title: Endovascular treatment of the infrapopliteal arteries in hemodialysis patients with critical limb ischemia: is it justified?
abstract: BACKGROUND
  To evaluate the feasibility and clinical efficacy of endovascular treatment of the infrapopliteal arteries (IPA) in hemodialysis patients with critical limb ischemia (CLI).
  
  
  METHODS
  Between January 2005 and December 2010, patients undergoing hemodialysis who were treated with endovascular treatment of IPA were prospectively collected and evaluated with regard to demographics, clinical risk factors (including duration of hemodialysis), presentation of CLI, lesion type, target arteries, and treatment type. Follow-up was performed on clinical and duplex ultrasonographic evaluation at 1, 3, 6, and 12 months and annually thereafter. End points included technical success, limb salvage, primary and assisted patency, and survival and were calculated using the Kaplan-Meier method. Risk factors were analyzed by Fisher exact test for categorical data and the Mann-Whitney U test for nonparametric quantitative data.
  
  
  RESULTS
  Thirty-nine patients (29 men; mean age: 70.6 ± 11 years) with 46 limbs and 91 target tibial arteries were treated. The mean duration of hemodialysis was 5.5 years. A trophic lesion was present in 95.7% of the limbs. The intent-to-treat was made on 47 (51.6%) tibial artery stenoses, 21 (23.1%) obstructions <4 cm in length, and 23 (25.3%) obstructions ≥4 cm in length. Multiple tibial arteries were treated in 60.9% of the limbs. Technical success was obtained in 89% of the target tibial arteries. The mean follow-up was 9.2 ± 9.9 months. At 1, 6, 12, and 24 months, limb salvage was 85.5%, 72.5%, 72.5%, and 72.5%, respectively. Multiple artery treatment was statistically related with limb salvage (P = 0.042). Primary and assisted patency rates were 85%, 76.9%, 70.8%, 62.5%, and 85%, 76.9%, 73.9%, and 73.9%, respectively, at the same follow-up intervals. Short occlusive tibial artery lesions had a high risk of reocclusion (P = 0.006). Survival rates were 89.5%, 69.3%, 43.4%, and 36.2% at 1, 6, 12, and 24 months. No end points were affected by duration of hemodialysis.
  
  
  CONCLUSIONS
  Endovascular treatment of IPA in hemodialysis patients with CLI seems to be justified in terms of limb salvage and target vessel patency, but midterm survival remains poor.
authors.affiliation: Vascular Surgery, Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy. Electronic address: claudiobianchinim@gmail.com.
authors.forename: Claudio
authors.initials: C
authors.lastname: Bianchini Massoni
authors.affiliation: Vascular Surgery, Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Freyrie
authors.affiliation: Vascular Surgery, Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Natascia
authors.initials: N
authors.lastname: Muccini
authors.affiliation: Vascular Surgery, Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Gargiulo
authors.affiliation: Vascular Surgery, Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: GianLuca
authors.initials: G
authors.lastname: Faggioli
authors.affiliation: Vascular Surgery, Department of Specialistic Surgeries and Anesthesiological Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Stella
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003251:Constriction, Pathologic; D016638:Critical Illness; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy*; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000503:physiopathology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects; D012307:Risk Factors; D016909:Tibial Arteries / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency