Realistic expectations for pedal bypass grafts in patients with end-stage renal disease

Leers, Steven A.; Reifsnyder, Thomas; Delmonte, Rick; Caron, Michele

doi:10.1016/s0741-5214(98)70023-0

Cited by 78 publications

(69 citation statements)

References 17 publications

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“…The renal patient presents with unanimously recognized severe CLI features and consequent difficult revascularization patterns (Casserly, 2008;Conrad et al, 2009;Leers et al, 1998;Norgreen et al, 2007). A vast amount of contemporary literature shows the poor outcome commonly noted after surgical or endovascular arterial reconstruction in these patients (Arvela et al, 2010;Black et al, 2005;Casserly, 2008;Conrad et al, 2009;Leers et al, 1998).…”

Section: Discussionmentioning

confidence: 99%

“…A vast amount of contemporary literature shows the poor outcome commonly noted after surgical or endovascular arterial reconstruction in these patients (Arvela et al, 2010;Black et al, 2005;Casserly, 2008;Conrad et al, 2009;Leers et al, 1998). As the revascularization seems however feasible, particularly aggressive atherosclerosis coupled to long segment chronic occlusions, calcifications and depleted run-off, make further arterial patency and limb preservation quite questionable in ESRD subjects (Arvela et al, 2010;Black et al, 2005;Casserly, 2008;Leers et al, 1998). These poor clinical results are often associated with a high co-morbidity and mortality, independently from diabetes and other cardio-vascular risk factors (Leers et al, 1998;Mlekusch et al, 2004;Norgreen et al, 2007).…”

Section: Discussionmentioning

confidence: 99%

“…As the revascularization seems however feasible, particularly aggressive atherosclerosis coupled to long segment chronic occlusions, calcifications and depleted run-off, make further arterial patency and limb preservation quite questionable in ESRD subjects (Arvela et al, 2010;Black et al, 2005;Casserly, 2008;Leers et al, 1998). These poor clinical results are often associated with a high co-morbidity and mortality, independently from diabetes and other cardio-vascular risk factors (Leers et al, 1998;Mlekusch et al, 2004;Norgreen et al, 2007). Similar observations were described in the diabetic CLI context that adds the metabolic and neuropathic background, local sepsis, poor immune response and variable amounts of foot tissue loss (Abou-Zamzam et al, 2007;Apelqvist et al, 1993;Norgreen et al, 2007).…”

Section: Discussionmentioning

confidence: 99%

“…While non-diabetic subjects seem to express intima-layer, eccentric and patchy wall arterial calcifications, prevailing in the coronary also the peripheral vessels (the « type I » calcifications) (Irvin & Guzman, 2009), the diabetic also ESRD patients have media-layer, concentric and rather continuous wall calcifications (the "Mönckeberg sclerosis" or « type II » calcifications) (Irvin & Guzman, 2009). These particularly dense « type II » calcific deposits featuring the below-knee arterial trunks were independently associated with more severe CLI presentations (Irvin & Guzman, 2009 ;Leskinen et al, 2002), requiring additional technical challenges (Abou-Zamzam et al, 2007;Alexandrescu et al, 2011;Casserly, 2008;Leers et al, 1998) and consequent higher technical failures. They were also connected with low patency and discouraging limb loss rates (Casserly, 2008;Combe et al, 2009;Leers et al, 1998;Ohtake et al, 2011).…”

Section: Discussionmentioning

confidence: 99%

“…Although revascularization indisputably represents the primary therapy for limb salvage (Casserly, 2008;Conrad et al, 2009;Norgreen et al, 2007), renal patients seem to require strikingly more challenging interventions, that focus hostile and diffusely diseased leg segments (Andreoli et al, 2008;Casserly, 2008;Conrad et al, 2009;Randon et al, 2010). Literature on arterial reconstruction (surgical and endovascular) reveals poor patency, tissue recovery and limb preservation data, coupled to high short and mid-term mortality rates for ESRD subjects (independently from other cardio-vascular risk factors) (Abou-Zamzam et al, 2007;Bradbury et al, 2010;Casserly, 2008;Leers et al, 1998). Similar observations were independently documented in diabetic ischemic limbs that have the metabolic and neuropathic background, local sepsis and important amount of tissue loss (Apelqvist et al, 1993;Dormandy et al, 1999;Edmonds, 2008;Norgreen et al, 2007).…”

Section: Introductionmentioning

confidence: 99%

See 4 more Smart Citations

Is Limb Loss Always Inevitable for Critical Neuro-Ischemic Foot Wounds in Diabetic Patients with End Stage Renal Disease and Unfit for Vascular Reconstructions?

Alexandrescu¹

2012

Diseases of Renal Parenchyma

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Is Limb Loss Always Inevitable for Critical Neuro-Ischemic Foot Wounds in Diabetic Patients with End Stage Renal Disease and Unfit for Vascular Reconstructions?

Alexandrescu¹

2012

Diseases of Renal Parenchyma

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Patency and Limb Salvage After Infrainguinal Bypass With Severely Compromised ("Blind") Outflow

et al. 2001

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Infrainguinal graft patency and limb salvage are adversely affected by severely compromised outflow. Design: Retrospective review of all infrainguinal bypass procedures performed at a single institution during a 5-year period. Setting: University teaching hospital. Patients: Two hundred seventy-four patients underwent infrainguinal bypass for limb salvage (351 grafts in 307 limbs). Interventions: All infrainguinal bypasses originated from a femoral artery. The distal anastomosis in 279 grafts was located in an artery with at least 1 patent outflow vessel with anatomically normal end-artery runoff (Society for Vascular Surgery/International Society for Cardiovascular Surgery ad hoc committee runoff score, 1-9). The distal anastomosis of 72 grafts was located in an artery with only collateral outflow ("blind bypass"; runoff score, 10). Main Outcome Measures: Perioperative morbidity and mortality, primary-assisted and secondary graft patency, limb salvage, and survival. Results: All data are presented as mean±SEM. Patients undergoing blind bypass were older (age, 70±2 vs 66±1 years; P Ͻ.05) and had a higher incidence of hypertension (90% vs 70%; P Ͻ.05) and end-stage renal disease (24% vs 13%; P Ͻ.05). Comparing patients undergoing blind bypass to bypass with at least 1 patent outflow vessel, there were no differences in the use of nonautogenous conduits (50% vs 59%; P =.21) or postoperative warfarin (30% vs 32%; P=.69), or in perioperative mortality rates (2.7% vs 3.2%; P =.79). After a median follow-up of 13 months (range, 0-60 months), 2-year secondary graft patency for the entire group was 63% ± 4%. The secondary patency rate of blind bypass grafts was no different from that of grafts with at least 1 patent outflow vessel (67% ± 7% vs 64% ± 4%; P was not significant). However, the 2-year limb salvage rate in limbs with blind outflow was significantly worse than in limbs with at least 1 patent outflow vessel (67% ± 7% vs 76% ± 3%; P=.04). Conclusion: Acceptable long-term patency rates can be achieved in infrainguinal bypass grafts with blind outflow, although blind outflow remains a marker for subsequent limb loss in the chronically ischemic leg.

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Peripheral arterial disease in diabetic patients with renal insufficiency: a review

Lepäntalo

Fiengo

Biancari

2012

Diabetes Metabolism Res

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SummaryPeripheral arterial disease is common among diabetic patients with renal insufficiency, and most of the diabetic patients with end-stage renal disease (ESRD) have peripheral arterial disease. Ischaemia is probably overrepresented as an etiological factor for a diabetic foot ulcer in this group of patients compared with other diabetic patients. ESRD is a strong risk factor for both ulceration and amputation in diabetic patients. It increases the risk of nonhealing of ulcers and major amputation with an OR of 2.5-3. Renal disease is a more important predictor of poor outcome after revascularizations than commonly expected. Preoperative vascular imaging is also affected by a number of limitations, mostly related to side effects of contrast agents poorly eliminated because of kidney dysfunction. Patients with renal failure have high perioperative morbidity and mortality. Persistent ischaemia, extensive infection, forefoot and heel gangrene, poor run-off, poor cardiac function, and the length of dialysis-dependent renal failure all affect the outcome adversely. Despite dismal overall outcome, recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65-75% after revascularization among survivors. High 1-year mortality of 38% reported in a recent review has to be taken into consideration, though. The preferential use of endovascular-first approach is attractive in this vulnerable multimorbid group of patients, but the evidence for endovascular treatment is very scarce. The need for complete revascularization of the foot may be even more important than in other patients with ischaemic ulcerated diabetic foot because there are a number of factors counteracting healing in these patients. Typically, half of the patients are reported to lose their legs despite open bypass. To control tissue damage and improve chances of ulcer healing, one should understand that early referral to vascular consultation is necessary.

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Realistic expectations for pedal bypass grafts in patients with end-stage renal disease

Cited by 78 publications

References 17 publications

Is Limb Loss Always Inevitable for Critical Neuro-Ischemic Foot Wounds in Diabetic Patients with End Stage Renal Disease and Unfit for Vascular Reconstructions?

Is Limb Loss Always Inevitable for Critical Neuro-Ischemic Foot Wounds in Diabetic Patients with End Stage Renal Disease and Unfit for Vascular Reconstructions?

Patency and Limb Salvage After Infrainguinal Bypass With Severely Compromised ("Blind") Outflow

Peripheral arterial disease in diabetic patients with renal insufficiency: a review

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