Impact of Chronic Kidney Disease on the Effectiveness of Peripheral Endovascular Interventions

Abstract

Patients with severe chronic kidney disease (CKD) were excluded from the Society for Vascular Surgery objective performance goals (OPG) derivation cohort due to established poor surgical outcomes in this group. We examine the impact of diminished creatinine clearance (CrCl) on the long-term outcomes of peripheral endovascular interventions. Retrospective review of prospectively collected institutional outcomes data (2006-2012) included calculation of CrCl and stratification by CKD class. Outcomes among those with mild (class 1, 2) moderate (class 3), and severe (class 4, 5) CKD were compared using Society for Vascular Surgery OPG outcome metrics. Multivariate models were developed to identify risk factors for poor outcome and specifically assess the impact of CKD. 454 patients underwent treatment of 523 limbs for claudication (56%), rest pain (12%), or tissue loss (32%). Over 77% of patients had abnormally low CrCl, with moderate CKD noted in 37% and severe CKD in 13%. Increasing CKD class was associated with worse outcomes across all outcome metrics by crude survival analysis. Following adjustment for all other risk factors, the impact of severe CKD was independently associated with reduced overall survival (HR, 2.69; 95% CI, 1.70-4.26; P < .001), amputation-free survival (HR, 3.15; 95% CI, 2.04-3.86; P < .001), limb salvage (HR, 4.35; 95% CI, 1.50-12.33; P = .006), major adverse limb events (HR, 2.07; 95% CI, 1.02-4.20; P = .04), freedom from reintervention and amputation (HR, 1.82; 95% CI, 1.12-2.94; P = .015), and freedom from reintervention, amputation, and stenosis (HR, 1.58; 95% CI, 1.02-2.46; P = .041). Moderate and severe CKD are highly prevalent among patients with peripheral artery disease. While severe CKD adversely affects long-term outcomes after ET as well as surgical bypass, quantification of the impact of reduced CrCl on survival- and limb-based metrics may enhance risk adjustment for comparative effectiveness research and improve patient-centered clinical decision-making.