Abstract
OBJECTIVES: Hemodialysis-dependent (HD) patients with CLTI often present with complex, multi-level, calcified disease, and are among the highest-risk populations undergoing lower extremity revascularization. However, there are limited data evaluating outcomes among this cohort following tibial interventions. We aimed to compare outcomes in patients with CLTI and HD undergoing either infrapopliteal bypass (BPG) or angioplasty with or without stenting (PTA/S).
METHODS: All patients with HD undergoing a first-time infrapopliteal BPG or PTA/S for CLTI at our institution from 2005-2024 were retrospectively reviewed. Primary outcomes included perioperative complications, wound healing, patency, reintervention, major amputation, and amputation or death (amputation/death). Outcomes were evaluated using chi-squared, Kaplan-Meier, and Cox regression analyses.
RESULTS: Of 1,468 limbs undergoing a first-time infrapopliteal intervention for CLTI between 2005-2024, 280 had HD, of which 105 underwent BPG (87% ssGSV) and 175 PTA/S. Demographics were largely similar between BPG and PTA/S, with differences seen in non-white race (28% vs. 44%) and smoking history (65% vs. 44%) (all P<.05). BPG had higher rates of grade 4 femoropopliteal and infrapopliteal GLASS classification (35% vs. 8.0% and 43% vs. 28%, respectively) (all P<.05). Unadjusted perioperative outcomes were clinically yet not statistically different, including major amputation (1.0% (BPG) vs. 4.6% (PTA/S), P=.09), MI (1.0% vs. 6.3%, P=.05), and mortality (2.9% vs. 6.9%, P=.15), and remained non-significant following logistic regression. Following adjustment, data demonstrated an early protective effect of BPG against major amputation at two years (20% (BPG) vs. 32% (PTA/S); HR 0.10, 95% CI [0.03-0.40]), without long-term persistence (five-year rates: 31% vs. 38%; HR 0.37 [0.13-1.02]). BPG was associated with a 45% lower hazard of amputation/death (five-year rates: 71% vs. 83%; HR 0.55 [0.33-0.90]) and 44% lower hazard of death (66% vs. 79%; HR 0.56 [0.35-0.94]). A sensitivity analysis restricted to BPG performed with single-segment great saphenous vein (ssGSV) conduit demonstrated even greater benefit of BPG, with significantly higher likelihood of complete wound healing (six-month rates: 41% vs. 25%; HR 2.40 [1.03-5.58]) and lower hazard of major amputation (five-year rates: 27% vs. 38%; HR 0.36 [0.13-0.98]), in addition to amputation/death (73% vs. 83%; HR 0.56 [0.34-0.94]) and mortality (68% vs. 79%; HR 0.57 [0.33-0.96]) compared to PTA/S.
CONCLUSION: Patients with HD and CLTI undergoing infrapopliteal revascularization face high rates of amputation and mortality, yet contemporary advances in dialysis care have extended survival for many of these patients. As such, procedure durability and limb-preservation strategies have become increasingly relevant. Among appropriate surgical candidates, BPG is associated with lower mid- and long-term risk of major amputation, death, and amputation/death. In sensitivity analyses, ssGSV bypass offered even greater benefit, including higher wound-healing rates and substantially lower hazards of major amputation, amputation/death, and mortality. These findings support considering infrapopliteal bypass - particularly with high-quality ssGSV - in carefully selected hemodialysis-dependent patients.