Editor's Choice – Comparison of Outcomes After Open Surgical and Endovascular Lower Extremity Revascularisation Among End Stage Renal Disease Patients on Dialysis

Theodore H Yuo,Justin R Wallace,Larry Fish,Efthymios D Avgerinos,Steven A Leers,Georges E Al-Khoury,Michel S Makaroun,Rabih A Chaer

doi:10.1016/j.ejvs.2018.09.008

Abstract

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). 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. 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). 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.

Highlights

Patients with end stage renal disease (ESRD) have a high incidence of peripheral arterial disease (PAD); cross sectional studies suggest a prevalence of 27.5% in the United States with about 13% having a diagnosis of critical limb ischaemia (CLI).[1]
Multivariable logistic regression models adjusting for medical covariables and CLI versus claudication status demonstrated increased 30 day mortality risk with open surgical revascularisation (OSR) compared with Endovascular revascularisation (ER), myocardial infarction (MI), and the combined endpoint of mortality and major amputation, but lower odds of 30 day major amputation alone
In this retrospective analysis of an administrative database, End stage renal disease (ESRD) patients suffer from high mortality and amputation rates following lower extremity revascularisation

Summary

Introduction

Patients with end stage renal disease (ESRD) have a high incidence of peripheral arterial disease (PAD); cross sectional studies suggest a prevalence of 27.5% in the United States with about 13% having a diagnosis of critical limb ischaemia (CLI).[1]. Previous investigators have presented disappointing results with open surgical techniques in the ESRD population and have concluded that a selective approach to revascularisation is necessary.13e17

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