Research

OBJECTIVE: Hemodialysis-dependent (HD) patients with chronic limb-threatening ischemia (CLTI) often present with complex, multilevel, 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 to 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 χ2, Kaplan-Meier, and Cox regression analyses.

RESULTS: Of 1468 limbs undergoing a first-time infrapopliteal intervention for CLTI between 2005 and 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 Global Limb Anatomic Staging System 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), myocardial infarction (1.0% vs 6.3%; P = .05), and mortality (2.9% vs 6.9%; P = .15), and remained nonsignificant after logistic regression. After adjustment, data demonstrated an early protective effect of BPG against major amputation at 2 years (20% BPG vs 32% PTA/S; hazard ratio [HR], 0.10; 95% confidence interval [CI], 0.03-0.40), without long-term persistence (5-year rates: 31% vs 38%; HR, 0.37; 95% CI, 0.13-1.02). BPG was associated with a 45% lower hazard of amputation/death (5-year rates: 71% vs 83%; HR, 0.55; 95% CI, 0.33-0.90) and 44% lower hazard of death (66% vs 79%; HR, 0.56; 95% CI, 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 greater likelihood of complete wound healing (6-month rates: 41% vs 25%; HR, 2.40; 95% CI, 1.03-5.58) and a lower hazard of major amputation (5-year rates: 27% vs 38%; HR, 0.36; 95% CI, 0.13-0.98), in addition to amputation/death (73% vs 83%; HR, 0.56; 95% CI, 0.34-0.94) and mortality (68% vs 79%; HR, 0.57; 95% CI, 0.33-0.96) compared with PTA/S.

CONCLUSIONS: 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 BPG-particularly with high-quality ssGSV-in carefully selected HD patients.

BACKGROUND: Our institution previously reported excellent short- and long-term outcomes after dorsalis pedis bypass (DPB) for ischemic limb salvage; however, since then, percutaneous transluminal angioplasty with or without stenting (PTA/S) has become the more common management approach. This study aims to describe our nearly 20-year experience with DPB to compare the short- and long-term outcomes between these two revascularization strategies in patients with chronic limb-threatening ischemia.

METHODS: All patients undergoing DPB or tibial PTA/S between 2000 and 2022 at our institution were retrospectively reviewed. Primary outcomes included perioperative complications, complete wound healing, reintervention, major amputation, major adverse limb events, and a composite variable of major amputation or death (amputation/death). For a more direct comparison, analyses were restricted to procedures performed for chronic limb-threatening ischemia and after the introduction of PTA/S (2005) and to PTA/S patients that were suitable candidates for bypass, had Trans-Atlantic Inter-Society Consensus C or D disease, and a potential DPB target on angiography. Outcomes were evaluated using χ2, Kaplan-Meier, and Cox regression analyses.

RESULTS: Between 2000 and 2010, 462 DPB and 395 tibial PTA/S were performed; between 2011 and 2022, 101 DPB and 955 tibial PTA/S were performed. Of those, 259 DPB and 329 tibial PTA/S fit our criteria. Compared with tibial PTA/S patients, DPB patients were similar in age (69.9 years vs 70.8 years) yet were more often White (76% vs 64%) and male (73% vs 52%), and more commonly presented with tissue loss (91% vs 84%) (all P < .05). There were no differences in perioperative complications, including mortality (1.9% vs 3.9%), myocardial infarction (1.9% vs 2.1%), or acute kidney injury (5.8% vs 10%) (all P > .05). Between DPB and PTA/S, despite a trend toward higher rates of complete wound healing after DPB (6-month rate: 43% vs 32%; P = .07), no long-term outcome differences were seen, including reintervention (5-year rate: 41% vs 40%), major amputation (25% vs 24%), major adverse limb events (42% vs 40%), or amputation/death (59% vs 66%) (all P > .05). A sensitivity analysis comparing DPB with single-segment great saphenous vein (ssGSV; n = 213) vs tibial PTA/S demonstrated that DPB had higher rates of complete wound healing (6-month rate: 46% vs 32%; P = .03) and lower rates of amputation/death (5-year rate: 57% vs 66%; P = .04), both of which remained significant after Cox regression (hazard ratio [HR], 1.55 [95% confidence interval, 1.03-2.34] and HR, 0.73 [95% CI, 0.54-0.97], respectively). Conversely, non-ssGSV DPB (n = 47), compared with tibial PTA/S, were approximately 50% more likely to experience loss of patency (HR, 0.49; 95% CI, 0.25-0.98).

CONCLUSIONS: Although becoming less common, DPB still provides a durable repair, results in similar perioperative complications compared with tibial PTA/S, and, when performed with ssGSV, may result in higher rates wound healing and lower rates amputation or death. Ultimately, despite the notable decrease in DPB in the endovascular era, these data demonstrate the importance of both revascularization strategies in treating distal arterial disease.

OBJECTIVE: To determine the optimal estimated glomerular filtration rate (eGFR) cutoff for use in risk stratification and prediction models.

BACKGROUND: Chronic kidney disease increases morbidity and mortality in most vascular procedures. However, a binary classification of eGFR <60 mL/min/1.73 m 2 , which is often used in both modeling and clinical trials, may not be optimal for predicting clinical outcomes.

METHODS: Vascular quality initiative data for nonemergent, first-time open aortic repair, endovascular aortic aneurysm repair, thoracic endovascular aortic repair, carotid endarterectomy, carotid artery stenting, peripheral vascular intervention, supra-inguinal bypass, and infra-inguinal bypass were analyzed from 2013 to 2023 and divided into cohorts based on eGFR (≥60, 45-59, 30-44, <30, and preoperative dialysis). χ 2 and logistic regression were used to evaluate perioperative outcomes.

RESULTS: Compared with patients with eGFR ≥60, those with eGFR 45 to 59 had similar odds of mortality following all procedures, except thoracic endovascular aortic repair. Driven by this group, the combined cohort showed a slight increase in the odds of mortality for eGFR 45 to 59 (0.6% vs 0.7%, adjusted odds ratio(aOR): 1.16, P = 0.002). Those in the 30 to 44 group demonstrated increased odds of mortality both overall and in the individual procedure groups (0.6% vs 1.2%, aOR: 1.78, P < 0.001). The odds of mortality continued to increase with worsening eGFR. The overall rate of new permanent dialysis was low for all eGFR cohorts, with a 0.02% difference between those with eGFR ≥60 and those in the 45 to 59 cohort (0.04% vs 0.06%; aOR: 1.65, P < 0.001). The odds of permanent dialysis likewise continued to increase with decreasing eGFR.

CONCLUSIONS: Rather than a binary eGFR cutoff of ≥60 and <60 to stratify patient risk, better risk stratification may be achieved by using 5 groups of ≥60, 45 to 59, 30 to 44, <30, and preoperative dialysis.

OBJECTIVE: In October 2023, Centers for Medicare & Medicaid Services (CMS) approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Thus, we sought to compare outcomes among tfCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in standard-risk and high-risk patients.

METHODS: All carotid revascularization procedures in the Vascular Quality Initiative after the CMS decision (October 2023-March 2025) were analyzed. Patients were classified as standard-risk or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting was performed to mitigate selection bias in high-risk patients and included demographics, comorbidities, physician volume, and operative characteristics. Inverse probability of treatment weighting was also applied to symptomatic standard-risk patients to account for the large proportion of tfCAS cases performed outside of Society for Vascular Surgery guidelines.

RESULTS: Overall, 57,843 patients underwent revascularization (9123 tfCAS, 21,814 TCAR, and 26,906 CEA). Before weighting, tfCAS patients were more often symptomatic (standard-risk: tfCAS: 45% vs TCAR: 25% vs CEA: 31%, P < .01; high-risk: 35% vs 24% vs 28%, P < .01), more frequently had a modified Rankin score of 4 or 5 (standard-risk: 7.7% vs 2.4% vs 1.7%; high-risk: 6.6% vs 2.6% vs 2.4%, P < .01), and more frequently underwent urgent or emergent surgery (standard-risk: 33% vs 11% vs 16%, high-risk: 28% vs 12% vs 17%, P < .01). Standard-risk asymptomatic patients undergoing tfCAS had the highest rates of perioperative stroke/death (1.6% vs 1.2% vs 1.0%, P = .01), as did symptomatic patients (2.9% vs 1.9% vs 1.7%, P = .01). tfCAS was associated with higher overall odds of stroke/death compared with CEA (odds ratio [OR]: 1.89 [1.43, 2.48], P < .01) and TCAR (OR: 1.59 [1.15, 2.18], P < .01). Compared with CEA, tfCAS was associated with higher odds of stroke/death in both asymptomatic (OR: 1.71 [1.12, 2.55], P = .01) and symptomatic patients (adjusted OR [aOR]: 1.78 [1.21, 2.56], P < .01). After weighting, there were no significant differences in perioperative stroke/death overall for either tfCAS or TCAR compared with CEA in standard-risk symptomatic patients. In high-risk patients, TCAR was associated with lower odds of perioperative stroke/death overall compared with CEA (1.5% vs 2.1%, aOR: 0.75 [0.59, 0.94], P = .01), whereas tfCAS had higher odds of stroke/death compared with TCAR (1.5% vs 2.4%, aOR: 1.57 [1.25, 1.98], P < .01).

CONCLUSIONS: In this retrospective analysis, there were higher odds of perioperative stroke/death when comparing tfCAS with CEA overall and among asymptomatic and symptomatic standard-risk patients, as well as overall compared with TCAR. In high-risk patients, TCAR performed better with lower odds of stroke/death compared with both CEA and tfCAS.