Patients with Critical Limb Ischemia on Dialysis Have Worse Outcomes After Lower Extremity Revascularization
Justin Ady, MD, Viktor Dombrovskiy, MD, PhD, MPH, Saum Rahimi, MD, Khanjan H. Nagarsheth, MD, MBA.
Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
OBJECTIVES: Lower extremity revascularization (LER) improves outcomes for patients with critical limb ischemia (CLI). We sought to compare outcomes after LER in patients with chronic kidney disease with and without dialysis (CKDD and CKD, respectively).
METHODS: Patients aged 40 years old and above who were electively hospitalized with CLI as a principal diagnosis and underwent LER were selected from the Nationwide Inpatient Sample 2010-2014 with the appropriate ICD-9-CM codes. Those with normal kidney function (NKF) composed a control group. Rates of postoperative complications and hospital mortality were compared by Chi-square test and multivariable logistic regression analysis. Hospital length of stay (LOS) and cost were calculated as median with interquartile range and compared by Wilcoxon rank sum test.
RESULTS: A total of 33,033 patients (non-weighted) were identified: 2,370 CKDD; 4,004 CKD and 26,659 NKF. CKDD patients compared to CKD and NKF had greater rates of postoperative cardiac complications (3.7%, 2.4% and 1.9%, respectively; P<0.0001), respiratory complications (4.1%, 2.2%, 1.7%; P<0.0001), surgical site infection (1.3%, 1.0%, 0.8%; P<0.02) and sepsis (4.5%, 1.4%, 1.3%; P<0.0001). They had also greater rates of in-hospital major amputations (1.7%, 0.5%, 05%; P<0.0001) and mortality (3.1%, 0.7%, 0.5%, P<0.0001) without difference between endovascular procedure and open surgery that was confirmed in the multivariable logistic regression analysis with control for patient age, gender and race, major comorbidities, and type of surgical procedure. Overall, LOS and cost were the highest in CKDD and the lowest in NKF. In CKDD and CKD, LOS and cost for open surgery were significantly greater than for endovascular procedure; CKDD, LOS=6 days (3-9) vs 3 (1-7), cost=$21,523 (14,496-33,236) vs $17,799 (11,801-29,396); CKD, LOS=5 days (3-7) vs 2 (1-4), cost=$17,527 (12,316-25,574) vs 16,912 (11.879-24,284); P<0.0001. In NKF, LOS for open surgery was also greater (4 days (2-6) vs 2 (1-4)) but cost was smaller ($14,752 (10,279-22,068) vs 16,431 (11,007-24,947)); P<0.0001.
CONCLUSIONS: Patients with CLI on dialysis undergoing LER have significantly greater rates of postoperative complications, in-hospital major amputations and mortality that are similar for endovascular and open procedures. They have also increased hospital LOS and cost that are significantly greater for open surgery. These findings suggest endovascular revascularization should be pursued primarily in patients with CKDD with CLI and open should be considered sparingly.
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