Infrapopliteal arterial revascularization for limb-threatening ischemia in patients with chronic kidney disease

This study was undertaken to ascertain whether infrapopliteal arterial revascularization (IAR) for limb-threatening ischemia is worthwhile in patients with severe chronic kidney disease (CKD).

With prospectively entered data from a university teaching hospital's vascular registry, we reviewed the records of all patients with CKD who underwent IAR between January 1, 1990, and December 31, 2002. Primary, assisted primary and secondary patency rates, limb salvage, patient survival and amputation-free survival were assessed using Kaplan-Meier analysis. Factors influencing the outcome were evaluated with univariate and multivariate analyses.

Eighty-seven consecutive patients underwent 93 IARs; more than half (53%) of the patients were diabetic and nearly all (84%) had foot tissue loss. No patients died during the perioperative (30-day) period. At 1 and 5 years, primary patency rates were 92.3% and 77.2% in the series as a whole, 89.5% and 71.4% for diabetics vs. 95.3% and 83.4% for nondiabetics (p=0.164), and 78.9% and 49.1% for patients on dialysis vs. 95.7% and 85.3% for those not on dialysis (p=0.006). At 1 and 5 years, the secondary patency rates were 93.4% and 85.6% in the series as a whole, 91.7% and 82.1% for diabetics vs. 95.3% and 88.7% for nondiabetics (p=0.381), and 84.2% and 68% for patients on dialysis vs. 95.7% and 90.1% for those not on dialysis (p=0.002). At 1 and 5 years, the limb salvage rates were 96.8% and 80.6% in the series as a whole, 98% and 71.4% for diabetics vs. 100% and 88.7% for nondiabetics (p=0.104), and 94.7% and 61.7% for patients on dialysis vs 97.3% and 85.9% for those not on dialysis (p=0.020). There were 31 late deaths in the series as a whole, with a 5-year survival rate of 62.5%. At 1 and 5 years, the amputation-free survival probabilities were 93.4% and 54.4% in the series as a whole, 91.7% and 38.6% for diabetics vs. 95.2% and 70.2% for nondiabetics (p=0.011), and 89.5% and 39% for patients on dialysis vs. 94.4% and 58.8% for those not on dialysis (p=0.097). The dialysis treatment was the only predictor of primary patency failure (p=0.04).

Although the overall outcome was poorer in patients on dialysis, IARs for limb-threatening ischemia in patients with CKD can achieve satisfactory results in terms of graft patency, limb salvage and amputation-free survival, especially if the tissue loss is manageable and an adequate autologous conduit is available.