Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Comparative Study
. 2024 Aug;80(2):480-489.e5.
doi: 10.1016/j.jvs.2024.04.016. Epub 2024 Apr 10.

Comparison of mortality and amputation after lower extremity bypass versus peripheral vascular intervention in patients with chronic limb-threatening ischemia and comorbid chronic kidney disease

Jacob Cleman  1 , Juan G Sierra  2 , Gaëlle Romain  1 , Bella Capuano  1 , Lindsey Scierka  1 , Santiago Callegari  1 , Francky Jacque  1 , Poghni Peri-Okonny  1 , Sameer Nagpal  3 , Kim G Smolderen  4 , Carlos Mena-Hurtado  5
Affiliations
Comparative Study

Comparison of mortality and amputation after lower extremity bypass versus peripheral vascular intervention in patients with chronic limb-threatening ischemia and comorbid chronic kidney disease

Jacob Cleman et al. J Vasc Surg. 2024 Aug.

Abstract

Objective: Comorbid chronic kidney disease (CKD) is associated with worse outcomes for patients with chronic limb-threatening ischemia (CLTI). However, comparative effectiveness data are limited for lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) in patients with CLTI and CKD. We aimed to evaluate (1) 30-day all-cause mortality and amputation and (2) 5-year all-cause mortality and amputation for LEB vs PVI in patients with comorbid CKD.

Methods: Individuals who underwent LEB and PVI were queried from the Vascular Quality Initiative with Medicare claims-linked outcomes data. Propensity scores were calculated using 13 variables, and a 1:1 matching method was used. The mortality risk at 30 days and 5 years in LEB vs PVI by CKD was assessed using Kaplan-Meier and Cox proportional hazards models, with interaction terms added for CKD. For amputation, cumulative incidence functions and Fine-Gray models were used to account for the competing risk of death, with interaction terms for CKD added.

Results: Of 4084 patients (2042 per group), the mean age was 71.0 ± 10.8 years, and 69.0% were male. Irrespective of CKD status, 30-day mortality (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.63-1.42, P = .78) was similar for LEB vs PVI, but LEB was associated with a lower risk of 30-day amputation (sub-HR [sHR]: 0.66, 95% CI: 0.44-0.97, P = .04). CKD status, however, did not modify these results. Similarly, LEB vs PVI was associated with a lower risk of 5-year mortality (HR: 0.79, 95% CI: 0.71-0.88, P < .001) but no difference in 5-year amputation (sHR: 1.03, 95% CI: 0.89-1.20, P = .67). CKD status did not modify these results.

Conclusions: Regardless of CKD status, patients had a lower risk of 5-year all-cause mortality and 30-day amputation with LEB vs PVI. Results may help inform preference-sensitive treatment decisions on LEB vs PVI for patients with CLTI and CKD, who may commonly be deemed too high risk for surgery.

Keywords: Bypass; Chronic limb-threatening ischemia; Comparative effectiveness; Endovascular; Peripheral artery disease.

PubMed Disclaimer

Conflict of interest statement

Disclosures C.M.-H. reports unrestricted research grants from Philips and Shockwave, and is a consultant for Abbott Vascular, Cook, Medtronic, and Terumo. K.G.S. reports unrestricted research grants from Philips, Merck, Shockwave, and Johnson & Johnson, and she is a consultant for Terumo, Cook, and Twill Inc. All other authors have no competing interests.

Figures

Figure 1.
Figure 1.
A Strengthening the Reporting in Observational studies in Epidemiology (STROBE) diagram for the analytic cohort Abbreviations: VQI, Vascular Quality Initiative; LEB, Lower extremity bypass; PVI, Peripheral vascular intervention; CKD, Chronic kidney disease
Figure 2.
Figure 2.
Kaplan-Meier Survival curves for 30-day all-cause mortality for LEB vs. PVI in A) Patients without CKD, B) Patients with non-severe CKD (CKD stage 3), and C) Patients with severe CKD (CKD stage 5 or 6) Abbreviations: LEB, Lower extremity bypass; PVI, Peripheral vascular intervention; CKD, Chronic kidney disease
Figure 3.
Figure 3.
Cumulative incidence functions for 30-day amputation for LEB vs. PVI in A) Patients without CKD, B) Patients with non-severe CKD (CKD stage 3), and C) Patients with severe CKD (CKD stage 5 or 6) Abbreviations: LEB, Lower extremity bypass; PVI, Peripheral vascular intervention; CKD, Chronic kidney disease
Figure 4.
Figure 4.
Kaplan-Meier Survival curves for 5-year all-cause mortality for LEB vs. PVI in A) Patients without CKD, B) Patients with non-severe CKD (CKD stage 3), and C) Patients with severe CKD (CKD stage 5 or 6). Abbreviations: LEB, Lower extremity bypass; PVI, Peripheral vascular intervention; CKD, Chronic kidney disease.
Figure 5.
Figure 5.
Cumulative incidence functions for 5-year amputation for LEB vs. PVI in A) Patients without CKD, B) Patients with non-severe CKD (CKD stage 3), and C) Patients with severe CKD (CKD stage 5 or 6). Abbreviations: LEB, Lower extremity bypass; PVI, Peripheral vascular intervention; CKD, Chronic kidney disease.
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Nehler MR, Duval S, Diao L, Annex BH, Hiatt WR, Rogers K, Zakharyan A, Hirsch AT. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg. 2014;60:686–695 e682. doi: 10.1016/j.jvs.2014.03.290 - DOI - PubMed
    1. Abu Dabrh AM, Steffen MW, Undavalli C, Asi N, Wang Z, Elamin MB, Conte MS, Murad MH. The natural history of untreated severe or critical limb ischemia. J Vasc Surg. 2015;62:1642–1651 e1643. doi: 10.1016/j.jvs.2015.07.065 - DOI - PubMed
    1. Luders F, Bunzemeier H, Engelbertz C, Malyar NM, Meyborg M, Roeder N, Berger K, Reinecke H. CKD and Acute and Long-Term Outcome of Patients with Peripheral Artery Disease and Critical Limb Ischemia. Clin J Am Soc Nephrol. 2016;11:216–222. doi: 10.2215/CJN.05600515 - DOI - PMC - PubMed
    1. Anantha-Narayanan M, Sheikh AB, Nagpal S, Smolderen KG, Turner J, Schneider M, Llanos-Chea F, Mena-Hurtado C. Impact of Kidney Disease on Peripheral Arterial Interventions: A Systematic Review and Meta-Analysis. Am J Nephrol. 2020;51:527–533. doi: 10.1159/000508575 - DOI - PubMed
    1. Yuo TH, Wallace JR, Fish L, Avgerinos ED, Leers SA, Al-Khoury GE, Makaroun MS, Chaer RA. Editor’s Choice – Comparison of Outcomes After Open Surgical and Endovascular Lower Extremity Revascularisation Among End Stage Renal Disease Patients on Dialysis. Eur J Vasc Endovasc. 2019;57:248–257. doi: 10.1016/j.ejvs.2018.09.008 - DOI - PMC - PubMed

Publication types

MeSH terms