Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
Division of Nephrology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
Catheter Cardiovasc Interv. 2021 Aug 1;98(2):297-307. doi: 10.1002/ccd.29688. Epub 2021 Apr 6.
End-stage renal disease (ESRD) is associated with increased morbidity and mortality following lower extremity amputation for critical limb ischemia (CLI). Angioplasty and bypass are used in ESRD patients with CLI; however, the treatment of choice remains controversial. We compared the long-term outcomes in patients with CLI undergoing angioplasty or bypass to evaluate the differences between patients with ESRD and those without ESRD.
Established databases were searched for observational studies comparing outcomes following bypass or angioplasty for CLI in patients with ESRD to those in non-ESRD patients. End points included survival, limb salvage, amputation-free survival (AFS), and primary and secondary patency at 1-year post-procedure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effect model.
We included 20 studies with a total of 24,851 patients. ESRD patients compared to non-ESRD patients with CLI had significantly lower survival post-angioplasty (OR 0.51, 95% CI 0.36-0.72, p < .001) and post-bypass (OR 0.26, 95% CI 0.15-0.45, p < .001). ESRD patients had lower rates of limb salvage post-bypass (OR 0.33, 95% CI 0.21-0.53, p < .001) and post-angioplasty (OR 0.54, 95% CI 0.41-0.70, p < .001). AFS was significantly lower in ESRD patients compared to non-ESRD patients following angioplasty (OR 0.48, 95% CI 0.32-0.71, p < .001) and bypass (OR 0.28, 95% CI 0.16-0.47, p < .001) despite no significant differences in primary patency. ESRD patients had overall worse secondary patency post-angioplasty and/or bypass (OR 0.54, 95% CI 0.32-0.94, p = .03) compared to non-ESRD patients. A meta-analysis of four studies directly comparing survival in ESRD patients with CLI based on whether they underwent angioplasty or bypass showed no difference (OR 0.93, 95% CI 0.64-1.35, p = .69).
ESRD patients have worse survival, limb salvage, and AFS outcomes following angioplasty and bypass for CLI compared to non-ESRD patients. Large randomized controlled trials comparing these two modalities of treatment in this patient population are needed for further clarity.
终末期肾病（ESRD）与CLI 下肢截肢后发病率和死亡率增加有关。血管成形术和旁路手术用于 CLI 的 ESRD 患者；然而，治疗选择仍存在争议。我们比较了 CLI 接受血管成形术或旁路手术的患者的长期结果，以评估 ESRD 患者与非 ESRD 患者之间的差异。
检索了比较 ESRD 患者和非 ESRD 患者 CLI 血管成形术或旁路治疗结果的观察性研究的既定数据库。终点包括生存、肢体挽救、无截肢生存率（AFS）以及术后 1 年的主要和次要通畅率。使用随机效应模型计算合并的优势比（OR）和 95%置信区间（CI）。
我们纳入了 20 项研究，共 24851 名患者。与 CLI 的非 ESRD 患者相比，ESRD 患者血管成形术后（OR 0.51，95%CI 0.36-0.72，p<0.001）和旁路手术后（OR 0.26，95%CI 0.15-0.45，p<0.001）的生存率明显较低。ESRD 患者旁路手术后（OR 0.33，95%CI 0.21-0.53，p<0.001）和血管成形术后（OR 0.54，95%CI 0.41-0.70，p<0.001）的肢体挽救率较低。与非 ESRD 患者相比，ESRD 患者血管成形术后（OR 0.48，95%CI 0.32-0.71，p<0.001）和旁路手术后（OR 0.28，95%CI 0.16-0.47，p<0.001）的 AFS 明显较低，但主要通畅率无显著差异。尽管非 ESRD 患者的二次通畅率总体上优于 ESRD 患者，但 ESRD 患者的血管成形术和/或旁路术后的二次通畅率较差（OR 0.54，95%CI 0.32-0.94，p=0.03）。对四项直接比较 CLI 基于是否接受血管成形术或旁路手术的 ESRD 患者生存情况的研究进行荟萃分析显示，两者之间没有差异（OR 0.93，95%CI 0.64-1.35，p=0.69）。
与非 ESRD 患者相比，CLI 血管成形术和旁路手术的 ESRD 患者的生存率、肢体挽救和 AFS 结果更差。需要进行大型随机对照试验，以进一步明确比较这两种治疗方法在这一患者人群中的疗效。
