Outcomes after infrainguinal interventions for intermittent claudication in patients with end-stage renal disease are poor.

Abstract

Intermittent claudication (IC) interventions are predicated on safety, durability, and long-term expected benefit. Patients with end-stage renal disease (ESRD) have a higher risk of complications after many surgical procedures and have lower overall survival. Our goal was to assess perioperative and 1-year outcomes of IC interventions in patients with ESRD. The Vascular Quality Initiative was queried from 2010 to 2020 for peripheral vascular interventions (PVI) and infrainguinal bypasses (IIBs) for IC. Demographics, comorbidities, procedural details, and outcomes were analyzed in patients with and without ESRD. There were 83,698 PVIs (2% ESRD and 98% non-ESRD) and 10,935 IIBs (1.2% ESRD and 98.8% non-ESRD) performed for IC. For PVI, ESRD patients more often underwent femoropopliteal (65.1% vs 59.5%) and infrapopliteal (26.5% vs 10.1%), and less often iliac interventions (32.1% vs 46.4%) (all P < .001). There were no differences in access site complications; however, ESRD patients had higher 30-day mortality (2.2% vs 0.4%; P < .001). At 1 year, ESRD patients less often ambulated independently (74.3% vs 90.4%; P < .001). On Kaplan-Meier analysis, patient with ESRD had lower 1-year freedom from reintervention/major amputation/death (62.8% vs 86.7%), major amputation/death (67.8% vs 93.9%), and survival (81.7% vs 96.6%) (all P < .001). On multivariable analysis, ESRD was associated with reintervention/major amputation/death (hazard ratio [HR], 2.46; 95% confidence interval [CI], 2.1-2.8; P < .001), major amputation/death (HR, 3.72; 95% CI, 3.1-4.4; P < .001), and death (HR, 3.8; 95% CI, 3.2-4.58; P < .001). For IIB, ESRD patients more often had an infrapopliteal target (33.3% vs 20%; P < .001) and similar great saphenous vein use (43.9% vs 50.3%; P = .33). ESRD patients had more cardiac complications (8.7% vs 3.2%; P = .001) with a similar risk of 30-day mortality (1.6 % vs 0.5%; P = .11). At 1 year, ESRD patients less often ambulated independently (66.7% vs 88.5%; P = .006). On Kaplan-Meier analysis, ESRD patients had lower 1-year freedom from reintervention/major amputation/death (66.7% vs 81.3%), major amputation/death (70.3% vs 93.7%), and survival (81.6% vs 96.3%) (all P < .001). On multivariable analysis, ESRD was associated with reintervention/major amputation/death (HR, 1.72; 95% CI, 1.04-2.87; P = .034), major amputation/death (HR, 2.87,95% CI 1.59-5.15; P = .001), and death (HR, 3.58; 95% CI, 1.86-6.9; P < .001). Patients with ESRD have higher perioperative morbidity and long-term ambulatory impairment, limb loss, and mortality. The risks/benefit profile should be carefully assessed, and noninvasive interventions should be maximized in this population.