European Journal of Vascular & Endovascular Surgery
Volume 25, Issue 1 , Pages 29-34, January 2003

Infrainguinal arterial reconstruction for limb salvage in patients with end-stage renal disease

1Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, 2Department of Surgery, Saitama Medical Center, Saitama, Japan and 3Department of Surgery, Asahi General Hospital, Chiba, Japan

Accepted 15 August 2002.

*Please address all correspondence to: T. Miyata, Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.

Article Outline

Abstract 

Objectives: to evaluate the efficacy of infrainguinal bypass for limb-threatening ischaemia in patients with end-stage renal disease (ESRD). Materials and Methods: from 1991 through 2000, 28 limbs in 22 patients with ESRD received 33 infrainguinal bypasses, while 65 limbs in 57 patients with functioning kidneys underwent 77 bypasses for limb salvage. The prevalence of diabetes is higher in the ESRD group (p = 0.03). Results: perioperative mortality and patient survival rate in the follow-up period were significantly poorer in patients with ESRD (18% vs 0%; p = 0.001, and 45% vs 85%, p < 0.001, respectively). Most causes of death were related to atherosclerosis or respiratory diseases. In spite of no significant difference in 2-year primary and secondary graft patency rates and limb salvage between the ESRD and non-ESRD groups (76% vs 83%; p = 0.12, 85% vs 91%; p = 0.06, and 83% vs 93%; p = 0.06, respectively), two cases of early limb loss occurred as a result of uncontrolled infection in the ESRD group. In contrast to autogenous conduits, nonautogenous conduits revealed a poorer outcome in ESRD patients (p = 0.03). Conclusions: perioperative mortality and patient survival rate were significantly poorer in the ESRD group. Preoperative full evaluation of myocardial and brain ischaemia, revascularisation with autogenous conduits, appropriate treatment of wound infection, and strict follow-up for accompanying diseases may be needed in these patients.

Eur J Vasc Endovasc Surg 25, 29–34 (2003)

Keywords:  End-stage renal disease, Chronic renal failure, Critical limb ischaemia, Infrainguinal bypass, Autogenous conduit, Uncontrolled infection

 

Back to Article Outline

Introduction 

The population of patients with end-stage renal disease (ESRD) has been expanding in size and increasing in age because of improvements in the treatment of uremia and the availability of dialysis. The number of patients receiving dialysis in Japan was more than 197 000, 0.15% of the Japanese population at the end of 1999. More than 10 000 patients start dialysis every year, and diabetes mellitus accounts for 36% of new cases in Japan.1 There is a high prevalence of peripheral arterial occlusive disease in these patients, which often results in limb-threatening ischaemia. Although arterial reconstruction has been advocated for these severely ischaemic limbs, the results are discouraging because of higher morbidity and mortality and lower limb-salvaging rate, as compared with patients with functioning kidneys.2, 3, 4 We have aggressively performed arterial reconstruction, whenever feasible, in patients with ESRD, because critical ischaemia without vascular reconstruction predicted a poor outcome.5

In the present study, we documented the characteristic features of infrainguinal arterial reconstruction in patients with ESRD undergoing limb salvage operations compared with those of non-uremic controls.

Back to Article Outline

Patients and methods 

Patients background 

Medical records were reviewed for 79 consecutive patients with limb-threatening ischaemia due to arteriosclerosis obliterans (ASO) undergoing 110 infrainguinal arterial reconstructive bypasses in 93 limbs from January 1991 through December 2000 at the University of Tokyo Hospital, Saitama Medical Center and Asahi General Hospital were reviewed. These patients were divided into two groups, patiets with and without ESRD. There were 22 patients with ESRD with a mean age of 63 years, all dependent upon haemodialysis for a mean period of 88 months. Only one patient had a non-functioning transplanted kidney. There were 57 patients with functioning kidneys with a mean age of 68 years as controls. Fifteen patients (68%) with ESRD had diabetes mellitus, which is the leading cause of ESRD, and it is more prevalent in the ESRD group (p = 0.03). Critical foot ischaemia was the indication for arterial reconstruction. The demographic characteristics, associated risk factors, and the indication for arterial bypass are shown in Table 1.

Table 1. Demograghic characteristics and preoperative risk factors of patients with and without ESRD.
Patients with ESRDPatients without ESRD
No. of patients2257
No. of affected limbs2865
Follow-up period (months)
Mean (Range)21 (0–65)30 (1–106)
Age (years)
Mean (Range)63 (41–82)68 (45–87)
Sex
Male/female18/442/15
Risk factors
Diabetes mellitus15 (68%)*22 (38%)*
Hypertension8 (36%)35 (51%)
CAD11 (41%)15 (26%)
CVD6 (27%)8 (16%)
Indication for operation
Infected gangrene3 (11%)5 (8%)
Dry gangrene12 (43%)27 (42%)
Non-healing ulcer5 (18%)17 (26%)
Rest pain alone8 (29%)16 (25%)
*p = 0.03.

CAD: coronary artery disease. CVD: cerebrovascular disease.

All patients underwent preoperative angiography to evaluate the inflow and runoff vessels in the affected limbs. “Occlusive lesions” were termed as 100% occluded arteries at any length, and angiographic findings were compared at aorto-iliac, femoral, popliteal and tibial/peroneal (crural) levels between ESRD and non-ESRD groups. The results of angiography showed mutilevel involvement of occlusive lesions in crural as well as femoral arteries in both groups, and no difference was seen in the distribution of lesions between these groups.

Cardiac ultrasound has been performed for preoperative cardiac function assessment in all patients since 1993, and coronary angiography (CAG) was done in patients with a history or a suspicion of ischaemic heart disease due to abnormal electrocardiographic or ultrasound findings. Prior to arterial reconstruction for lower limb ischaemia, one patient was treated with percutaneous transluminal coronary angioplasty and two with coronary artery bypass grafting in the ESRD group, while exactly the same number of patients underwent each of these procedures in the non-ESRD group.

Surgical procedures 

The details of surgical procedures including conduit types and sites of distal anastomosis in both groups are shown in Table 2. A Dacron graft or human umbilical vein (HUV) was used for bypass to the aboveknee popliteal (AKP) artery, and an autovein graft was used for bypass to below-knee arteries, with the reversed saphenous vein being used most frequently. HUV was exclusively used for AKP bypass until 1995, but our preference shifted to a Dacron graft thereafter. All ischaemic limbs received complete arterial reconstruction in principle, and anastomoses at the AKP artery or more distal sites were performed by non-dissection method which spares vascular clamps.6, 7 Fifty-one ischaemic limbs (78%) in non-ESRD patients required bypass to the infragenicular artery, while only 15 limbs (54%) in ESRD patients underwent bypass to the infragenicular artery (p = 0.03). This result reflects the fact that six limbs (21%) in the ESRD group, while only three limbs (5%) in the non-ESRD group, were abandoned for distal bypass (p = 0.02) because of extensive atherosclerosis of infragenicular arteries or lack of an appropriate autovein graft.

Table 2. Number of iliac reconstruction, and conduit type and distal anastomotic location for infrainguinal bypass of patients with and without ESRD.
Patients with ESRDPatients without ESRD
No. of affected limbs2865
No. of infrainguinal bypasses3377
No. of iliac artery reconstruction#9 (32%)17 (26%)
Conduit type
Prosthesis (Dacron)5 (15%)15 (19%)
Human umbilical vein4 (12%)11 (14%)
Autovein24 (73%)51 (66%)
Distal anastomosis
Above-knee popliteal13 (46%)*14 (22%)*
Below-knee popliteal4 (14%)5 (8%)
Tibial/peroneal8 (29%)30 (46%)
Paramalleolar3 (11%)16 (25%)
# Bypass grafting or percutaneous transluminal angioplasty with or without stenting. * p = 0.03.

Statistics 

Differences between these groups were analyzed using Student's t-test and Chi-square test. Primary or secondary graft patency, limb salvage and survival were estimated by the Kaplan–Meier method in accordance with the Ad Hoc Committee on Reporting Standards.8 The patency of reconstructed vessels was assessed by history or physical examination supplemented by Doppler pulse recordings and recently by duplex scanning. Limb salvage was defined as relief of rest pain or healing of ischaemic lesions, or amputation at the level of the digit or foot.

Back to Article Outline

Results 

Twelve patients (55%) had systemic or local complications, and four patients among them (18%) died in the ESRD group. In contrast, 14 patients (25%) had complications, but no patient died in the non-ESRD group within 30 days after operation. These results showed higher mortality and morbidity in the ESRD group (p = 0.001 and 0.011, respectively). The causes of early deaths were myocardial infarction in two, cerebral infarction in one, and aspiration pneumonia in one patient. There was no difference in perioperative occurrence of graft failure and wound infection between these groups. However, progressive necrosis despite a patent graft was seen in two limbs of the ESRD patients due to uncontrolled infection. Major amputation was performed in the perioperative period in two patients with ESRD and one patient without ESRD due to extensive necrosis.

Follow-up is complete for all patients except four non-ESRD patients. Nine grafts (27%) in ESRD patients and 15 grafts (19%) in non-ESRD patients failed during the follow-up period. By life-table analysis, cumulative primary and secondary graft patency at 2 years had lower rates in ESRD patients compared with non-ESRD patients (75% vs 85%; p = 0.12 and 83% vs 91%; p = 0.06, respectively) (Fig 1 for secondary graft patency), but these differences were not significant.

  • View full-size image.
  • Fig. 1. 

    Cumulative secondary patency in patients with and without ESRD. There was no significant difference between these rates (p = 0.06). Dotted line represents SEM > 10%. The numbers of grafts at risk are listed at the bottom of the graph for ESRD (top row) and non-ESRD (bottom row) groups.

The use of autogenous and nonautogenous conduits was similarly applied for bypass grafting in both groups (Table 2). Cumulative primary and secondary patency rates at 2 years with the use of autogenous conduits were not different between these groups (81% vs 80%; p = 0.71 and 85% vs 90%; p = 0.37). In contrast, those rates with the use of nonautogenous conduits revealed a significantly poorer outcome in ESRD patients (64 vs 94%; p = 0.02 and 76% vs 94%; p = 0.03). Ipsilateral major amputations were required in three patients with ESRD and 4 patients without ESRD during the follow-up period later than 30 days after revascularization. The ESRD patientswhounderwent major amputations werelisted in Table 3.
Table 3. Patients with ESRD who underwent major amputation during follow-up period.
Age, sexIndication for operationDistal siteConduit typeGraft patencyAmputation levelReason for amputation
41,MDry gangreneAKPHUVFailed (0 mo.)BK→AK (0 mo.→ 1 mo.)Graft infection
71,MDry gangreneAKPAutoveinPatentBK (0 mo.)Preoperative extensive necrosis
70,MInfected gangreneATAAutoveinFailed*(1 mo.)BK(1 mo)Uncontrolled infection despite a patent graft
74,MRest painAKPDacronFailed (3 mo.)AK (4 mo.)Graft thrombosis
66,MDry gangreneAKP/PTAyDacron/autovein †Failed (33 mo.)AK (33 mo.)Graft thrombosis
* Thrombosed after major amputation. † Dacron graft for above-knee femoropopliteal bypass and autovein graft for below-knee popliteal-PTA bypass.

AKP: above-knee popliteal artery, ATA: anterior tibial artery, PTA: posterior tibial artery, HUV: human umbilical vein, BK: below-knee, AK: above-knee, mo.: month.

The cumulative limb salvage rate at 2 years was 83% vs 93% in patients with and without ESRD. Limb salvage was worse in patients undergoing ESRD (p = 0.06), but showed no significant difference. Sixteen deaths occurred in patients with ESRD during a mean follow-up period of 22 months, and the causes of these deaths include atherosclerosisrelated disease (coronary artery disease or cerebrovascular disease) in nine and respiratory failure in three patients. By life-table analysis, survival rates at 1 and 2 years were significantly poorer in dialysisdependent patients compared with patients with functioning kidneys (59% vs 93% at 1 year, and 45% vs 84% at 2 years; p < 0.001) (Fig. 2).
  • View full-size image.
  • Fig. 2. 

    Patient survival in ESRD and non-ESRD groups. Overall survival was significantly lower in the ESRD than in the non-ESRD groups (p < 0.001). Dotted line represents SEM > 10%. The numbers of patients at risk are listed at the bottom of the graph for ESRD (top row) and non-ESRD (bottom row) groups.

Back to Article Outline

Discussion 

The characteristic features of arterial reconstruction for limb-threatening ischaemia due to ASO in ESRD patients in comparison with non-ESRD patients were as follows; (1) failure to control infection of the affected limb despite a patent graft, (2) poorer graft patency rate with nonautogenous conduits but comparable graft patency with autogenous conduits, (3) higher mortality in the perioperative period and (4) inferior survival rate in the follow-up period.

The presence of diabetes and ESRD is associated with advanced atherosclerosis and multilevel occlusion of arteries, often including the crural artery, while non-diabetic and non-uremic ischaemia often shows occlusion of the superficial femoral artery.9 In this study, there is no difference in the distribution of occlusive lesions between ESRD and non-ESRD groups. This may be explained by the fact that all the patients, whether with or without ESRD, presented with limb-threatening ischaemia which often accompanies multilevel occlusive lesions. These patterns of occlusion require bypass grafting to the below-knee level or more distal sites. However, only a half of reconstructions were performed to the infragenicular artery in patients with ESRD, while nearly 80% of grafts were bypassed to the below-knee arteries in patients with functional kidneys. This difference is explained by the fact that significantly more limbs were abandoned for complete reconstruction in the ESRD group.

The 2-year primary and secondary graft patency rates of 75 and 83%, respectively, in ESRD patients are not significantly different from those of non-ESRD patients (p = 0.12 and 0.06, respectively), and comparable to those of previous reports concerning arterial reconstruction in patients with renal failure.3, 10, 11 Graft patency with nonautogenous conduits including HUV and Dacron grafts was significantly poorer in the ESRD group. In contrast, no significant difference was seen in graft patency with autogenous conduits between these groups. It is generally accepted that an autogenous vein is the best conduit for infrainguinal revascularisation. Graft patency and limb salvage are superior with autoveins in comparison with nonautogenous conduits for above-knee femoropopliteal bypass grafting,12, 13 although many studies reported the use of nonautogenous grafts is a reasonable alternative.14, 15, 16 Autovein grafts are preferable especially in ESRD patients with foot infection because of better resistance to infection than nonautogenous grafts.

The cumulative limb salvage rate in the ESRD group at 2 years was lower than that in the non-ESRD group, but the difference was not significant (p = 0.06). There were two main causes of limb loss in the ESRD group: progressive necrosis with infection and graft thrombosis. Early major amputation was performed in two patients due to infection. Early limb loss is often related to uncontrolled infection of necrotic tissues or wound infection despite a patent graft in patients with renal failure.10, 17 This is probably due to impaired wound healing and immune incompetence in the presence of diabetes or ESRD.18 Therefore, it is widely accepted that dialysisdependent patients with extensive tissue necrosis of forefoot with infection should be offered for primary amputation.2, 19, 20, 21 Major amputation following graft thrombosis was performed in two ESRD patients later than 30 days after revascularisation. Poor runoff and advanced calcification of arteries9 often complicate bypass grafting in ESRD patients. In addition, a lack of appropriate autovein grafts may necessitate placement of distal anastomoses at arteries affected by atherosclerosis.

Four perioperative deaths occurred in the ESRD group, three of which were attributed to cardio- or cerebrovasuclar disease. Early mortality in the ESRD group was significantly higher than that in the non-ESRD group (p = 0.001), and similar results were reported previously.3, 22, 23 Several reports proposed that the indication for arterial reconstruction in ESRD patients should be restricted to only limbthreatening ischaemia because of the high postoperative morbidity and mortality.19, 20, 21 None of our ESRD patients who died in the perioperative period had received CAG or carotid artery ultrasound prior to bypass. Preoperative full evaluation of myocardial and brain ischaemia may help decrease such serious complications in the perioperative period. Thus, we have been performing CAG and ultrasound of the carotid arteries in as many patients as possible prior to bypass grafting since the year 2000, although we have not yet determined the benefit of these procedures.

The overall survival rate at 2 years showed a significantly poorer outcome in dialysis-dependent patients (p < 0.001). Atherosclerosis-related diseases are the main cause of death, accounting for 56% in ESRD patients. In addition, the ESRD group exhibited significantly higher prevalence of diabetes (p = 0.03). Coexisting morbidity such as diabetes, atherosclerosis and cardiac disease determines the survival of dialysis-dependent patients,24, 25 and may explain significantly poorer survival rate in the ESRD group.

Back to Article Outline

Conclusion 

Poorer outcomes with respect to perioperative mortality and long-term survival in ESRD patients were found in this study. However, graft patency and limb salvage rates in the ESRD group were comparable to those in the non-ESRD group, if autogenous grafts were used. Thus, we should aggressively perform arterial reconstruction in ESRD patients if we can reduce perioperative morbidity and increase the survival rate, because successful bypass grafting greatly improves their physical activity and thus their quality of life. Preoperative full evaluation of myocardial and brain ischaemia may be beneficial for that purpose. To improve the graft patency rate in ESRD patients, who have low resistance to infection and poor wound healing, reconstruction with autogenous veins is preferable.

Back to Article Outline

References 

  1. Committee JSfDT . An overview of dialysis treatment in Japan (as of Dec. 1999). J Japan Soc Dialysis Ther (in Japanese). 2001;34:1–31
  2. Edwards JM, Taylor LM. Porter JM. Limb salvage in end-stage renal disease (ESRD). Comparison of modern results in patients with and without ESRD. Arch Surg. 1988;123:1164–1168
  3. Chang BB, Paty PS, Shah DM, et al.  Results of infrainguinal bypass for limb salvage in patients with end-stage renal disease. Surgery. 1990;108:742–747
  4. Wassermann RJ, Saroyan RM, Rice JC, Kerstein MD. Infrainguinal revascularization for limb salvage in patients with end-stage renal disease. South Med J. 1991;84:190–192
  5. Lepantalo M, Matzke S. Outcome of unreconstructed chronic critical leg ischaemia. Eur J Vasc Endovasc Surg. 1996;11:153–157
  6. Sato O, Miyata T, Shindo S, et al.  Nondissection method in distal arterial bypass surgery. Acta Chir Belg. 1999;99:147–150
  7. Takayama Y, Takagi A, Sato O, et al.  Use of a nondissection method in lower extremity revascularization: a report on our 12-year experience of autogenous vein bypass surgery. Surg Today. 1996;26:910–914
  8. Rutherford RB, Baker JD, Ernst C, et al.  Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–538
  9. McManus JF, Hughson MD. Histopathology of arteries and veins in the end-stage/dialysis kidney. Pathol Annu. 1979;14:23–59
  10. Korn P, Hoenig SJ, Skillman JJ, Kent KC. Is lower extremity revascularization worthwhile in patients with end-stage renal disease?. Surgery. 2000;128:472–479
  11. Harrington EB, Harrington ME, Schanzer H, Haimov M. End-stage renal disease–is infrainguinal limb revascularization justified?. J Vasc Surg. 1990;12:691–696
  12. Jackson MR, Belott TP, Dickason T, et al.  The consequences of a failed femoropopliteal bypass grafting: comparison of saphenous vein and PTFE grafts. J Vasc Surg. 2000;32:498–505
  13. Johnson WC, Lee KK. A comparative evaluation of polytetrafluoroethylene, umbilical vein, and saphenous vein bypass grafts for femoral-popliteal above-knee revascularization: a prospective randomized Department of Veterans Affairs cooperative study. J Vasc Surg. 2000;32:268–277
  14. Burger DH, Kappetein AP, Van Bockel JH, Breslau PJ. A prospective randomized trial comparing vein with polytetrafluoroethylene in above-knee femoropopliteal bypass grafting. J Vasc Surg. 2000;32:278–283
  15. Abbott WM, Green RM, Matsumoto T, et al.  Prosthetic above-knee femoropopliteal bypass grafting: results of a multicenter randomized prospective trial. J Vasc Surg. 1997;25:19–28 Above-Knee Femoropopliteal Study Group
  16. Green RM, Abbott WM, Matsumoto T, et al.  Prosthetic aboveknee femoropopliteal bypass grafting: five-year results of a randomized trial. J Vasc Surg. 2000;31:417–425
  17. Johnson BL, Glickman MH, Bandyk DF, Esses GE. Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg. 1995;22:280–286
  18. Drutz DJ. Altered cell-mediated immunity and its relationship to infection susceptibility in patients with uremia. Dialysis Transplant. 1979;8:320–323
  19. Lumsden AB, Besman A, Jaffe M, et al.  Infrainguinal revascularization in end-stage renal disease. Ann Vasc Surg. 1994;8:107–112
  20. Sanchez LA, Goldsmith J, Rivers SP, et al.  Limb salvage surgery in end stage renal disease: is it worthwhile?. J Cardiovasc Surg. 1992;33:344–348
  21. Baele HR, Piotrowski JJ, Yuhas J, et al.  Infrainguinal bypass in patients with end-stage renal disease. Surgery. 1995;117:319–324
  22. Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney J Dis. 1990;15:458–482
  23. Bergamini TM, Towne JB, Bandyk DF, et al.  Experience with in situ saphenous vein bypasses during 1981 to 1989: determinant factors of long-term patency. J Vasc Surg. 1991;13:137–149
  24. Mailloux LU, Bellucci AG, Mossey RT, et al.  Predictors of survival in patients undergoing dialysis. Am J Med. 1988;84:855–862
  25. Hellerstedt WL, Johnson WJ, Ascher N, et al.  Survival rates of 2728 patients with end-stage renal disease. Mayo Clin Proc. 1984;59:776–783

PII: S1078-5884(03)70182-8

doi:10.1053/ejvs.2002.1767

European Journal of Vascular & Endovascular Surgery
Volume 25, Issue 1 , Pages 29-34, January 2003

Article Tools

* Image Usage & Resolution