Nationwide Trends in Hospital Outcomes and Utilization After Lower Limb Revascularization in Patients on Hemodialysis

Abstract

Objectives: This study aimed to describe the temporal trends and outcomes of endovascular and surgical revascularization in a large, nationally representative sample of patients with end-stage renal disease on hemodialysis hospitalized for peripheral artery disease (PAD).

Background: PAD is prevalent among patients with end-stage renal disease on hemodialysis and is associated with significant morbidity and mortality. There is a paucity of information on trends in endovascular and surgical revascularization and post-procedure outcomes in this population.

Methods: We used the Nationwide Inpatient Sample (2002 to 2012) to identify hemodialysis patients undergoing endovascular or surgical procedures for PAD using diagnostic and procedural codes. We compared trends in amputation, post-procedure complications, mortality, length of stay, and costs between the 2 groups using trend tests and logistic regression.

Results: There were 77,049 endovascular and 29,556 surgical procedures for PAD in hemodialysis patients. Trend analysis showed that endovascular procedures increased by nearly 3-fold, whereas there was a reciprocal decrease in surgical revascularization. Post-procedure complication rates were relatively stable in persons undergoing endovascular procedures but nearly doubled in those undergoing surgery. Surgery was associated with 1.8 times adjusted odds (95% confidence interval: 1.60 to 2.02) for complications and 1.6 times the adjusted odds for amputations (95% confidence interval: 1.40 to 1.75) but had similar mortality (adjusted odds ratio: 1.05; 95% confidence interval: 0.85 to 1.29) compared with endovascular procedures. Length of stay for endovascular procedures remained stable, whereas a decrease was seen for surgical procedures. Overall costs increased marginally for both procedures.

Conclusions: Rates of endovascular procedures have increased, whereas those of surgeries have decreased. Surgical revascularization is associated with higher odds of overall complications. Further prospective studies and clinical trials are required to analyze the relationship between the severity of PAD and the revascularization strategy chosen.

Keywords: hemodialysis; peripheral artery disease; revascularization procedures.

Figure 1. Trends in endovascular(A) and open revascularizations(B) by age

This figure demonstrates the temporal trends in the proportion of hospitalizations for different revascularization procedures among end-stage renal disease (ESRD) patients with peripheral artery disease (PAD), subdivided by age, across 2002–2012 in the United States. The dots represent the number of hospitalizations for a given procedure per 10,000 hospitalizations in given year for a given age group. Panel A pertains to endovascular revascularization and Panel B pertains to open revascularization.

Figure 2. Trends in endovascular(A) and open revascularization(B) by gender

This figure demonstrates the temporal trends in the proportion of hospitalizations for different revascularization procedures among end-stage renal disease (ESRD) patients with peripheral artery disease (PAD), subdivided by sex, across 2002–2012 in the United States. The dots represent the number of hospitalizations for a given procedure per 10,000 hospitalizations in a given year for a given sex. Panel A pertains to endovascular revascularization and Panel B pertains to open revascularization.

Figure 3. Trends in endovascular (A) and open (B) revascularization by All Patient Refined Diagnosis Related Group (APRDRG) status

This figure demonstrates the temporal trends in the proportion of revasculrization hospitalizations for end-stage renal disease (ESRD) patients with peripheral artery disease (PAD) with different All Patient Refined Diagnosis Related Group (APRDRG) Scores, across 2002–2012 in the United States. Panel A pertains to endovascular revascularization and Panel B pertains to open revascularization. The blue dots represent the proportion of hospitalizations for patients undergoing with APRDRG scores from 0 to 2, while the orange dots represent those with scores from 3 to 4.

Figure 4. Trends in mortality for endovascular and open revascularization

This figure demonstrates temporal trends in in-hospital mortality for revascularization hospitalizations among end-stage renal disease (ESRD) patients with peripheral artery disease (PAD) across the period 2002–2012 in the United States. The blue dots represent the incidence of in-hospital mortality for endovascular revascularization hospitalizations, while the orange dots represent in-hospital mortality for open revascularization hospitalizations.

Figure 5. Trends in amputation incidence for endovascular and open revascularization

This figure demonstrates the temporal trends in amputations for hospitalized end-stage renal disease (ESRD) patients with peripheral artery disease (PAD) undergoing endovascular and open revascularization across the period 2002–2012 in the United States. The blue and green dots represent the incidence of minor and major amputations respectively for those undergoing endovascular procedures, while the orange and red dots represent the incidence of minor and major amputations respectively for those undergoing open revascularization.

Figure 6. Trends in complications for endovascular (A) and open (B) revascularization

This figure demonstrates the temporal trends in complications for hospitalized end-stage renal disease (ESRD) patients with peripheral artery disease (PAD) undergoing endovascular and open revascularization across the period 2002–2012 in the United States. The blue dots represent the incidence of overall complications in a given year, whereas the various other colored dots each represent the incidence of a particular complication. Panel A pertains to endovascular procedures, while panel B refers to open revascularizations.

Figure 7. Trends in mean costs and length of stay for endovascular (A) and open (B) revascularization

This figure demonstrates the trends in length of stay (LoS) and cost of endovascular and open revascularizations for hospitalized end-stage renal disease (ESRD) patients with peripheral artery disease (PAD) across 2002–2012 in the United States. The orange dots represent LoS in days and the blue bars represent cost in US dollars. Panel A pertains to endovascular procedures, while panel B refers to open revascularizations.