Department of Surgery, Temple University Hospital, Philadelphia, Pa.
Department of Surgery, Temple University Hospital, Philadelphia, Pa.
J Vasc Surg. 2019 Feb;69(2):491-496. doi: 10.1016/j.jvs.2018.05.229. Epub 2018 Aug 25.
Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia.
The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications.
The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01).
CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.
在患有慢性肾脏病（CKD）的患者中，选择进行开放式下肢血运重建仍然是一个临床挑战。本研究旨在调查 CKD 对下肢旁路术治疗严重肢体缺血患者早期移植物失败、术后并发症和死亡率的影响。
从 2012 年至 2015 年，国家手术质量改进计划数据库中检索所有使用靶向血管组进行严重肢体缺血下肢旁路术的患者。肾小球滤过率（GFR）使用慢性肾脏病流行病学合作研究方程计算。根据国家肾脏基金会肾脏病预后质量倡议分期标准确定 CKD 类别。患者分为三组：CKD 3 或 4 期（轻度至中度 CKD）、CKD 5 期（重度 CKD）和血液透析（HD）。采用多变量分析来检查移植物失败、死亡率和术后并发症。
国家手术质量改进计划数据库共确定了 6978 例在研究期间接受下肢动脉旁路术的患者。其中 6101 例（87.4%）为轻度至中度 CKD，327 例（4.7%）为重度 CKD，550 例（7.9%）为 HD。重度 CKD 和 HD 患者更可能因组织丧失而行血运重建（54.9% vs. 68.8%和 74.7%；P<.01）。重度 CKD 和 HD 患者早期移植物失败、术后心肌梗死和再次手术的发生率较高。多变量分析证实了这些结果，表明 HD 与术后心肌梗死、再入院和死亡率增加有关。还表明重度 CKD 与移植物失败（比值比[OR]，1.67；95%置信区间[CI]，1.12-2.50；P=.01）、术后心肌梗死（OR，2.16；95%CI，1.35-3.45；P<.01）和再入院（OR，1.38；95%CI，1.06-1.80；P=.02）有关。其他与移植物失败相关的因素包括功能状态（OR，1.39；95%CI，1.08-1.80；P=.01）、非裔美国人种族（OR，1.72；95%CI，1.39-2.13；P<.01）和远端旁路（OR，1.33；95%CI，1.09-1.61；P<.01）。
CKD 是下肢旁路术后围手术期发病率的重要预测因素。重度 CKD 患者术后预后较差，但死亡率无增加。HD 患者的生存率和术后结局更差。
