Long-Term Outcomes after Infrainguinal Revascularization in Patients with Critical Limb Ischemia on End-Stage Renal Disease Patients (ESRD) and Comparison Results with Non-ESRD Population

Abstract

Infrainguinal revascularization in end-stage renal disease patients is controversial, despite of patency and limb salvage rates observed in several studies. This study provides more favourable overall survival and amputation free-survival rates than the contemporary study of the same characteristics. The revascularization of patients with ESRD is frequently conditioned by poor survival. With the data we provide, approximately half of the patients were alived and their limb was salvaged at 3 years, and this is encouraging. Thus, we can be more aggressive in daily practice and offer revascularization in ESRD patients. Objective: This study analyzed long-term outcomes and evaluate the benefits and limits of infrainguinal revascularization (IR) both surgical and endovascular revascularization with critical limb ischemia (CLI) in patients with and without ESRD. Material and Methods: A total of 1188 patients were prospectively collected and analyzed retrospectively. We included 108 (9.1%) patients with ESRD and of them 70 (64.8%) receiving hemodialysis. Results: The 30-day mortality rate was higher in ESRD group (5.6 vs. 1.8, p=0,009). The second patency was similar in both groups at 1 and 3 years (87.6% and 85.3% vs. 82.9% and 81.6%). ESRD patients had a lower overall survival and amputation free-survival (AFS) (at 1 year 79.6% vs. 91.8% and at 3 years 57.9% vs. 79.1%, p<0.001) and (at 1 year 68.2% vs. 78.8% and at 3 years 45.7% vs. 64.6%, p<0,001) than non- ESRD patients. The limb salvage rates achieved excellent outcomes during follow-up at 1 and 3 years. (83.5% and 83.2% vs. 66.0% and 77.6% (p=0.194). Cox regression analysis showed that hemodialysis was an independent predictor of all-cause mortality and AFS (HR=2.38, 95% CI 1.54- 3.68, p<0,001). Octogenarian patients and coronary disease was independent predictor of all-cause mortality (HR=3.05, 95% CI 2.3-4.01, p<0.001) and (HR=1.49, 95% CI 1.14-1.95, p=0.03). Conclusions: The long-term patency and limb salvage rates in patients who underwent IR with CLI and ESRD was comparable with non- ESRD patients. Despite, the overall survival and amputation free-survival rates was poorer in ESRD patients, we advocated for aggressive revascularization attitude in ESRD patients but we must individualize treatment decision and should be offered revascularization for patients with acceptable life expectancy.