Kikuchi S, et al. - This study was designed to determine the efficacy of paramalleolar or inframalleolar bypass (PIMB) in hemodialysis-dependent (HD) patients with critical limb ischemia (CLI) and nonhemodialysis-dependent (NHD) patients in terms of clinical outcomes. In both HD and NHD patients, PIMB performed for CLI resulted in excellent limb salvage (LS) rates with low operative mortality and complications. However, significantly lower amputation-free survival (AFS) rate in HD patients was observed in comparison to that observed in NHD patients, indicating the necessity of a specific management program to improve AFS after LS in HD patients.

Methods

• 333 consecutive arteriosclerosis obliterans patients with CLI underwent 401 PIMB procedures for limb salvage (LS) from January 2000 to December 2013.
• 188 of the 333 patients(56.5%) were HD patients.
• Researchers exclusively used vein grafts, and performed 172 paramalleolar and 229 inframalleolar bypasses.
• The two groups were compared regarding five-year primary and secondary cumulative graft patency, LS, and amputation-free survival (AFS) rates and in each group, the independent determinants of these outcomes were identified.

Results

• In HD patients, the 5-year primary and secondary cumulative graft patency rates were 53% and 82% and in NHD patients, these were 69% and 92% (primary cumulative graft patency, P < .05; secondary cumulative graft patency, nonsignificant), respectively.
• In HD patients and NHD patients, the LS rates were 87% and 99% (P < .01), respectively.
• Overall, before PIMB, 48% and 70% of HD and NHD patients were ambulatory (P < .01).
• 12 months after PIMB, 73% and 85% of HD and NHD patients were ambulatory (including 1-year survivors; nonsignificant), respectively, illustrating drastic post-PIMB improvement in HD patients.
• In the HD and NHD groups, the 5-year AFS rates were 27% and 69% (P < .01), respectively, demonstrating very poor AFS rates in HD patients.
• Female gender (hazard ratio [HR], 2.102; 95% confidence interval [CI], 1.254-3.524), history of congestive heart failure (HR, 2.075; 95% CI, 1.395-3.085), and preoperative nonambulatory status (HR, 1.974; 95% CI, 1.305-2.986) were the factors negatively associated with AFS in HD patients, whereas older age (HR, 2.601; 95% CI, 1.372-4.931) and history of congestive heart failure (HR, 2.928; 95% CI, 1.496-5.731) were identified as independent factors negatively associated with AFS in NHD patients.