Prognostic Factors After Distal Bypass Grafting in Dialysis and Nondialysis Patients With Critical Limb Ischemia

Abstract

Listen

Translate article

The aim of this study was to elucidate efficacy of distal bypass grafting (DBG) for critical limb ischemia (CLI) and to detect predictors involved with life expectancy in hemodialysis patients (HD) and nonhemodialysis patients (NHD). Between September 2006 and August 2011, 188 consecutive ASO patients with CLI underwent 223 DBG for limb salvage (LS). Sixty-two percent (117 patients) had dialysis-dependent renal failure. All bypasses were performed using vein grafts, which included 43% of paramalleolar bypass grafting and 57% of pedal bypass grafting. Primary and secondary graft patency, LS, and amputation-free survival rates (AFS) 5 years after surgery were estimated using the Kaplan-Meier method and compared between two groups. Multivariable analysis by Cox proportional hazard ratio (HR) was performed to explore the independent determinants in each group. Five-year primary and secondary graft patency rates were 52%, 74% in HD and 73% and 84% in NHD, respectively, showing significant difference was seen in primary patency (P < .05) but not in secondary patency. LS rate was 90% in HD and 99% in NHD 5 years after surgery (P = .042). Only 38.5% of patients in HD were ambulatory before surgery compared with 70.5 % NHD group (P < .01). Seventy percent of HD surviving patients, however, regained their ambulatory status only then 12 months after surgery compared with 85% of NHD surviving patients. AFS was 29% in HD and 67% in NHD 5 years after surgery (P < .01). Multivariable analysis showed four statistically significant predictors of AFS in HD: history of congestive heart disease (HR, 2.296; 95% confidence interval [CI], 1.457-3.618) nonambulatory status at baseline (HR, 2.081; 95% CI, 1.244-3.481); history of infrainguinal bypass (HR, 2.564; 95% CI, 1.429-4.598); and β-blocker user (HR, 2.074; 95% CI, 1.248-3.436). Two factors that independently predicted AFS in NHD were identified: history of congestive heart disease (HR, 3.270; 95% CI, 1.236- 8.655) and statin use (HR, 0.184; 95% CI, 0.052-0.645). Although DBG achieved agreeable LS rates against CLI in both groups, there were distinct differences in prognosis after DBG between the groups. Extremely poor prognostic patients were included in HD, leading patient selections appropriate to surgery in HD are necessary.