Outcomes of Distal Lower Extremity Bypass Based on Dialysis Status
Mark D. Balceniuk, MD, Peng Zhao, MD, Brian C. Ayers, MBA, Adam J. Doyle, MD, Roan J. Glocker, MD, MPH, Michael C. Stoner, MD.
University of Rochester Medical Center, Rochester, NY, USA.
Introduction:
Attributable to improved medical therapy, increasing numbers of dialysis-dependent patients are undergoing lower extremity revascularization. Previous studies have shown that there is a significant difference in outcomes of lower extremity bypass based on dialysis status; however, distal bypass outcomes have not been well assessed. The objective of this study is to evaluate the short-term outcomes of dialysis-dependent patients undergoing distal lower extremity surgical revascularization for critical limb ischemia.
Methods:
The Vascular Quality Initiative (VQI) infra-inguinal bypass database (2003-2018) was evaluated. Distal bypass was defined as the distal target being at the tibioperoneal trunk or more distal. Groups were based on dialysis status. The primary outcomes of the study were 30-day patency and overall amputation rates. Secondary outcomes included 30-day composite complication profile as well as ambulatory status.
Results:
10679 patients were included, of which 967 were on dialysis. The dialysis group had a higher rate of listed comorbidities (Table). The dialysis group demonstrated a higher incidence of tissue loss indication (767 (79%) vs 5585 (58%), p<0.001). Primary patency was significantly lower in the dialysis group (841 (87%) vs 8882 (91%), p<0.001), leading to increased primary-assisted patency procedures (55 (6%) vs 316 (3%), p<0.001). Similarly, amputation rates were significantly higher in the dialysis group (267 (28%) vs 1313 (14%), p<0.001). Postoperative myocardial infarction and death were also higher for the dialysis group. Ambulatory functional status was lower in the dialysis group (162 (17%) vs 3135 (32%), p<0.001). Subgroup analysis of the dialysis cohort demonstrates higher rates of amputation following bypass for patients with tissue loss as the initial indication (225 (84%) vs 542 (77%), p=0.021).
Conclusions:These data are the first to use the VQI to demonstrate short-term outcomes of distal bypass based on dialysis status. Patients on dialysis have a significantly higher risk of complication and failure compared to non-renal replacement therapy patients. Additionally, the high incidence of early amputation in dialysis patients with tissue loss prompts consideration for primary amputation in this subset of patients. This study further documents the risk profile associated with the intersection of the two end-stage atherosclerotic processes: renal failure and critical limb ischemia.
| No Dialysis (N=12,006) | % or ąSE | Dialysis (N=1,014) | % or ąSE | p-Value | |
| Age | 68.4 | 0.12 | 67.3 | 0.35 | 0.003 |
| Male | 6851 | 71% | 674 | 70% | 0.580 |
| White | 7523 | 77% | 573 | 59% | <0.001 |
| Comorbidities | |||||
| CHF Hx | 1815 | 19% | 369 | 38% | <0.001 |
| CAD Hx | 209 | 2% | 29 | 3% | 0.108 |
| COPD Hx | 2257 | 23% | 192 | 20% | 0.018 |
| Diabetes Hx | 5501 | 57% | 784 | 81% | <0.001 |
| HTN Hx | 8679 | 89% | 936 | 97% | <0.001 |
| Indication | |||||
| Rest Pain | 2982 | 31% | 101 | 10% | <0.001 |
| Tissue Loss | 5585 | 58% | 767 | 79% | <0.001 |
| Acute Ischemia | 1126 | 12% | 99 | 10% | 0.224 |
| Patency | |||||
| Primary | 8882 | 91% | 841 | 87% | <0.001 |
| Prim-Assisted | 316 | 3% | 55 | 6% | <0.001 |
| Secondary | 224 | 2% | 21 | 2% | 0.910 |
| Amputation | 1313 | 14% | 267 | 28% | <0.001 |
| Complication Profile | |||||
| MI | 382 | 4% | 60 | 6% | 0.001 |
| Stroke | 822 | 8% | 100 | 10% | 0.054 |
| Death | 104 | 1% | 39 | 4% | <0.001 |
| Ambulatory | 3135 | 32% | 162 | 17% | <0.001 |
| Dialysis subgroup analysis | Patent Bypass | Amputation | |||
| Tissue loss | 542 | 77% | 225 | 84% | 0.021 |
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