Outcomes of dialysis patients with critical limb ischemia after revascularization compared with patients with normal renal function
Alexander Meyer, Cornelia Fiessler, Konstantinos Stavroulakis, Giovanni Torsello, Theodosios Bisdas, Werner Lang, CRITISCH collaborators, Farzin Adili, Kai Balzer, Arend Billing, Dittmar Böckler, Daniel Brixner, Sebastian E Debus, Konstantinos P Donas, Hans-Henning Eckstein, Hans-Joachim Florek, Asimakis Gkremoutis, Reinhardt Grundmann, Thomas Hupp, Tobias Keck, Joachim Gerß, Klonek Wojciech, Björn May, Bernhard Mühling, Alexander Oberhuber, Holger Reinecke, Christian Reinhold, Ralf-Gerhard Ritter, Hubert Schelzig, Christian Schlensack, Thomas Schmitz-Rixen, Karl-Ludwig Schulte, Mathias Spohn, Markus Steinbauer, Martin Storck, Matthias Trede, Christian Uhl, Barbara Weis-Müller, Heiner Wenk, Thomas Zeller, Alexander Zimmermann, Alexander Meyer, Cornelia Fiessler, Konstantinos Stavroulakis, Giovanni Torsello, Theodosios Bisdas, Werner Lang, CRITISCH collaborators, Farzin Adili, Kai Balzer, Arend Billing, Dittmar Böckler, Daniel Brixner, Sebastian E Debus, Konstantinos P Donas, Hans-Henning Eckstein, Hans-Joachim Florek, Asimakis Gkremoutis, Reinhardt Grundmann, Thomas Hupp, Tobias Keck, Joachim Gerß, Klonek Wojciech, Björn May, Bernhard Mühling, Alexander Oberhuber, Holger Reinecke, Christian Reinhold, Ralf-Gerhard Ritter, Hubert Schelzig, Christian Schlensack, Thomas Schmitz-Rixen, Karl-Ludwig Schulte, Mathias Spohn, Markus Steinbauer, Martin Storck, Matthias Trede, Christian Uhl, Barbara Weis-Müller, Heiner Wenk, Thomas Zeller, Alexander Zimmermann
Abstract
Objective: An analysis was conducted of intermediate outcomes and possible influencing factors in patients with end-stage renal disease (ESRD) and critical limb ischemia after lower limb revascularization compared with patients with regular renal function (non-ESRD).
Methods: Data collection was performed by inquiry of the German multicenter registry of First-Line Treatments in Patients with Critical Limb Ischemia (CRITISCH); 102 ESRD patients and 674 non-ESRD patients were included. Four different therapy modalities were analysed: bypass surgery, endovascular therapy (EVT), femoral artery endarterectomy, and no vascular intervention (conservative treatment or primary major amputation). Predefined end points were amputation-free survival (AFS), death, major amputation, and reintervention. Cox regression models were built to analyze independent risk factors for outcome parameters.
Results: ESRD patients showed inferior results at 2 years in the rate of AFS (ESRD, 35.4%; non-ESRD, 67.2%; P < .001). Similarly, death rate (ESRD, 55.0%; non-ESRD, 20.7%; P < .001) and major amputation rate (ESRD, 24.5%; non-ESRD, 15.8%; P = .029) were significantly elevated for ESRD patients. The choice of therapeutic approach in ESRD did not influence the incidence of the investigated end points (death or major amputation: EVT, 56.9% vs bypass, 76.9% [P = .225]; death: EVT, 46.2% vs bypass, 61.5% [P = .372]; amputation: EVT, 15.4% vs bypass, 15.4% [P = 1.000]; reintervention: EVT, 32.3% vs bypass, 15.4% [P = .324]). Cox regression analysis indicated that dialysis patients carry a twofold increased hazard of death or major amputation (hazard ratio, 2.27; 95% confidence interval, 1.67-3.10; P < .001), and open surgical treatment (all patients combined) was associated with reduced risk of death compared with EVT (hazard ratio, 0.58; 95% confidence interval, 0.37-0.91; P = .017). Comorbidities were not found to have a noticeable impact on AFS, survival, reintervention, or major amputation.
Conclusions: Two-year AFS, overall survival, and freedom from major amputation were decreased in ESRD patients compared with non-ESRD patients with critical limb ischemia. Cardiovascular comorbidities were without significant impact on outcome parameters, whereas choice of treatment modality within the ESRD group did not influence AFS. Decision-making in ESRD as to choice of therapeutic approach in dialysis patients should notably account for the individual's lesion characteristics and vascular disease; surgical revascularization and EVT may be used as complementary options.
Trial registration: ClinicalTrials.gov NCT01877252.
Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Source: PubMed