End-stage Renal Disease, But Not Moderate Renal Dysfunction, Is Associated With Poor Long-time Survival After Infrainguinal Bypass For Chronic Limb Threat Ischemia
Daniel Kronenfeld, M.D., Alik Farber, M.D., Elizabeth King, M.D., Scott Levin, M.D., Maha Haqqani, M.D., Denis Rybin, Ph.D., Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.
Objectives: End-stage renal disease (ESRD) has been associated with poor perioperative and short term outcomes after infrainguinal bypass. Our goal was to examine 3 year outcomes after lower extremity bypass for chronic limb threatening ischemia (CLTI).
Methods: A retrospective analysis of lower extremity bypass for CLTI was performed at a single medical center between 2007 and 2018. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60), moderate dysfunction (eGFR 15-59), and ESRD (eGFR <15). Multivariable analysis was used to evaluate perioperative and long-term outcomes.
Results: There were 221 infrainguinal bypasses were identified. Average age was 66 years and 65% were male. The majority (58%) were to infrapopliteal targets and used ipsilateral greater saphenous vein (58%). 59%, 24% and 16% of patients had normal renal function, moderate dysfunction, and ESRD, respectively. 77% of patients had tissue loss; 9%, 45%, 24% and 22% were WIFi stages 1, 2, 3 and 4, respectively. ESRD patients had more diabetes, hypertension, anemia, higher WIFi stage, and lower current smoking.
90-day mortality was higher for ESRD patients compared to those with moderate dysfunction and normal renal function (11.4 vs. 1.9 vs. 0.8, P=.002); 90-day readmission was 69% vs. 55% vs. 43%, P=.017, respectively. 3 year Kaplan Meier survival analysis for ESRD, moderate dysfunction, and normal renal function was 72% vs. 96% vs. 94% (P=.001) and reintervention free survival (60% vs. 76% vs 84%, P=.033), with no difference in major amputation free survival (64% vs. 77% vs 71%, P=.96) or occlusion free survival (44% vs. 51% vs. 56%, P=.45). On multivariable analysis, ESRD was associated with higher 90 day mortality (OR 16.9, 95% 1.83 - 156.6, P=.014) and readmission (OR 3.3, 95% CI 1.26 - 8.63, P=.015). For 3-year outcomes, ESRD was associated with higher mortality (HR 4.95, 95% CI 1.5-16.2, P=.008) and primary assisted patency loss/death (1.6, 95% CI, 1.205.5, P = .012) with no difference in primary patency loss/death or amputation/death. Moderate renal dysfunction did not affect these outcomes.
Conclusion: ESRD, but not moderate renal dysfunction, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary assisted patency, this did not translate to differences in primary patency or limb loss.
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