Contemporary outcomes of surgical revascularization of the lower extremity in patients on dialysis

Ajit Rao, Melissa Baldwin, James Cornwall, Michael Marin, Peter Faries, Ageliki Vouyouka
Journal of Vascular Surgery 2017, 66 (1): 167-177

OBJECTIVE: Peripheral arterial disease is a common comorbidity found in up to 38% of patients with end-stage renal disease (ESRD). With an increase in the survival rate of patients with ESRD by >25%, there is a lack of contemporary data on the safety of open surgical revascularization of the lower extremity (OSRLE) in this population of patients. We sought to identify the perioperative morbidity and mortality and independent risk factors of mortality in dialysis patients undergoing OSRLE.

METHODS: We reviewed data from 34,941 patients who underwent OSRLE from January 2011 to December 2014 at all hospitals in North America participating in the National Surgical Quality Improvement Program (NSQIP). Trauma, emergencies, aneurysms, and endovascular cases were excluded. We compared the 30-day outcomes of 1623 patients on dialysis with those of 33,318 patients not on dialysis.

RESULTS: Patients on dialysis were younger (66.0 vs 66.7; P < .01), were more likely to be treated for critical limb ischemia (49.7% vs 33.1%; P < .01), and had more comorbidities compared with patients not on dialysis. Dialysis patients had higher mortality (7.8% vs 2.1%; P < .01) and postoperative complication rates after OSRLE, including myocardial infarction (3.5% vs 1.4%; P < .01), return to the operating room (6.1% vs 2.8%; P < .01), and unplanned readmission (5.2% vs 2.9%; P < .01). Although 30-day patency was not different (0.4% vs 0.4%; P = .56) between the two study groups, major amputation rate was threefold higher in dialysis patients (1.7% vs 0.57%; P < .01). In addition, we identified multiple risk factors that predispose dialysis patients to worse outcome after OSRLE, including older age, African American race, and congestive heart failure. In a subgroup analysis by procedure, dialysis patients who underwent aortobifemoral bypass carried the highest mortality risk (25% vs 3.6%; P < .01). Dialysis patients had higher rates of unplanned reoperation (7.9% vs 3.9%; P < .01) and unplanned readmission (6.2% vs 3.7%; P < .01) and increased length of stay (67.5% vs 47.3%; P < .01) after femoral-distal bypass.

CONCLUSIONS: With improvements in the medical care of ESRD patients resulting in a large increase in survival rates, little is known about how dialysis patients fare after OSRLE in the contemporary period. Our study shows that despite advances in the medical management of dialysis patients, improvements in outcomes after revascularization have not yet been realized. We found that specific clinical and procedural factors increase the risk for inferior results. Careful selection of dialysis patients suitable for OSRLE according to these risk factors may improve the management of this still high-risk vascular population.

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