Rao Ajit, Baldwin Melissa, Cornwall James, Marin Michael, Faries Peter, Vouyouka Ageliki
Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
J Vasc Surg. 2017 Jul;66(1):167-177. doi: 10.1016/j.jvs.2017.01.029. Epub 2017 Apr 5.
Peripheral arterial disease is a common comorbidity found in up to 38% of patients with end-stage renal disease (ESRD). With an increase in the survival rate of patients with ESRD by >25%, there is a lack of contemporary data on the safety of open surgical revascularization of the lower extremity (OSRLE) in this population of patients. We sought to identify the perioperative morbidity and mortality and independent risk factors of mortality in dialysis patients undergoing OSRLE.
We reviewed data from 34,941 patients who underwent OSRLE from January 2011 to December 2014 at all hospitals in North America participating in the National Surgical Quality Improvement Program (NSQIP). Trauma, emergencies, aneurysms, and endovascular cases were excluded. We compared the 30-day outcomes of 1623 patients on dialysis with those of 33,318 patients not on dialysis.
Patients on dialysis were younger (66.0 vs 66.7; P < .01), were more likely to be treated for critical limb ischemia (49.7% vs 33.1%; P < .01), and had more comorbidities compared with patients not on dialysis. Dialysis patients had higher mortality (7.8% vs 2.1%; P < .01) and postoperative complication rates after OSRLE, including myocardial infarction (3.5% vs 1.4%; P < .01), return to the operating room (6.1% vs 2.8%; P < .01), and unplanned readmission (5.2% vs 2.9%; P < .01). Although 30-day patency was not different (0.4% vs 0.4%; P = .56) between the two study groups, major amputation rate was threefold higher in dialysis patients (1.7% vs 0.57%; P < .01). In addition, we identified multiple risk factors that predispose dialysis patients to worse outcome after OSRLE, including older age, African American race, and congestive heart failure. In a subgroup analysis by procedure, dialysis patients who underwent aortobifemoral bypass carried the highest mortality risk (25% vs 3.6%; P < .01). Dialysis patients had higher rates of unplanned reoperation (7.9% vs 3.9%; P < .01) and unplanned readmission (6.2% vs 3.7%; P < .01) and increased length of stay (67.5% vs 47.3%; P < .01) after femoral-distal bypass.
With improvements in the medical care of ESRD patients resulting in a large increase in survival rates, little is known about how dialysis patients fare after OSRLE in the contemporary period. Our study shows that despite advances in the medical management of dialysis patients, improvements in outcomes after revascularization have not yet been realized. We found that specific clinical and procedural factors increase the risk for inferior results. Careful selection of dialysis patients suitable for OSRLE according to these risk factors may improve the management of this still high-risk vascular population.
外周动脉疾病是终末期肾病（ESRD）患者中常见的合并症，高达38%的ESRD患者存在该疾病。随着ESRD患者生存率提高超过25%，目前缺乏关于该人群下肢开放手术血管重建术（OSRLE）安全性的当代数据。我们旨在确定接受OSRLE的透析患者的围手术期发病率、死亡率及死亡的独立危险因素。
我们回顾了2011年1月至2014年12月期间在北美所有参与国家外科质量改进计划（NSQIP）的医院接受OSRLE的34941例患者的数据。排除创伤、急诊、动脉瘤及血管内治疗病例。我们比较了1623例透析患者与33318例非透析患者的30天结局。
透析患者更年轻（66.0岁对66.7岁；P <.01），更可能因严重肢体缺血接受治疗（49.7%对33.1%；P <.01），与非透析患者相比合并症更多。透析患者死亡率更高（7.8%对2.1%；P <.01），OSRLE术后并发症发生率更高，包括心肌梗死（3.5%对1.4%；P <. /01）、返回手术室（6.1%对2.8%；P <.01）及非计划再入院（5.2%对2.9%；P <.01）。尽管两个研究组之间30天通畅率无差异（0.4%对0.4%；P =.56），但透析患者的大截肢率高出三倍（1.7%对0.57%；P <.01）。此外，我们确定了多个使透析患者在OSRLE后预后更差的危险因素，包括年龄较大、非裔美国人种族及充血性心力衰竭。在按手术方式进行的亚组分析中，接受主-双股动脉旁路移植术的透析患者死亡风险最高（25%对3.6%；P <.01）。透析患者在股-腘动脉旁路移植术后非计划再次手术率更高（7.9%对3.9%；P <.01）、非计划再入院率更高（6.2%对3.7%；P <.01）且住院时间延长（67.5%对47.3%；P <.01）。
随着ESRD患者医疗护理的改善导致生存率大幅提高，目前对于当代透析患者接受OSRLE后的情况了解甚少。我们的研究表明，尽管透析患者的医疗管理有所进步，但血管重建术后结局的改善尚未实现。我们发现特定的临床和手术因素会增加不良结果的风险。根据这些危险因素仔细选择适合OSRLE的透析患者可能会改善对这个仍然高危的血管人群的管理。
