Outcomes of Lower Extremity Bypass for Chronic Limb-threatening Ischemia in Patients with Chronic Kidney Disease

Author Type(s)

Faculty

Document Type

Abstract

Publication Date

6-2023

Journal Title

Journal of Vascular Surgery

Department

Surgery

Abstract

Objectives

While chronic kidney disease (CKD) has been identified as a risk factor for peripheral arterial occlusive disease, its impact on outcomes after lower extremity bypass (LEB) is not well-established. The aim of the study was to characterize the association between CKD and postoperative outcomes in patients with chronic limb-threatening ischemia (CLTI).

Methods

All patients undergoing LEB for CLTI were queried from the Vascular Quality Initiative database (2003-2021). Patients were categorized based on the severity of CKD: (1) normal/mild (glomerular filtration rate [GFR] ≥60), (2) moderate (GFR 15-59), and (3) severe (GFR <15). Patient demographics, clinical and operative factors and in-hospital outcomes were analyzed. Multivariable logistic regression models were used to estimate odds ratios (ORs) associated with the severity of CKD and adjusted for patient demographics and clinical covariates.

Results

Of 27,107 patients undergoing LEB for CLTI, 7340 (27.1%) and 2016 (7.4%) patients had moderate and severe CKD, respectively. Patients with severe CKD were more likely to be African American and nonambulatory preoperatively, compared to those with normal/mild and moderate CKD. They also had higher prevalence of cardiovascular disease and diabetes and were more likely to undergo LEB for tissue loss. Intraoperatively, patients with severe CKD were more likely to undergo use of a prosthetic graft with higher blood loss and operative time. Postoperatively, severe CKD cohort had higher rates of mortality (5.3% vs 0.9% vs 2%; P < .001), reoperation (29.3% vs 13% vs 13.2%; P < .001), major amputation (4.1% vs 1.5% vs 1.5%; P < .001), and major adverse cardiac event (MACE; 12.7% vs 5.6% vs 9.4%; P < .001), but similar rates of primary and secondary bypass patency, compared to mild and moderate CKD cohorts. After controlling for confounders, severe CKD was associated with increased odds of in-hospital mortality (OR, 3.19; P < .001), major amputation (OR, 2.40; P < .001) and major adverse cardiac event (MACE; OR, 1.81; P < .001), compared to normal/mild CKD. However, moderate CKD was not associated with increased odds of mortality, major amputation and MACE, compared to normal/mild CKD. Both moderate and severe CKDs were not associated with increased odds of primary and secondary graft patency, compared to normal/mild CKD.

Conclusions

While the severity of CKD did not appear to influence bypass patency, severe CKD was associated with increased perioperative mortality, major amputation and MACE in patients undergoing LEB for CLTI, compared to normal/mild CKD. However, these trends were not observed in moderate CKD. Therefore, careful selection of patients with severe CKD suitable for LEB may improve the management of this high-risk group.

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