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Outcomes Among End-stage Kidney Disease Patients Undergoing Infrapopliteal Revascularization For CLTI
Jeremy D. Darling, MD, Isa F. van Galen, MD, Camila R. Guetter, MD, MPH, Michael A. Ciaramella, MD, Jemin Park, MD, Christina Marcaccio, MD, Patric Liang, MD, Andy Lee, MD, Lars Stangenberg, MD, PhD, Mark C. Wyers, MD, Allen D. Hamdan, MD, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
OBJECTIVES: Patients with end-stage kidney disease (ESKD) and CLTI often present with complex, multi-level, calcified disease, and are among the highest-risk populations undergoing lower extremity revascularization. However, given the limited data assessing outcomes among this cohort following tibial interventions, we aimed to compare patients with CLTI and ESKD undergoing either infrapopliteal bypass (BPG) or angioplasty +/- stenting (PTA/S).
METHODS: All patients with ESKD undergoing a first-time infrapopliteal BPG or PTA/S for CLTI at our institution from 2005-2024 were retrospectively reviewed. Primary outcomes included perioperative complications, wound healing, reintervention, major amputation, and amputation or death (amputation/death). Outcomes were evaluated using chi-squared, Kaplan-Meier, and Cox regression analyses.
RESULTS: Of 1,468 limbs undergoing a first-time infrapopliteal intervention for CLTI between 2005-2024, 280 had ESKD: 105 BPG (90% ssGSV) and 175 PTA/S. Demographics were largely similar between BPG and PTA/S, with differences seen in non-white race (28% vs. 44%) and smoking history (65% vs. 44%) (all
P<.05). BPG had higher rates of Grade 4 femoropopliteal and infrapopliteal GLASS classification (33% vs. 11% and 43% vs. 29%, respectively) (all
P<.05). Unadjusted perioperative outcomes were clinically yet not statistically different, including major amputation (BPG 1.0% vs. PTA/S 4.6%,
P=.09), MI (1.0% vs. 6.3%,
P=.05), and mortality (2.9% vs. 6.9%,
P=.15), and remained non-significant following logistic regression. Long-term outcomes showed no difference in reintervention rates (five-year: 56% vs. 51%, P=.45), a trend toward higher rates of complete wound healing following BPG (six-month: 39% vs. 21%,
P=.06), and a trend towards lower rates of major amputation following BPG (31% vs. 37%;
P=.08). At five years, BPG was associated with a significantly lower rate of amputation/death (71% vs. 83%,
P<.01)(
Figure I). Cox regression demonstrated an early protective effect of BPG against major amputation at two years (HR 0.15, 95% CI[0.08-0.52]), without long-term persistence (HR 0.40[0.14-1.13]). Lastly, BPG was associated with 45% lower hazard of amputation/death (HR 0.55[0.33-0.92]).
CONCLUSIONS: Patients with ESKD and CLTI undergoing infrapopliteal revascularization face high rates of amputation and mortality. These data demonstrate that, among those suitable for open surgery, BPG is associated with lower mid-term risk of major amputation and lower long-term risk of amputation/death.
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