Abstract
Optimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention. A regional multicenter registry was queried between 2003 and 2013 for HD patients (N= 689) undergoing open surgical bypass (n= 295) or endovascular intervention (n= 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation. Among the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb ischemia and 8% for claudication. Overall survival at 1, 2, and 5years survival remained low at 60%, 43%, and 21%, respectively. Overall 1- and 2-year AFS was 40% and 17%. Mortality accounted for the primary mode of failure for both open bypass (78%) and endovascular interventions (80%) at two years. Survival, AFS, and freedom from major adverse limb event outcomes did not differ significantly between revascularization techniques. At 2years, endovascular patency was higher than open bypass (76% vs 26%; 95% confidence interval [CI], 0.28-0.71; P= .02). Multivariate analysis identified age ≥80years (hazard ratio [HR], 1.9; 95% CI,1.4-2.5; P< .01), indication of rest pain or tissue loss (HR, 1.8; 95% CI, 1.3-2.6; P< .01), preoperative wheelchair/bedridden status (HR, 1.5; 95% CI, 1.1-2.1; P< .01), coronary artery disease (HR, 1.5; 95% CI, 1.2-1.9; P< .01), and chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8; P= .01) as independent predictors of death. The presence of three or more risk factors resulted in predicted 1-year mortality of 64%. Overall survival and AFS among HD patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings and justifies a prudent approach to patient selection. Focus for improved results should emphasize predictors of survival to better identify those most likely to benefit from revascularization.
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