Predictors of 2-Year Mortality and Risk Stratification After Surgical or Endovascular Revascularization of Infrainguinal Artery Disease in Hemodialysis Patients With Critical Limb Ischemia.
OBJECTIVE
To examine the 2-year mortality in hemodialysis (HD) patients with critical limb ischemia (CLI) and determine predictors that may aid in the selection of a revascularization strategy [bypass surgery or endovascular therapy (EVT)] according to current guidelines.


METHODS
From 2007 to 2009, 246 consecutive CLI patients (mean age 69±10 years; 170 men) on HD underwent revascularization for de novo infrainguinal lesions (178 EVT and 68 bypass grafting). The majority of the patients had diabetes (170, 69%) and tissue loss (194, 79%); nearly half (111, 45%) were nonambulatory. Overall survival after revascularization was estimated by Kaplan-Meier analysis. Predictors for 2-year mortality after revascularization were determined using a Cox proportional hazards model; results are given as the hazard ratio (HR) and 95% confidence interval (CI).


RESULTS
Overall survival rate was 77% at 1 year and 66% at 2 years. Predictors of 2-year mortality after revascularization were age >75 years (HR 1.82, 95% CI 1.14 to 2.91, p=0.012), albumin <3 g/dL (HR 2.31, 95% CI 1.39 to 3.84, p=0.001), and ejection fraction <50% (HR 1.73, 95% CI 1.06 to 2.83, p=0.027). Patients with more predictors had a higher incidence of death within 2 years after revascularization.


CONCLUSIONS
Advanced age, low albumin level, and low ejection fraction were independently associated with 2-year mortality after revascularization in HD patients with CLI. Risk stratification by these factors would be useful for deciding on a revascularization strategy.
Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan.
Tatsuya
T
Shiraki
Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan iida.osa@gmail.com.
Osamu
O
Iida
Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
Mitsuyoshi
M
Takahara
Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.
Yoshimitsu
Y
Soga
Department of Vascular Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Japan.
Shinsuke
S
Mii
Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan.
Jin
J
Okazaki
Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan.
Sosei
S
Kuma
Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan.
Terutoshi
T
Yamaoka
Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan.
Daisuke
D
Kamoi
Department of Cardiology, Shin-Koga Hospital, Kurume, Japan.
Yoshiaki
Y
Shintani
Department of Cardiology, Oita Oka Hospital, Oita, Japan.
Toshinobu
T
Ishikawa
Department of Surgery, Shinsuma General Hospital, Kobe, Japan.
Ikuro
I
Kitano
Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan.
Masaaki
M
Uematsu
D000367:Age Factors; D000368:Aged; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D015897:Comorbidity; D016638:Critical Illness; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006331:Heart Diseases / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D034141:Hypoalbuminemia / Q000401:mortality; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D007564:Japan / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016016:Proportional Hazards Models; D012042:Registries; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D014680:Veins / Q000637:transplantation*
bypass graft; bypass surgery; critical limb ischemia; endovascular therapy; hemodialysis; infrainguinal disease; mortality; occlusion; stenosis