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Published on: October 2, 2020
Sex-based outcomes of lower extremity bypass surgery in hemodialysis patients
Isibor Arhuidese1, Amber Kernodle2, Besma Nejim2
1Vascular and Endovascular Clinical Research Center, Johns Hopkins Bayview Medical Center, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla.
Insights
Men more often received autogenous conduits for lower extremity bypass surgery, while women had higher acute graft failure with prosthetic conduits. Improved conduit selection is needed for all patients, regardless of gender.
Area of Science:
- Vascular Surgery
- Nephrology
- Health Services Research
Background:
- Lower extremity bypass surgery is a critical intervention for patients with critical limb ischemia.
- Hemodialysis patients represent a high-risk population undergoing these procedures.
- Understanding gender-based differences in conduit use and outcomes is essential for optimizing surgical care.
Purpose of the Study:
- To compare conduit utilization and surgical outcomes between men and women undergoing open lower extremity bypass surgery while on hemodialysis.
- To identify potential gender-specific disparities in graft patency, failure rates, limb salvage, and patient survival.
Main Methods:
- Analysis of the United States Renal Data System (USRDS) database for hemodialysis patients undergoing infrainguinal bypass (2006-2011).
- Comparison of patient demographics, bypass characteristics, and conduit types (autogenous vs. prosthetic) between genders.
- Utilized Kaplan-Meier, logistic regression, and Cox regression analyses to assess outcomes including graft patency, acute graft failure, limb salvage, and mortality.
Main Results:
- Autogenous conduit use was higher in men (61%) compared to women (55%).
- Women receiving prosthetic conduits experienced higher odds of acute graft failure (adjusted odds ratio, 1.23) compared to men.
- Despite differences in conduit choice and initial failure rates, no significant gender-based differences were observed in primary patency, assisted patency, secondary patency, limb salvage, or overall survival.
Conclusions:
- Lower utilization of autogenous conduits in women undergoing lower extremity bypass surgery was observed.
- Women using prosthetic conduits faced a higher risk of acute graft failure.
- The study highlights the importance of optimizing autogenous conduit selection for all patients, irrespective of gender, to improve bypass outcomes.
Objective:
The objective of this study was to compare conduit use and surgical outcomes of hemodialysis-dependent men and women after open lower extremity bypass surgery.
Methods:
Using the United States Renal Data System, we studied all hemodialysis patients in the United States who underwent infrainguinal bypass surgery between January 1, 2006, and December 31, 2011. Univariate methods (χ2, analysis of variance) were employed to compare patient and bypass characteristics between men and women. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were employed to evaluate outcomes that included patency, graft failure, and mortality at 30 days. In addition, we compared limb salvage and patient survival rates between men and women.
Results:
There were 9739 bypasses performed in 5927 (61%) men and 3812 (39%) women who presented most commonly with critical limb ischemia (men, 73%; women, 71%; P = .04). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). The prevalence of autogenous conduits was higher for men (61 vs 55%; P < .001), and they were associated with higher patency compared with prosthetics (adjusted hazard ratio [aHR], 1.10; 95% confidence interval [CI], 1.01-1.19; P = .03). The risk-adjusted analyses revealed higher odds of acute graft failure for women compared with men who received prosthetic conduits (adjusted odds ratio, 1.23; 95% CI, 1.03-1.46; P = .021) but not among patients who received autogenous conduits (adjusted odds ratio, 1.07; 95% CI, 0.91-1.25; P = .41). Despite the difference in choice of conduit, there was no significant difference in primary patency (aHR, 1.00; 95% CI, 0.95-1.06; P = .90), primary assisted patency (aHR, 1.03; 95% CI, 0.97-1.10; P = .28), secondary patency (aHR, 1.01; 95% CI, 0.95-1.08; P = .75), limb salvage (aHR, 0.97; 95% CI, 0.90-1.04; P = .41), and survival (aHR, 0.97; 95% CI, 0.92-1.03; P = .45) for women compared with men.
Conclusions:
We found lower use of autogenous conduits in women than in men. In patients who received prosthetic conduit, acute graft failure was higher for women than for men. The benefits of autogenous conduits over prosthetic grafts underscore the need to improve the selection of appropriately sized autogenous conduits for bypass irrespective of gender.
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