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An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease
Maximiano Albers1, Marcello Romiti, Nelson De Luccia
1Vascular Surgery Section, Department of Surgery, Health and Medical Sciences Sector, Lusiada Foundation (UNILUS), Santos, SP, Brazil. albersm@uol.com.br
Insights
Infrainguinal bypass grafts offer limb salvage for critical limb ischemia in end-stage renal disease patients, but patient survival remains poor. Careful patient selection is crucial to avoid amputation despite a patent graft.
Area of Science:
- Vascular Surgery
- Nephrology
- Critical Limb Ischemia Management
Background:
- Previous meta-analysis on mid-term outcomes of infrainguinal bypass grafts for critical limb ischemia (CLI) in end-stage renal disease (ESRD) patients.
- Need for precise assessment of bypass surgery outcomes due to competing endovascular procedures.
- Study aimed to refine and update previous findings by expanding the review scope and follow-up duration.
Purpose of the Study:
- To update and refine the meta-analysis of mid-term outcomes for infrainguinal bypass grafts in ESRD patients with CLI.
- To estimate primary graft patency rates.
- To investigate early amputation rates despite patent grafts and extend follow-up time.
Main Methods:
- Systematic review and meta-analysis of studies published from 1987 to 2005.
- Data extraction from electronic databases, life tables, survival curves, and texts by two independent investigators.
- Construction of pooled survival curves for graft patency, limb salvage, and patient survival using a random-effects model.
Main Results:
- Included 28 articles; 10% (84/844) of limbs experienced amputation despite patent grafts.
- Perioperative mortality was 8.8% (88/996) of patients.
- Five-year pooled estimates: primary patency 50.4%, secondary patency 50.8%, limb salvage 66.6%, patient survival 23.0%.
Conclusions:
- Bypass grafting can achieve limb salvage in most ESRD patients with CLI.
- Patient survival following bypass surgery for CLI in ESRD patients is notably poor.
- Avoidance of early amputation necessitates careful patient selection, excluding those with extensive tissue loss or infection.
Background:
A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft.
Methods:
Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis.
Results:
Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected.
Conclusions:
Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.
