Infrainguinal bypass grafting in patients with end-stage renal disease and critical limb ischaemia:: is it worthwhile?

Patients with end-stage renal disease (ESRD) constitute an increasing proportion of patients undergoing infrainguinal bypass surgery for critical limb ischaemia (CLI). The aim of this retrospective study was to determine graft patency, healing of pedal lesions, limb salvage and survival following infrainguinal arterial reconstruction in this high-risk subset of patients. 34 patients with ESRD undergoing 37 bypass procedures for CLI (rest pain 2; tissue loss 35) were identified from the vascular registry. These included 13 femoropopliteal and 24 femorotibial bypasses with autogenous (67.6%) or prosthetic (32.4%) materials. The median age in this series was 62 years and 79% were diabetics. Using life-table analysis, the cumulative primary patency rate was 88% at 1 month and 81% at 2 years. The resulting limb salvage rate amounted to 94 and 86% at 1 month and 2 years, respectively. Healing of the pedal lesions was accomplished in only 50% of patients at 6 months. Toe lesions could be treated more successfully than forefoot and deep heel defects (p = 0.04). With a perioperative mortality of 3/37 cumulative survival rate declined to 21% at 2 years. Late mortality correlated significantly with a history of previous myocardial infarction or congestive heart failure (p = 0.001). Infrainguinal revascularisation can be performed in dialysis-dependent patients with acceptable patency and limb salvage rates. However, bypass grafting should be mainly reserved to patients without severe cardiac disease and to those without extensive tissue loss.