Annals of Vascular Surgery
Volume 23, Issue 5 , Pages 560-568, September 2009

Impact of Chronic Kidney Disease on Outcomes of Superficial Femoral Artery Endoluminal Interventions

  • Andrew M. Bakken

      Affiliations

    • Department of Surgery, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • ,
  • Clinton D. Protack

      Affiliations

    • Department of Surgery, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • ,
  • Wael E. Saad

      Affiliations

    • Department of Imaging Sciences, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • ,
  • Joseph P. Hart

      Affiliations

    • Department of Surgery, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • ,
  • Jeffrey M. Rhodes

      Affiliations

    • Department of Surgery, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • ,
  • David L. Waldman

      Affiliations

    • Department of Imaging Sciences, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • ,
  • Mark G. Davies

      Affiliations

    • Department of Surgery, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • Department of Imaging Sciences, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY
    • Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX
    • Corresponding Author InformationCorrespondence to: Mark G. Davies, MD, PhD, MBA, Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin, Smith Tower, Suite 1401, Houston, TX 77030, USA

published online 06 January 2009.

Article Outline

While aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of chronic kidney disease (CKD) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without varying stages of CKD. A database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried, and two groups were defined: estimated glomerular filtration rate (eGFR) ≤60 and >60 mL/min/1.73 cm2. Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC-II) and Society for Vascular Surgery criteria. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean ± standard deviation where appropriate. There were 525 limbs in 535 patients (68% male, average age 66 ± 14 years) that underwent endovascular treatment for claudication or chronic critical limb ischemia (51%). Patients with eGFR ≤60 were older and had significantly more coronary artery disease, congestive heart failure, diabetes mellitus, and hyperlipidemia. TASC-II lesion distribution was equivalent (37% for TASC-II C and D), but tibial runoff was significantly worse in the eGFR ≤60 group. In addition, there were more inflow and outflow interventions in the eGFR ≤60 group. In patients with claudication, there was no difference in patency or limb salvage between those with eGFR ≤60 and >60. In patients with critical limb ischemia, there was no difference in patency between those with eGFR ≤60 and >60. Limb salvage was worse in patients with eGFR ≤60 compared to eGFR >60. With respect to limb salvage, six factors were significantly associated with a reduction in rates: presence of tissue loss at presentation (relative risk [RR] = 6.45, p = 0.003), 0 or 1 vessel tibial runoff (RR = 2.56, p < 0.01), progression of distal disease noted in follow-up (RR = 4.62, p < 0.01), embolization at the initial intervention (RR = 2.70, p < 0.05), diabetes mellitus (RR = 3.71, p < 0.01), and a history of congestive heart disease (RR = 2.42, p < 0.01). Notable factors that were not significantly associated included lesion calcification (p = 0.64), TASC C or D lesion categorization (p = 0.99), acute occlusion at initial intervention (p = 0.40), and adjuvant stenting (p = 0.67). CKD does not impact the patency of SFA interventions. Limb salvage in patients with critical ischemia is significantly worse when the eGFR is ≤60 mL/min/1.73 cm2.

 

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Introduction 

Patients with chronic kidney disease (CKD) represent a large and growing public health problem in the United States. The estimated prevalence of CKD stages 1-4 has increased from 10.0% in 1988-1994 to 13.1% in 1999-2004.1 There were an additional 472,099 patients undergoing renal replacement therapy in 2004 (approximately 0.2% of the U.S. population),2 with the annual growth rate at just under 3% since 2001 according the 2007 Annual Data Report of the U.S. Renal Data System. CKD is a well-recognized risk factor for the development of cardiovascular disease,3 with individuals having CKD more likely to die from cardiovascular disease than to develop kidney failure.4 Patients with CKD (glomerular filtration rate [GFR] ≤60 mL/min/1.73 m2) are also known to be specifically at greater risk for peripheral arterial disease (PAD), having an adjusted odds ratio of 2.5 for reduced ankle-brachial index prevalence based on the National Health and Nutrition Examination Survey, 1999-2000.5 Utilizing data from the Atherosclerosis Risk in Communities study, patients with CKD (GFR ≤60 mL/min/1.73 cm2) were identified as having an incident PAD relative risk (RR) of 1.56 after adjusting for demographic and cardiovascular risk factors.6 A large series on endovascular outcomes for the treatment of critical limb ischemia (CLI) in patients with kidney insufficiency is lacking.7

Although patients with kidney disease are evidently at greater risk for the development of lower extremity arterial disease, the impact of kidney disease on outcomes following surgical intervention is not as clearly defined. Numerous retrospective surgical series have consistently identified end-stage renal disease as a significant risk factor for increased mortality and limb loss following surgical bypass.8, 9, 10, 11, 12, 13, 14, 15, 16 By comparison, relatively little data have been reported on the outcomes of patients with advanced kidney disease following endoluminal revascularization. The goal of this study was to define patency and limb salvage outcomes for superficial femoral artery (SFA) endoluminal interventions across the spectrum of kidney disease defined by estimated GFR (eGFR).

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Methods 

Study Design 

A database of patients undergoing percutaneous transluminal angioplasty (PTA) and/or stenting of the SFA between 1986 and 2007 was queried. Patients were categorized preoperatively by eGFR <=60 or >60 mL/min/1.73 cm2. Intention-to-treat analysis was performed. Results were standardized to Second TransAtlantic Inter-Society Consensus (TASC-II)17 and Society for Vascular Surgery (SVS) criteria.18 Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables.

Methodology 

For each patient identified, demographics, symptoms, existing comorbid conditions, and risk factors for atherosclerosis were identified. All patients with claudication were encouraged to exercise daily, and their risk factors were identified and corrected through their primary care providers. Those patients who developed tissue loss or deteriorating symptoms on these regimens were offered endoluminal intervention. Patients with critical ischemia were treated within the same hospitalization. Therapy for individual patients was dictated by individual attending physician preference and was not regulated by unit guidelines. All patients received aspirin daily (81 or 325 mg) as a general cardiovascular protection agent. Noninvasive studies were performed initially; however, patients with serious symptoms or signs of severe stenosis/occlusion based upon the initial noninvasive tests received angiograms. Angiograms and angiographic reports were reviewed, lesions were categorized under the TASC-II system, and the preoperative distal runoff was scored. Angioplasty was performed under systemic heparin administration (40-60 units/kg), and completion angiography was performed to assess the technical result. Stents were utilized (at the discretion of the operator) for flow-limiting dissections (grade C or higher), intimal flaps, acute occlusions, or poor technical results (≥50% residual stenosis). No procedures or interventions were performed that could have potentially jeopardized the outflow vessel. Patients who had a successful endoluminal intervention received 75 mg of clopidogrel. While a patient was on clopidogrel, aspirin therapy was maintained at 81 mg/day. Patients who were already on clopidogrel prior to the intervention were left on clopidogrel after the intervention. Patients underwent routine duplex follow-up at 1, 3, and 6 months after the procedure and every 6 months thereafter. During follow-up, angiograms were performed only if noninvasive studies suggested restenosis/occlusion and the patient was symptomatic.

Definitions 

Coronary artery disease was defined as a history of angina pectoris, myocardial infarction, congestive heart disease, or prior coronary artery revascularizations. Cerebrovascular disease was defined as a history of stroke, transient ischemic attack, or carotid artery revascularization. The TASC-II classification of disease severity for femoral lesions was used to define the categories of lesions. GFR was estimated from the abbreviated equation developed using data from the Modification of Diet in Renal Disease study19, 20 as follows: eGFR = 186.3 ∗ (serum creatinine)-1.154 ∗ age-0.203 ∗ 0.742 (if the individual is female) ∗ 1.212 (if the individual is African American). A death within 30 days of the procedure was considered “procedure-related.” A major complication was defined as any event, regardless of how minimal, not routinely observed after endoluminal therapy that required treatment with a therapeutic intervention or rehospitalization within 30 days of the procedure. Runoff at the tibial level was determined by the number of patent vessels present with a maximum of 3 (scored as 0, 1, 2, or 3) and by a modified SVS scoring system.21

Statistical Analysis 

The data set was reported by GFR <=60 or >60 mL/min/1.73 cm2. Measured values are reported as percentages or means ± standard deviation (SD). Patency and limb salvage rates were calculated using Kaplan-Meier analysis and reported using current SVS criteria.18 Standard errors were reported in Kaplan-Meier analyses. Cox proportional hazard analyses were performed to identify factors associated with outcomes. Analyses were performed using JMP software, version 7.0.1 (SAS Institute, Cary, NC).

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Results 

Patient Population 

Eight hundred and thirty seven limbs in 635 patients underwent endoluminal treatment of the SFA over the study period (Table I). Patients with eGFR ≤60 mL/min/1.73 cm2 were older and had more coronary artery disease, congestive heart failure, diabetes mellitus, hypothyroidism, and hyperlipidemia. Of this group 51% had CLI (Table I). There was an equivalent TASC-II lesion distribution between the groups, but tibial runoff was significantly worse in the eGFR ≤60 mL/min/1.73 cm2 group (Table II). In addition, there were more concomitant inflow and outflow interventions in the eGFR <=60 mL/min/1.73 cm2 group (Table II).

Table I. Characteristics and presentation of patients
GFR >60GFR <60
Demographics
Patients345290
Limbs treated450387
% Male64%64%
Average age (years)66 ± 1469 ± 12∗
Presenting symptoms
Claudication67%49%∗
Critical ischemia33%51%∗
Rest pain13%21%∗
Tissue loss20%30%∗
Comorbidities
Current smoker18%9%∗
History of myocardial infarction40%52%∗
Congestive heart failure18%37%∗∗
Hypertension79%87%
Diabetes mellitus41%62%∗
Cerebrovascular disease12%14%
Hypothyroidism6%12%∗∗
Hyperlipidemia58%68%∗

∗p < 0.05.

∗∗p < 0.01 compared to eGFR >60 mL/min/1.73 cm2.

Table II. Location of disease, TASC category, tibial runoff, and adjunctive procedures
GFR >60GFR <=60
Anatomic location
Proximal SFA34%35%
Mid-SFA46%48%
Distal SFA52%52%
Popliteal28%40%∗
TASC II
A38%33%
B23%32%
C24%21%
D16%14%
Tibial runoff
Tibial runoff2.1 ± 0.041.9 ± 0.04∗
SVS runoff score5.3 ± 0.26.0 ± 0.2∗
Adjunct procedures
Use of intravascular stents17%15%
Aortoiliac intervention12%6%∗∗
Tibial intervention6%9%∗
Thrombolysis/embolectomy6%8%

∗p < 0.05.

∗∗p < 0.01 compared to eGFR >60 mL/min/1.73 cm2.

Short-Term Outcomes 

Mortality was equivalent between the two groups. However, those patients with eGFR <30 mL/min/1.73 cm2 or on hemodialysis had a 2% mortality rate. There was a significant increase in morbidity (systemic and access-related) in the <=60 group compared to the >60 (Table III).

Table III. Complications
GFR >60GFR <=60
30-day mortality1%1%
Morbidity9%13%∗
Systemic1%4%∗
Site-specific8%8%
Access-specific2%4%∗

∗p < 0.05 compared to eGFR >60 mL/min/1.73 cm2.

Hemodynamic success was better in the ≤60 compared to the >60 eGFR group (54% vs. 46%, p < 0.05). The majority of patients in both eGFR groups reported equivalent symptom improvement or resolution (83% vs. 86% for <=60 vs. >60). There were a small number of cases where in situ thrombosis or distal embolization occurred (Table III). In these cases, thrombolysis and embolectomy were required. There was no difference between the two groups.

Longer-Term Outcomes 

In patients with claudication, there was no difference in patency or limb salvage between those with eGFR >60 and <=60 mL/min/1.73 cm2, with 5-year cumulative patency being 78 ± 4% and 79 ± 5% and 5-year limb salvage being 95 ± 3% and 92 ± 5%, respectively (Fig. 1). In patients with CLI, there was no difference in patency between those with eGFR >60 and <=60 mL/min/1.73 cm2, with 5-year cumulative patency being 63 ± 8% and 63 ± 9%, respectively (Fig. 2A-C). Limb salvage was worse in patients with eGFR <=60 compared to eGFR >60 mL/min/1.73 cm2, with 4-year limb salvage being 48 ± 8% and 62 ± 9%, respectively (Fig. 2D). There was a notable number of inflow and outflow interventions performed in both groups. We therefore examined the cohort patients who exclusively underwent SFA interventions (Fig. 3, Fig. 4). There were significant differences between the claudication and critical ischemia groups for patency (5-year cumulative patency: claudication, 77 ± 4% and 82 ± 5%, and CLI, 67 ± 9% and 60 ± 9% for eGFR >60 and <=60, respectively) and limb salvage (5-year salvage: claudication, 90 ± 6% and 93 ± 5%, and CLI, 67 ± 9% and 47 ± 9% for eGFR >60 and <=60, respectively) in this subset similar to the entire population. When this subset was separated by symptom (claudication and critical ischemia) and eGFR (<=60 vs. >60 mL/min/1.73 cm2), eGFR did not predict a difference in patency (Fig. 3, Fig. 4). However, while limb salvage was equivalent in the claudication group between the two eGFR groups, it was markedly different in the critical ischemia group between patients with eGFR <=60 vs. >60 mL/min/1.73 cm2 (p < 0.01).

  • View full-size image.
  • Fig. 1 

    All patients with claudication. Life-table analysis of all patients (SFA and adjunctive interventions) presenting with claudication grouped by eGFR ≤60 and >60 mL/min/1.73 cm2. Data are the mean and standard error of the mean, and numbers at risk are shown in the table. A Primary patency, B assisted primary patency, C secondary patency, D limb salvage.

  • View full-size image.
  • Fig. 2 

    All patients with CLI. Life-table analysis of all patients (SFA and adjunctive interventions) presenting with CLI grouped by eGFR ≤60 and >60 mL/min/1.73 cm2. Data are the mean and standard error of the mean, and numbers at risk are shown in the table. A Primary patency, B assisted primary patency, C secondary patency, D limb salvage.

  • View full-size image.
  • Fig. 3 

    SFA interventions only: patients with claudication. Life-table analysis of all patients (SFA interventions only) presenting with claudication grouped by eGFR ≤60 and >60 mL/min/1.73 cm2. Data are the mean and standard error of the mean, and numbers at risk are shown in the table. A Primary patency, B assisted primary patency, C secondary patency, D limb salvage.

  • View full-size image.
  • Fig. 4 

    SFA interventions only: patients with CLI. Life-table analysis of all patients (SFA interventions only) presenting with CLI grouped by eGFR ≤60 and >60 mL/min/1.73 cm2. Data are the mean and standard error of the mean, and numbers at risk are shown in the table. A Primary patency, B assisted primary patency, C secondary patency, D limb salvage.

Factors Affecting Outcome 

Cox proportional hazards analysis was undertaken to investigate the impact of pre- and perioperative factors related to outcomes of patency as well as limb salvage between the claudication and critical ischemia groups subdivided by eGFR. No comorbid conditions affected primary patency. Lesion calcification (RR = 2.62, p < 0.01), TASC C or D lesion categorization (RR = 2.44, p < 0.01), acute occlusion at the initial intervention (RR = 3.81, p < 0.01), and tissue loss at presentation (RR = 7.38, p = 0.02) were significantly associated with reductions in primary patency. Factors significantly associated with a reduction in assisted primary and secondary patency also included calcification (RR = 6.31, p < 0.01), TASC C or D lesions (RR = 4.20, p < 0.01), acute occlusion at the initial intervention (RR = 4.37, p < 0.01), and tissue loss at presentation (RR = 7.43, p < 0.01). Tibial runoff of 0 or 1 and modified SVS score >8 were also associated with a reduction in assisted primary and secondary patency (RR = 3.72, p < 0.05). The use of stents was not significant. With respect to limb salvage, six factors were significantly associated with a reduction in rates: presence of tissue loss at presentation (RR = 6.45, p = 0.003), 0 or 1 vessel tibial runoff (RR = 2.56, p < 0.01), progression of distal disease noted in follow-up (RR = 4.62, p < 0.01), embolization at the initial intervention (RR = 2.70, p < 0.05), diabetes mellitus (RR = 3.71, p < 0.01), and a history of congestive heart disease (RR = 2.42, p < 0.01). Notable factors that were not significantly associated included lesion calcification (p = 0.64), TASC C or D lesion categorization (p = 0.99), acute occlusion at initial intervention (p = 0.40), and adjuvant stenting (p = 0.67).

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Discussion 

The current study demonstrates that CKD appears to have little impact on SFA interventions in patients presenting with claudication, in part because patients with minimal renal impairment present with claudication while patients with more severe renal impairment present with critical ischemia. Despite a large number of patients undergoing adjunctive inflow and outflow procedures, patency of SFA interventions was still dependent on the presenting symptoms irrespective of eGFR. In contrast, renal impairment does significantly influence limb salvage in CLI.

As noted by others,14, 22, 23 we found that the preponderance of patients with advanced renal disease presented with CLI. These results are qualitatively similar to other published reports on infrainguinal bypass for patients with varied levels of renal dysfunction.22, 23, 24, 25 Given the demonstrated safety profile of endoluminal intervention in other patient populations, it has been suggested by some authors26 that such intervention in patients with advanced renal dysfunction might mitigate some of the inherent perioperative mortality risk associated with infrainguinal bypass. While we did not have an open surgical cohort in this series, we did find a low periprocedural mortality in the endoluminally treated patients, with 30-day mortality of 1% in patients with low eGFR; those patients with eGFR <30 or on hemodialysis had a 2% mortality rate. These results are better than those of Graziani et al.,26 who encountered a 30-day mortality of 8% among 107 dialysis patients following PTA for ischemia, and the Veterans Affairs’ National Surgical Quality Improvement Program data reported by O'Hare and colleagues,22 demonstrating 10% 30-day mortality for both dialysis-dependent patients and those with GFR <30 mL/min not requiring dialysis. Another report comparing angioplasty and bypass showed that when compared to patients who underwent angioplasty the risk of all-cause, cardiac, and infectious mortality was greater among patients who underwent bypass.27 These data, therefore, suggest an immediate advantage to endoluminal intervention for patients with renal impairment. However, we did note a >10% morbidity rate in patients with advanced renal impairment, which appeared to be driven by systemic and access site complications.

In a 2004 study of 800 patients undergoing an initial revascularization procedure by surgical bypass or angioplasty, the overall incidence of subsequent amputation was 16.3/100 person-years, 22.6 for bypass and 5.7 for angioplasty. After adjustment for patient characteristics, the risk of amputation was higher for bypass versus angioplasty (relative hazard [RH] = 4.00, 95% confidene interval 2.46-6.57).27

Previous reports on bypass have demonstrated higher rates of limb salvage at 1 year for National Kidney Foundation stage 4 patients (88%)23 and dialysis-dependent patients (71-78%).23, 28 Similarly, Graziani et al.26 reported 1-year limb salvage of 86% following PTA. Potentially confounding our results is a higher rate of diabetes mellitus in this study (85-87% of CLI patients with eGFR ≤60 mL/min/1.72 cm2) relative to the rate reported in the aforementioned studies (53-59%).23, 26 Diabetes has previously been reported to significantly impact limb salvage rates following endoluminal therapy in CLI.29, 30 Additional confounding variables may include different rates of tissue ulceration, gangrene, and active infection-which were not specifically defined for our study-and tibial runoff, both of which have been associated with diminished outcomes.22, 23, 24 Furthermore, we have demonstrated that runoff will significantly impact the outcomes of intervention in CLI.21 When we examined limb salvage as a function of eGFR ≤60 and >60 mL/min/1.73 cm2, we found that eGFR ≤60 was associated with a lower limb salvage rate whether we examined the entire cohort or the subgroup where only SFA intervention was performed. These data suggest that while limb savage is poor in CLI, the added effect of eGFR <=60 mL/min/1.73 cm2 does impact limb salvage but that these efforts have a lower perioperative mortality.

A recent meta-analysis reported 1-year primary and secondary patencies of 75% and 81%, respectively, for end-stage renal disease patients undergoing infrainguinal bypass.28 In our data set, 1-year primary patency was 86% for claudication and 69% for CLI in patients with eGFR <=60 mL/min/1.73 cm2. One-year secondary patency was 90% for claudication and 75% for CLI in patients with eGFR <=60 mL/min/1.73 cm2. The patencies in claudication and CLI were similar to the >60 mL/min/1.73 cm2 group. At 5 years patients with claudication had primary and secondary patencies of 63% and 82%, respectively, in those with eGFR <=60 mL/min/1.73 cm2. For CLI the primary and secondary patencies were 49% and 59%, respectively, in patients with eGFR <=60 mL/min/1.73 cm2. Five-year primary and secondary patencies in the >60 mL/min/1.73 cm2 claudication and CLI groups were equivalent. If those patients who underwent SFA intervention only were analyzed, similar conclusions are drawn. It appears that eGFR did not influence the anatomic patency of interventions on the SFA and that our cumulative results are as durable as those reported for bypass in this population with a lower morbidity.

It should be noted that the data discussed in this report represent a retrospective analysis of unselected, nonrandomized patients. The presence of selection bias is therefore possible, if not expected. In practice, patients are often referred/considered for endoluminal intervention because of their constellation of comorbidities. This may lead to intervention on more complex patients with more complex systemic vascular disease, leading to diminished reported outcomes as a consequence of the unique patient population. Conversely, some patients are not considered for endoluminal intervention because of diffuse and complicated vascular pathology thought to preclude such therapy. This may in turn lead to out-migration of these complicated patients, artificially inflating outcomes. Unfortunately, we cannot currently make any judgment concerning the relative contribution of either phenomenon based on the available data.

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Conclusions 

Patients presenting for SFA intervention with claudication generally have minimal renal impairment, while patients with critical ischemia are more likely to have more severe renal impairment. Chronic renal disease does not appear to impact the patency of SFA interventions. Limb salvage in patients with critical ischemia are significantly worse when eGFR is <=60 mL/min/1.73 cm2. The factors significantly associated with poor limb salvage in the low eGFR group were the presence of tissue loss at presentation, poor vessel tibial runoff, progression of distal disease, embolization at the initial intervention, diabetes mellitus, and a history of congestive heart disease.

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References 

  1. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;17:2038–2047
  2. Foley RN, Collins AJ. End-stage renal disease in the United States: an update from the United States Renal Data System. J Am Soc Nephrol. 2007;18:2644–2648
  3. Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension. 2003;42:1050–1065
  4. Shulman NB, Ford CE, Hall WD, et al. Prognostic value of serum creatinine and effect of treatment of hypertension on renal function. Results from the hypertension detection and follow-up program. The Hypertension Detection and Follow-up Program Cooperative Group. Hypertension. 1989;13(Suppl):180–193
  5. O'Hare AM, Glidden DV, Fox CS, Hsu CY. High prevalence of peripheral arterial disease in persons with renal insufficiency: results from the National Health and Nutrition Examination Survey 1999-2000. Circulation. 2004;108:320–323
  6. Wattanakit K, Folsom AR, Selvin E, et al. Kidney function and risk of peripheral arterial disease: results from the Atherosclerosis Risk in Communities (ARIC) Study. J Am Soc Nephrol. 2007;18:629–636
  7. Casserly IP. Interventional management of critical limb ischemia in renal patients. Adv Chronic Kidney Dis. 2008;15:384–395
  8. Biancari F, Kantonen I, Matzke S, et al. Infrainguinal endovascular and bypass surgery for critical leg ischemia in patients on long-term dialysis. Ann Vasc Surg. 2002;15:210–214
  9. Cox MH, Robison JG, Brothers TE, Elliott BM. Contemporary analysis of outcomes following lower extremity bypass in patients with end-stage renal disease. Ann Vasc Surg. 2001;15:374–382
  10. Georgopoulos S, Filis K, Vourliotakis G, et al. Lower extremity bypass procedures in diabetic patients with end-stage renal disease: is it worthwhile?. Nephron Clin Pract. 2005;99:c37–c41
  11. Kimura H, Miyata T, Sato O, et al. Infrainguinal arterial reconstruction for limb salvage in patients with end-stage renal disease. Eur J Vasc Endovasc Surg. 2003;25:29–34
  12. Lantis JC, Conte MS, Belkin M, et al. Infrainguinal bypass grafting in patients with end-stage renal disease: improving outcomes?. J Vasc Surg. 2001;33:1171–1178
  13. Meyerson SL, Skelly CL, Curi MA, et al. Long-term results justify autogenous infrainguinal bypass grafting in patients with end-stage renal failure. J Vasc Surg. 2001;34:27–33
  14. Ramdev P, Rayan SS, Sheahan M, et al. A decade experience with infrainguinal revascularization in a dialysis-dependent patient population. J Vasc Surg. 2002;36:969–974
  15. Reddan DN, Marcus RJ, Owen WFJ, et al. Long-term outcomes of revascularization for peripheral vascular disease in end-stage renal disease patients. Am J Kidney Dis. 2001;38:57–63
  16. Whittemore AD, Donaldson MC, Mannick JA. Infrainguinal reconstruction for patients with chronic renal insufficiency. J Vasc Surg. 1993;17:32–41
  17. TASC II Working Group. TASC-II: Inter-Society Consensus for the management of peripheral vascular arterial disease. J Vasc Surg. 2007;45(Suppl):S1–S67
  18. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–538
  19. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130:461–470
  20. National Kidney Foundation . K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl. 1):S1–S266
  21. Davies MG, Saad WE, Peden EK, Mohiuddin IT, Naoum JJ, Lumsden AL. Impact of runoff on superficial femoral artery endoluminal interventions for rest pain and tissue loss. J Vasc Surg. 2008;48(3):619–625
  22. O'Hare AM, Feinglass J, Sidawy AN, et al. Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs' National Surgical Quality Improvement Program. J Am Soc Nephrol. 2003;14:1287–1295
  23. O'Hare AM, Sidawy AN, Feinglass J, et al. Influence of renal insufficiency on limb loss and mortality after initial lower extremity surgical revascularization. J Vasc Surg. 2004;39:709–716
  24. O'Hare AM, Bertenthal D, Shlipak MG, et al. Impact of renal insufficiency on mortality in advanced lower extremity peripheral arterial disease. J Am Soc Nephrol. 2005;16:514–519
  25. Owens CD, Ho KJ, Kim S, et al. Refinement of survival prediction in patients undergoing lower extremity bypass surgery: stratification by chronic kidney disease classification. J Vasc Surg. 2007;45:944–952
  26. Graziani L, Silvestro A, Bertone V, et al. Percutaneous transluminal angioplasty is feasible and effective in patients on chronic dialysis with severe peripheral artery disease. Nephrol Dial Transplant. 2007;22:1144–1149
  27. Jaar BG, Astor BC, Berns JS, Powe NR. Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients. Kidney Int. 2004;65:613–620
  28. Albers M, Romiti M, De Luccia N, et al. An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. J Vasc Surg. 2007;45:536–542
  29. O'Hare AM, Bertenthal D, Sidawy AN, et al. Renal insufficiency and use of revascularization among a national cohort of men with advanced lower extremity peripheral arterial disease. Clin J Am Soc Nephrol. 2006;1:297–304
  30. Bakken AM, Palchik E, Hart JP, Rhodes JM, Saad WE, Davies M. Impact of diabetes on the outcomes of superficial femoral artery endoluminal interventions. J Vasc Surg. 2007;46:946–958

 Presented in part at the Peripheral Vascular Surgery Society Winter Meeting, Park City, UT, January 27–29, 2006.

PII: S0890-5096(08)00417-2

doi:10.1016/j.avsg.2008.11.010

Annals of Vascular Surgery
Volume 23, Issue 5 , Pages 560-568, September 2009

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