Infrainguinal bypass grafting in patients with endstage renal disease: Improving outcomes?

Objective: This study was undertaken to examine recent trends in the outcom es of patients with end-stage renal disease (ESRD) undergoing infrainguinal bypass grafting (IBG) with autogenous vein. Methods: A retrospective analysis of all IBGs performed on patients with ES RD at a single tertiary care institution during the interval 1993 to 1999 w as undertaken. The comparison groups consisted of concurrent series of pati ents with elevated creatinine (creatinine level > 1.2 mg/dL) and patients w ith normal renal function undergoing IBG. Procedural variables, angiographi c runoff scores, and extent of tissue necrosis at presentation were correla ted with outcome. Categoric parameters were compared with chi (2) analysis; rates were computed with life-table analysis. Results: Of an overall cohort of 622 IBGs performed during this interval, 7 8 IBGs (12.5%) were performed on 60 patients with ESRD, with a perioperativ e mortality rate of 1.3% that was comparable to controls. Ah reconstruction s in the ESRD cohort were for limb salvage indications. Four-year survival, primary, assisted primary, and secondary patency rates for the ESRD group were 51% +/- 9%, 60% +/- 11%, 86% +/- 5%, and 86% +/- 5%, respectively; the se were not statistically different from the control groups. Limb salvage i n the ESRD group was 77% +/- 6% at 4 years and was significantly less then either the elevated creatinine (92% +/- 4%; P < .02) or the normal renal fu nction group (90% +/- 2%: P < .02). Of 16 amputations in the ESRD group, ni ne were performed in limbs with patent grafts. The only absolute predictor of limb loss despite a patent graft was the presence of a heel ulcer more t han 4 cm in diameter. Age, runoff score of the International Society for Ca rdiovascular Surgery/Society for Vascular Surgery, isolated tibial bypass g raft, and location of distal anastomosis were not predictive of hemodynamic failure. Conclusions: Patients with ESRD constitute an increasing proportion of pati ents undergoing LEG in a tertiary care setting. Pour-year survival, periope rative mortality, and graft patency rates are similar to patients with norm al renal function and support an aggressive approach to this population. Ma jor limb amputation despite a patent graft remains a problem of unique freq uency in patients with ESRD. Adequate predictors of hemodynamic failure of LEG in this group do not exist, although a heel ulcer more than 4 cm may in dicate an unsalvageable foot.