title: Outcomes of lower extremity revascularization among the hemodialysis-dependent.
abstract: OBJECTIVE
  Optimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention.
  
  
  METHODS
  A regional multicenter registry was queried between 2003 and 2013 for HD patients (N = 689) undergoing open surgical bypass (n = 295) or endovascular intervention (n = 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation.
  
  
  RESULTS
  Among the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb ischemia and 8% for claudication. Overall survival at 1, 2, and 5 years survival remained low at 60%, 43%, and 21%, respectively. Overall 1- and 2-year AFS was 40% and 17%. Mortality accounted for the primary mode of failure for both open bypass (78%) and endovascular interventions (80%) at two years. Survival, AFS, and freedom from major adverse limb event outcomes did not differ significantly between revascularization techniques. At 2 years, endovascular patency was higher than open bypass (76% vs 26%; 95% confidence interval [CI], 0.28-0.71; P = .02). Multivariate analysis identified age ≥80 years (hazard ratio [HR], 1.9; 95% CI, 1.4-2.5; P < .01), indication of rest pain or tissue loss (HR, 1.8; 95% CI, 1.3-2.6; P < .01), preoperative wheelchair/bedridden status (HR, 1.5; 95% CI, 1.1-2.1; P < .01), coronary artery disease (HR, 1.5; 95% CI, 1.2-1.9; P < .01), and chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8; P = .01) as independent predictors of death. The presence of three or more risk factors resulted in predicted 1-year mortality of 64%.
  
  
  CONCLUSIONS
  Overall survival and AFS among HD patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings and justifies a prudent approach to patient selection. Focus for improved results should emphasize predictors of survival to better identify those most likely to benefit from revascularization.
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: john.m.fallon@hitchcock.org.
authors.forename: John M
authors.initials: JM
authors.lastname: Fallon
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.affiliation: Division of Vascular Surgery, The Massachusetts General Hospital, Boston, Mass.
authors.forename: Virendra I
authors.initials: VI
authors.lastname: Patel
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.affiliation: Division of Vascular Surgery, Boston University Medical Center, Boston, Mass.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kalish
authors.affiliation: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Yuanyuan
authors.initials: Y
authors.lastname: Zhao
authors.affiliation: Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Allen D
authors.initials: AD
authors.lastname: Hamdan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D007674:Kidney Diseases / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D012042:Registries; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality