Lower extremity bypass procedures in diabetic patients with end-stage renal disease: is it worthwhile?

Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia.

A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated.

Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year.

Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.