Lower Extremity Bypass Procedures in Diabetic Patients with End-Stage Renal Disease: Is It Worthwhile?

Abstract

Backgroud/Aims: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. Methods: A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. Results: Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1–93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. Conclusion: Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.

The Diabetic Foot in End Stage Renal Disease

“…[83] Another group performed infra-inguinal or axillofemoral bypass surgery in diabetic patients with ESRD. [84] Survival was 63% at one year and 45% at two years, while limb salvage rate was 65% at one year. Primary graft patency rates were 64% at one year and 58% at three years.…”

“…Primary graft patency rates were 64% at one year and 58% at three years. [84] Improved limb salvage and patient survival rates, as well as reduced time to heal, have been accomplished by appropriate revascularization (angioplasty, femoro-popliteal, femoral-distal, popliteal-distal bypass surgery). [85] The department of vascular surgery at Beth Israel Deaconess Medical Center in Boston has reported primary graft patency rates of 84% and 64% at one and three years, respectively.…”

Evaluation of the Paramalleolar Bypass for Critical Limb Ischemia Patients on Hemodialysis with Diabetes Mellitus and Chronic Renal Failure

“…7) According to other reports, also, the survival rate was low in patients on hemodialysis, but the graft patency rate was not inferior, and the results of bypass surgery for limb salvage were reasonable, encouraging aggressive revascularization. [8][9][10][11][12] In patients with DM and those undergoing HD, the obstructive lesion is often located in a lower leg artery and is accompanied by marked calcification. Therefore, a sufficient blood supply to the foot by dorsalis pedis, posterior tibial, or plantar artery bypass surgery using a venous graft, which is obtained primarily from the greater saphenous vein, is necessary.…”

Impact of Femoropopliteal Bypass Surgery on the Survival and Amputation Rate of End-Stage Renal Disease Patients with Critical Limb Ischemia

“…While some investigators have found that bypass surgery may be beneficial to this patient population, others could not support this finding. Georgopoulos et al [1] have found that the limb salvage rate in patients with ESRD and diabetes justifies limb revascularization, despite the decreased survival of this population. Treiman et al [2] stated that patients with impaired renal function are at increased risk for treatment failure due to potential impaired wound healing, but they nonetheless should not be denied revascularization surgeries, since the wounds may successfully heal.…”