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Vascular Surgery In The Final Year Of Life In Patients With End-stage Kidney Disease - Is It Beneficial?
Richard Paul Ebanks, Jr., BS1, Dan Neal
1, David H. Stone, MD
2, Benjamin N. Jacobs, MD
1, Salvatore T. Scali, MD
1, Samir K. Shah, MD, MPH
1.
1University of Florida College of Medicine, Gainesville, FL, USA,
2Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
Background: Vascular surgeons often operate electively on patients with end-stage kidney disease (ESKD) despite limited life expectancy and high perioperative risk. Because ESKD patients are underrepresented in trials and guidelines, clinicians must weigh risk, prognosis, and benefit. This knowledge gap in frequency of surgery and outcomes is most important for non-limb/life-threatening indications (claudication, asymptomatic carotid disease, intact abdominal aortic aneurysm [AAA]). We quantified frequency, timing, regional variation, and downstream utilization of non-urgent vascular operations in the last year of life among ESKD decedents.
Methods: Using the United States Renal Data System (USRDS), we identified all ESKD patients who died during 2017-2019 and ascertained non-urgent/emergent cerebrovascular, peripheral arterial, and aortic operations performed within 365 days before death using ICD-10-PCS codes. Outcomes included timing relative to death (7/30/90/365 days), acute-care utilization (hospital days, admissions), hospice enrollment, and hospital referral region (HRR) variation. We modeled surgery probability by HRR population-per-bed, age, sex, race, and income.
Results: We found 8,092 procedures among 4,146 patients with ≥1 non-urgent operation within 365 days of death(41% occurred within 90 days; 19% within 30 days)(
Fig1a). Leg revascularization (90.7%) and carotid endarterectomy (4.5%) predominated(
Fig1b). Median time to death differed by operation (CEA 189[IQR 72-285] vs open AAA 114[15-244] days; p<0.0001). Compared with decedents without operations, the surgery group had higher utilization (mean hospital days 45.6 vs 21.3; admissions 5.2 vs 2.6; both p<0.0001)(
Fig1c) with similar hospice enrollment (27.6%). Surgery rates varied across HRRs (median 1.3%[IQR 0.9-1.8], range 0-4.5%). In adjusted models, younger age and male sex increased odds, while Black and Asian race (vs White) and greater HRR population-per-bed lowered odds (OR 0.96 per +100 persons/bed; 95%CI 0.936-0.987; p=0.004).
Conclusions: Among ESKD decedents, non-urgent vascular surgery near end of life is not rare, often in the last 1-3 months. Operations are dominated by limb revascularization, and time-to-death varies by indication—signals to inform counseling on futility versus benefit. Care is associated with substantially higher inpatient use and is more frequent where hospital capacity is greater. These findings provide context for shared decision-making, benchmarking, and guideline development.
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