title: Clinical outcome after infrapopliteal bypass surgery in chronic hemodialysis patients with critical limb ischemia.
abstract: OBJECTIVE
  Lower extremity bypass surgery has been widely performed to treat critical limb ischemia (CLI) in patients on hemodialysis (HD). However, the clinical outcome still remains unclear. We investigated the limb salvage rate after infrapopliteal bypass surgery in HD patients with CLI.
  
  
  METHODS
  From April 2006 to January 2013, 226 patients with 236 limbs who electively underwent bypass surgery for treatment of CLI due to infrapopliteal disease were enrolled. Patients were grouped by those who were on HD (n = 177) and those who were not (n = 49). They were monitored for 5 years or until December 2013 if the follow-up period was <5 years. Amputation-free survival, defined as freedom from major amputation or all-cause death, was primarily evaluated. Incidence of reintervention was also analyzed.
  
  
  RESULTS
  Ulcer/gangrene was present in 206 patients (91.2%), and 233 limbs (98.7%) were treated using autogenous vein. Age was younger (67 ± 9 vs 72 ± 9 years; P = .0011) and ulcer/gangrene was more prevalent (93.8% vs 81.6%, P = .0080) in HD patients than in non-HD patients. During the follow-up period (median, 28 months), 33 (14.6%) major amputations and 28 reinterventions (12.4%) occurred, and 65 patients (28.8%) died. The 5-year amputation-free survival rate was significantly lower in HD patients than in non-HD patients (43.6% vs 78.8%, P = .0033), and the adjusted hazard ratio (HR) for amputation or death for HD patients was 2.36 (95% confidence interval [CI], 1.13-4.92; P = .022). Compared with non-HD patients, the status of HD was similarly an independent risk of major amputation (72.4% vs 92.5%; adjusted HR, 4.36; 95% CI, 1.04-18.3; P = .045) and mortality (56.9% vs 83.2%; adjusted HR, 2.81; 95% CI, 1.30-6.09; P = .0085). However, freedom from reintervention was comparable between the two groups (84.3% vs 86.8%; P = .89). In HD patients, body mass index (HR, 0.86; 95% CI, 0.76-0.96; per 1 kg/m(2) increase; P = .014) and C-reactive protein (HR, 1.06; 95% CI, 1.01-1.11; P = .014) independently predicted major amputation. Elevated C-reactive protein levels were also associated with death (HR, 1.04; 95% CI, 1.01-1.09; P = .047).
  
  
  CONCLUSIONS
  The clinical outcome after infrapopliteal bypass surgery was poorer in HD patients with CLI compared with non-HD patients. Malnutrition or chronic inflammation was associated with poor outcome in HD patients with CLI due to infrapopliteal occlusive disease.
authors.affiliation: Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu, Japan.
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Kumada
authors.affiliation: Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu, Japan.
authors.forename: Haruhiko
authors.initials: H
authors.lastname: Nogaki
authors.affiliation: Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan. Electronic address: hkishii@med.nagoya-u.ac.jp.
authors.forename: Hideki
authors.initials: H
authors.lastname: Ishii
authors.affiliation: Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan.
authors.forename: Toru
authors.initials: T
authors.lastname: Aoyama
authors.affiliation: Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Kamoi
authors.affiliation: Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Takahashi
authors.affiliation: Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Toyoaki
authors.initials: T
authors.lastname: Murohara
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D015897:Comorbidity; D016638:Critical Illness; D018572:Disease-Free Survival; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D007249:Inflammation / Q000453:epidemiology; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D007564:Japan; D053208:Kaplan-Meier Estimate; D007674:Kidney Diseases / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D044342:Malnutrition / Q000453:epidemiology; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality