporary population-based cohort of hemodialysis patients. We studied all hemodialysis patients who underwent infrainguinal open operation using autogenous versus prosthetic conduits in the United States Renal Data System between January 2007 and December 2011.

METHODS

Univariate methods (χ², analysis of variance) were used to compare the characteristics of the patient and type of bypass. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were used to evaluate 30-day postoperative outcomes as well as patency, limb salvage, and mortality in the long term.

RESULTS

There were 9,739 (autogenous: 59%, prosthetic: 49%) infrainguinal open bypass operations performed in this cohort. Of these, 4,717 (48%) were femoral-popliteal, 3,321 (34%) were femoral-tibial, and 1,701 (18%) were popliteal-tibial bypasses. Bypass operations were performed most commonly for critical limb ischemia (72%). Primary patency was 18% for both types of conduits at 5 years (P = .16). Comparing autogenous versus prosthetic conduits, primary-assisted patency was 23% vs 20% at 5 years (P = .98), while secondary patency was 30% for both conduits at 5 years (P = .05). Limb salvage was 35% vs 41% at 5 years (P < .001). Multivariable analyses demonstrated greater patency (adjusted hazard ratio [aHR]: 1.16; 95% confidence interval, 1.05-1.28; P = .003) and limb salvage (aHR: 1.12; 95% confidence interval, 1.01-1.24; P = .03) for autogenous compared to prosthetic bypasses. The advantage conferred by autogenous conduits was most clinically relevant for femoral-tibial (aHR: 1.34; 95% confidence interval, 1.17-1.55; P < .001) and popliteal-tibial (aHR: 1.55; 95% confidence interval, 1.09-2.21; P = .014) configurations.

CONCLUSION

This large study evaluated the long-term outcomes of open bypass operations in patients on hemodialysis. The data confirm the long-term benefits of autogenous conduits compared with prosthetic conduits in this high-risk population of patients, especially for the treatment of distal lesions. Individual patient life expectancy, availability of adequate autogenous conduit options, indication for operation, level of disease, as well as potential need for future options for additional access for dialysis should be taken into consideration when deciding to construct an open bypass in a hemodialysis patient.

Perioperative and long-term impact of chronic kidney disease on carotid artery interventions

OBJECTIVE

Chronic kidney disease (CKD) increases morbidity and mortality after vascular procedures and adversely affects late survival of patients. The presence of CKD also confers increased risk of stroke in patients with asymptomatic carotid stenosis. Patients undergoing carotid intervention in the Vascular Study Group of New England database were stratified by CKD status referable to periprocedural and late outcomes.

METHODS

All carotid artery stenting and carotid endarterectomies (CEAs) performed from 2003 to 2013 were stratified by CKD severity as mild (estimated glomerular filtration rate [eGFR] >60 mL/min/1.73 m²), moderate (eGFR 30-59), and severe (eGFR <30). The impact of CKD on outcomes of carotid procedures was evaluated using univariate and multivariate methods.

RESULTS

Of 12,568 patients identified, 11,746 (93%) underwent CEA and 822 (7%) underwent carotid artery stenting. Procedures were performed for symptomatic disease in 40%. CKD severity was mild in 58%, moderate in 35%, and severe in 7%. The 30-day stroke rate was very low across all CKD groups (1.76% mild vs 1.84% moderate and 1.34% severe; P = .009). The 30-day mortality increased with worsening renal function (0.4% mild vs 0.9% moderate and 0.9% severe; P = .01). Independent predictors of 30-day stroke or death included American Society of Anesthesiologists (ASA) class 4 or 5 (odds ratio, 2.3; 95% confidence interval [CI], 1.5-3.4; P = .0001). Multivariable Cox hazards regression showed that severe CKD (hazard ratio [HR], 1.8; 95% CI, 1.3-2.6), ASA class 4 or 5 (HR, 1.7; 95% CI, 1.3-2.2), preoperative cortical symptoms (HR, 1.5; 95% CI, 1.2-1.8), history of diabetes (HR, 1.4; 95% CI, 1.1-1.7), and age (HR, 1.03/y; 95% CI, 1.02-1.04) independently (all P < .01) predicted neurologic events or death at median follow-up of 12.7 months (interquartile range, 10.3-15.2 months). CKD did not increase the risk of neurologic events at 1-year follow-up. Predictors (P < .05) of late death included moderate CKD (HR, 1.3; 95% CI, 1.01-1.7), severe CKD (HR, 2.2; 95% CI, 1.6-2.9), ASA class 4 or 5 (HR, 1.6; 95% CI, 1.2-2.0), history of diabetes (HR, 1.4; 95% CI, 1.2-1.7), chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8), and cortical symptoms (HR, 1.3; 95% CI, 1.05-1.6). The 1-, 5-, and 10-year survival rates decreased with worsening renal function (log-rank test, P < .001), but patients with severe CKD maintained a 71% survival at 5 years.

CONCLUSIONS

CKD severity increases risk of perioperative mortality as well as late mortality. Patients with CKD benefit from stroke-free survival especially after CEA. Unlike patients with peripheral arterial occlusive disease, for whom severe CKD reduces median survival to ∼2.5 years, patients with CKD and carotid disease exhibit much longer survival. This suggests that carotid interventions have utility in carefully selected patients with moderate and severe CKD, particularly in symptomatic disease.

Impact of Chronic Renal Failure on Safety and Effectiveness of Paclitaxel-Eluting Stents for Femoropopliteal Artery Disease: Subgroup Analysis from Zilver PTX Post-Market Surveillance Study in Japan

Purpose

Favorable long-term outcomes of the Zilver PTX drug-eluting stent (DES) in femoropopliteal lesions have been demonstrated. Chronic renal failure (CRF) has been shown to be a risk factor for restenosis and decreased limb salvage. The results of the DES in patients with CRF have not previously been reported. This study compares the results with the DES in patients with CRF and those without CRF.

Methods

This retrospective analysis from the Zilver PTX Japan Post-Market Surveillance Study included 321 patients with CRF and 584 patients without CRF. Outcomes included freedom from target lesion revascularization (TLR) and patency.

Results

Of the patients included in this subgroup analysis, 2-year data were available for 209 patients in the CRF group and 453 patients in the non-CRF group. The two groups were similar in terms of lesion length and the frequency of in-stent restenosis. Critical limb ischemia, severe calcification, and diabetes were more common in patients with CRF, whereas total occlusion was more common in patients without CRF. Freedom from TLR rates were 81.4 versus 84.9% (p = 0.24), and patency rates were 70.7 versus 70.3% (p = 0.95) in patients with and without CRF at 2 years, respectively.

Conclusion

This is the first comparative study of the DES in femoropopliteal artery lesions in patients with and without CRF. These results indicate that the DES placed in femoropopliteal artery lesions of CRF patients is safe and effective with similar patency and TLR rates to patients without CRF.

Level of Evidence

Level 3, Post-Market Surveillance Study.

Lower Extremity Revascularization in End-Stage Renal Disease

Patients with end-stage renal disease (ESRD) who present with critical limb ischemia (CLI) have become an increasingly common and complex treatment problem for vascular surgeons. Dialysis patients have high short-term mortality rates regardless of whether revascularization is pursued. ESRD patients with CLI can be managed with: local wound care, endovascular or surgical revascularization, or amputation. Some patients may heal small foot wounds with local wound care alone, even if distal perfusion is marginal, as long as any infectious process has been controlled. Surgical revascularization has a mortality rate of 5-10% but has a high chance of limb salvage. However, overall 5-year survival may be as low as 28%. Endovascular therapy also carries a high perioperative mortality risk in this population with similar limb salvage rates. Amputation is indicated in patients with advanced stage CLI, as described by the Society for Vascular Surgery’s Wound, Ischemia and foot Infection (WIfI) system. Statistical models predict that endovascular or surgical revascularization strategies are less costly and more functionally beneficial to patients than primary amputation alone. Decisions on how to manage ESRD patients with CLI are complex but revascularization can often result in limb salvage, despite limited overall survival. Dialysis patients with good life expectancy and good quality conduit may benefit most from surgical bypass.