LEA3. Open Distal Revascularization in Chronic Kidney Disease: Is It Worthwhile?

Abstract

The incidence of chronic kidney disease (CKD) has reached pandemic proportions across the world. Occlusive arterial disease causing critical limb ischemia and sepsis in the CKD patient is a huge clinical challenge often culminating in major amputation or mortality. Successful revascularization of these patients is challenging with added limitations due to impaired renal function, difficulties in contrast-enhanced imaging, heavily calcified arteries, and overall comorbid status. All patients with Fontaine stage IV critical limb ischemia with tibial occlusive disease for whom angioplasty was either contraindicated or unsuccessful were considered. All those with overwhelming sepsis that warranted primary amputation were excluded. A prospective single-center case-control study was done to evaluate the outcome of surgical revascularization in those with CKD (group 1, estimated glomerular filtration rate [eGFR] of 15-90 mL/min/1.73 m2), those with end-stage renal failure (ESRF; group 2, eGFR <15 mL/min/1.73 m2), and those with preserved renal function (group 3, eGFR >90 mL/min/1.73 m2). The mean ages of the three groups were 54, 58, and 51 years, respectively. The study period was December 2014 to December 2017; the 6-month patient survival, graft patency, limb salvage rates were compared. All had autogenous vein grafts with standardized surgical technique. There were 149 consecutive surgical revascularizations performed (group 1, 62; group 2, 28; group 3, 59). There was one perioperative death (group 1) on day 2. The respective rates of 6-month patient survival were 92%, 89%, and 93% (P > .05). The corresponding graft patency rates of group 1 and group 3 were 89% and 96% (P > .05), whereas limb salvage rates were 91% and 96% (P > .05). However, group 2 showed a significant decline in both graft patency (76%) and limb salvage (71%). Four patients (two in group 1, two in group 2) had below-knee amputations with a functioning graft because of advancing sepsis. There was no significant difference in graft patency or limb salvage in comparing those who had previously failed endovascular intervention with those who had primary surgical revascularization. The presence of advanced CKD including ESRF should not be considered a limiting factor in limb revascularization. Whereas meticulous planning and care are needed to safeguard and to preserve remaining renal functions as well as to optimize outcomes in those with ESRF, the resulting limb salvage results have been excellent.