Infrainguinal bypass grafting in patients with end-stage renal disease: Improving outcomes?

Abstract

Objective: This study was undertaken to examine recent trends in the outcomes of patients with end-stage renal disease (ESRD) undergoing infrainguinal bypass grafting (IBG) with autogenous vein. Methods: A retrospective analysis of all IBGs performed on patients with ESRD at a single tertiary care institution during the interval 1993 to 1999 was undertaken. The comparison groups consisted of concurrent series of patients with elevated creatinine (creatinine level > 1.2 mg/dL) and patients with normal renal function undergoing IBG. Procedural variables, angiographic runoff scores, and extent of tissue necrosis at presentation were correlated with outcome. Categoric parameters were compared with χ 2 analysis; rates were computed with life-table analysis. Results: Of an overall cohort of 622 IBGs performed during this interval, 78 IBGs (12.5%) were performed on 60 patients with ESRD, with a perioperative mortality rate of 1.3% that was comparable to controls. All reconstructions in the ESRD cohort were for limb salvage indications. Four-year survival, primary, assisted primary, and secondary patency rates for the ESRD group were 51% ± 9%, 60% ± 11%, 86% ± 5%, and 86% ± 5%, respectively; these were not statistically different from the control groups. Limb salvage in the ESRD group was 77% ± 6% at 4 years and was significantly less then either the elevated creatinine (92% ± 4%; P < .02) or the normal renal function group (90% ± 2%: P < .02). Of 16 amputations in the ESRD group, nine were performed in limbs with patent grafts. The only absolute predictor of limb loss despite a patent graft was the presence of a heel ulcer more than 4 cm in diameter. Age, runoff score of the International Society for Cardiovascular Surgery/Society for Vascular Surgery, isolated tibial bypass graft, and location of distal anastomosis were not predictive of hemodynamic failure. Conclusions: Patients with ESRD constitute an increasing proportion of patients undergoing IBG in a tertiary care setting. Four-year survival, perioperative mortality, and graft patency rates are similar to patients with normal renal function and support an aggressive approach to this population. Major limb amputation despite a patent graft remains a problem of unique frequency in patients with ESRD. Adequate predictors of hemodynamic failure of IBG in this group do not exist, although a heel ulcer more than 4 cm may indicate an unsalvageable foot. (J Vasc Surg 2001;33:1171-8.)