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Endovascular Management Of Critical Limb Ischemia In Renal Failure Patients

Introduction and Objectives: Renal failure is the most significant predictor of perioperative and long-term mortality in open lower extremity revascularizations. It also likely portends more advanced and calcified vascular disease. Endovascular management may be preferable, but technical success and durability in these patients is unknown.
Methods: All patients on hemodialysis or with renal transplants treated with lower extremity intervention in a single center between August 2004 and March 2006 were retrospectively reviewed for demographic characteristics, risk factors, clinical presentation, procedural details, and outcomes.
Results: Endovascular interventions were performed on 53 limbs in 42 patients, 27 were dialysis dependent and 15 had functioning renal transplants. Mean age was 64, 62% were male, 86% diabetic, and 95% hypertensive. All patients were treated for critical limb ischemia (CLI). Treated regions included 11 iliac, 12 superficial femoral, 6 popliteal and 25 infrapopliteal arteries, as well as 13 bypass grafts. 21% had multilevel disease. Limbs were 42% TASC-A, 24% TASC-B, 15% TASC-C and 19% TASC-D. 93% of interventions were technically successful and included 37 primary angioplasties (70%), 10 primary stents (19%), and 6 selective stents (11%). Failures included 1 TASC-A, 1 TASC-C and 2 TASC-D lesions. Perioperative mortality was 4%. The complication rate was 8%, including 1 myocardial infarction, 1 hematoma, 2 pseudoaneurysms, and one case of transient renal insufficiency in a transplant patient. 1 year survival was 79%, 69% in dialysis patients vs. 100% in transplant patients (p=0.015). Limb salvage at 1 year was 84%, 77% in dialysis patients vs. 94% in transplants (p=0.27). Freedom from re-intervention or bypass was 81% at 10 months.
Conclusions: Endovascular management of CLI in renal failure patients results in good technical success and limb salvage at 1 year. Given poor short-term survival in dialysis patients, endovascular therapy is a reasonable primary treatment option for this high risk group.