SLR - March 2019 - Nicole L. Zahn

Open Versus Endovascular Revascularization of Below-Knee Arteries in Patients with End-Stage Renal Disease and Critical Limb Ischemia

Reference: Meyer Alexander, MD; Schilling Anne, Kott Magdalena; Rother Ulrich, MD; Lang Werner, MD; Regus Susanne, MD. Open Versus Endovascular Revascularization of Below-Knee Arteries in Patients With End-Stage Renal Disease and Critical Limb Ischemia. Vascular and Endovascular Surgery 2018, Vol. 52(8) 613–620.

Reviewed By: Nicole L. Zahn, DPM
Residency Program: Bethesda Health East Hospital

Podiatric Relevance: Unfortunately, a significant proportion of patients we treat with critical limb ischemia (CLI) have comorbidities, such as diabetes and end-stage renal disease, both of which are associated with poor prognosis and limited success with regard to limb salvage and wound healing. Despite working closely with vascular surgeons during these limb salvage procedures, 45.5 percent of patients who underwent open revascularization repair (OR) and 52.4 percent of those who underwent endovascular repair (EVT) still suffer limb loss at one year. This study was designed to observe the impact and possible differences with influence on individual choice of treatment modality between EVT and OR patients.

Methods: Patients with ESRD undergoing revascularization of the infrapopliteal segment for CLI between 2007 and 2017 were included in this study. Target arteries included the infrageniculate popliteal artery, posterior tibial, anterior tibial and/or peroneal arteries, as well as the pedal vessels. Within the entire study period, a total of 2,511 patients with CLI and a total of 108 patients with ESRD and CLI were treated. CLI patients with ESRD undergoing primary amputation and conservative treatment as well as with isolated above-knee lesions were excluded.

Results: Over a 24-month postoperative period: Amputation-free survival rate: OR 38.3 percent; EVT 23.9 percent. Overall survival rate: OR 47.4 percent; EVT 27.7 percent. Wound healing: OR 29 percent; 31 percent EVT. There was no significant differences between the OR and EVT groups for pedal arch category, and there was no difference found in the one-year amputation risk between both groups. There was, however, significantly more major adverse cardiac events (MACE) found in the EVT patients: 40 percent OR vs. 67 percent EVT.

Conclusion: Revascularization plays a critical role in limb preservation and improving outcomes after lower-extremity amputation. Aggressive revascularization has shown to dramatically improve the outcome of limb salvage. Both groups were comparable, considering age, presence of comorbidities, peripheral runoff and risk profile at patient’s admission, and wound classification. Statistical evaluation did not detect differences in wound healing. The basis of decision-making as to choice of therapy modality turned out to be lesion characteristics and the severity of comorbidities as indicated by the higher number of MACE in EVT. This study concluded that both EVT and OR should be considered as optimal procedure choices for revascularization, with the choice of procedure dependent upon the patient's overall health and the severity of arterial occlusion.

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