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Impact of severe chronic kidney disease on outcomes of infrainguinal peripheral arterial intervention.
J Vasc Surg 2014; 59(2):368-75JV

Abstract

OBJECTIVE

Patients with severe chronic kidney disease (CKD) and peripheral vascular disease are at increased risk of major adverse limb events (MALEs) and death; however, patients with end-stage renal disease have been excluded in current objective performance goals. We evaluated the effect of severe (class 4 and 5) CKD on outcomes after infrainguinal endovascular arterial interventions.

METHODS

All primary peripheral vascular interventions (PVIs) performed at a single institution (January 2002 through December 2009) were included. End points were defined by Society for Vascular Surgery objective performance goals for critical limb ischemia (CLI), which include all-cause mortality, reintervention, and composite end points of death or amputation and MALEs (reintervention or amputation). Univariate and multivariable analysis was used to examine the effect of severe CKD on study end points.

RESULTS

A total of 879 PVIs were performed, with severe CKD in 125 (14%). Severe CKD patients were significantly (P < .05) more likely to have diabetes (64% vs 46%), CLI (72% vs 11%), and need a multilevel PVI (34% vs 19%) or tibial intervention (35% vs 20%) compared with the remainder of the cohort. Distribution of TransAtlantic Inter-Society Consensus C and D lesions were similar (19% severe CKD vs 15%; P = .2). Severe CKD predicted perioperative (30-day) reintervention (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.5-4; P = .05), amputation or death (OR, 3.1; 95% CI, 1.1-9; P = .04), and MALEs (OR, 2.8; 95% CI, 1.3-6.1; P = .04), which was independent of CLI in multivariable regression analysis. On Kaplan-Meier analysis, severe CKD was significantly (log-rank P < .05) associated with death (31% ± 4% vs 7% ± 1%), amputation (14% ± 3% vs 3% ± 1%), and MALEs (40% ± 5% vs 26% ± 2%) at 1 year. Freedom from reintervention was similar at 1 year (70% ± 5% severe CKD vs 75% ± 2%; P = .23). Risk-adjusted (age, CLI, diabetes, coronary artery disease) Cox proportional hazards regression showed that severe CKD increased the risk of late mortality (hazard ratio [HR], 2.4; 95% CI, 1.8-3.2; P < .01), amputation (HR, 2.1; 95% CI, 1.1-3.9; P = .02), and death or amputation (HR, 1.8; 95% CI, 1.3-2.4; P = .04), without increasing the risk of late reinterventions or MALEs.

CONCLUSIONS

CKD independently predicts early and late adverse events after a PVI, in particular, excessive mortality. CKD should figure prominently in clinical decision making for patients with peripheral vascular disease.

Authors+Show Affiliations

Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address: vpatel4@partners.org.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

24176634

Citation

Patel, Virendra I., et al. "Impact of Severe Chronic Kidney Disease On Outcomes of Infrainguinal Peripheral Arterial Intervention." Journal of Vascular Surgery, vol. 59, no. 2, 2014, pp. 368-75.
Patel VI, Mukhopadhyay S, Guest JM, et al. Impact of severe chronic kidney disease on outcomes of infrainguinal peripheral arterial intervention. J Vasc Surg. 2014;59(2):368-75.
Patel, V. I., Mukhopadhyay, S., Guest, J. M., Conrad, M. F., Watkins, M. T., Kwolek, C. J., ... Cambria, R. P. (2014). Impact of severe chronic kidney disease on outcomes of infrainguinal peripheral arterial intervention. Journal of Vascular Surgery, 59(2), pp. 368-75. doi:10.1016/j.jvs.2013.09.006.
Patel VI, et al. Impact of Severe Chronic Kidney Disease On Outcomes of Infrainguinal Peripheral Arterial Intervention. J Vasc Surg. 2014;59(2):368-75. PubMed PMID: 24176634.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Impact of severe chronic kidney disease on outcomes of infrainguinal peripheral arterial intervention. AU - Patel,Virendra I, AU - Mukhopadhyay,Shankha, AU - Guest,Julie M, AU - Conrad,Mark F, AU - Watkins,Michael T, AU - Kwolek,Christopher J, AU - LaMuraglia,Glenn M, AU - Cambria,Richard P, Y1 - 2013/10/28/ PY - 2012/11/20/received PY - 2013/09/04/revised PY - 2013/09/04/accepted PY - 2013/11/2/entrez PY - 2013/11/2/pubmed PY - 2014/3/22/medline SP - 368 EP - 75 JF - Journal of vascular surgery JO - J. Vasc. Surg. VL - 59 IS - 2 N2 - OBJECTIVE: Patients with severe chronic kidney disease (CKD) and peripheral vascular disease are at increased risk of major adverse limb events (MALEs) and death; however, patients with end-stage renal disease have been excluded in current objective performance goals. We evaluated the effect of severe (class 4 and 5) CKD on outcomes after infrainguinal endovascular arterial interventions. METHODS: All primary peripheral vascular interventions (PVIs) performed at a single institution (January 2002 through December 2009) were included. End points were defined by Society for Vascular Surgery objective performance goals for critical limb ischemia (CLI), which include all-cause mortality, reintervention, and composite end points of death or amputation and MALEs (reintervention or amputation). Univariate and multivariable analysis was used to examine the effect of severe CKD on study end points. RESULTS: A total of 879 PVIs were performed, with severe CKD in 125 (14%). Severe CKD patients were significantly (P < .05) more likely to have diabetes (64% vs 46%), CLI (72% vs 11%), and need a multilevel PVI (34% vs 19%) or tibial intervention (35% vs 20%) compared with the remainder of the cohort. Distribution of TransAtlantic Inter-Society Consensus C and D lesions were similar (19% severe CKD vs 15%; P = .2). Severe CKD predicted perioperative (30-day) reintervention (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.5-4; P = .05), amputation or death (OR, 3.1; 95% CI, 1.1-9; P = .04), and MALEs (OR, 2.8; 95% CI, 1.3-6.1; P = .04), which was independent of CLI in multivariable regression analysis. On Kaplan-Meier analysis, severe CKD was significantly (log-rank P < .05) associated with death (31% ± 4% vs 7% ± 1%), amputation (14% ± 3% vs 3% ± 1%), and MALEs (40% ± 5% vs 26% ± 2%) at 1 year. Freedom from reintervention was similar at 1 year (70% ± 5% severe CKD vs 75% ± 2%; P = .23). Risk-adjusted (age, CLI, diabetes, coronary artery disease) Cox proportional hazards regression showed that severe CKD increased the risk of late mortality (hazard ratio [HR], 2.4; 95% CI, 1.8-3.2; P < .01), amputation (HR, 2.1; 95% CI, 1.1-3.9; P = .02), and death or amputation (HR, 1.8; 95% CI, 1.3-2.4; P = .04), without increasing the risk of late reinterventions or MALEs. CONCLUSIONS: CKD independently predicts early and late adverse events after a PVI, in particular, excessive mortality. CKD should figure prominently in clinical decision making for patients with peripheral vascular disease. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/24176634/Impact_of_severe_chronic_kidney_disease_on_outcomes_of_infrainguinal_peripheral_arterial_intervention_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(13)01697-2 DB - PRIME DP - Unbound Medicine ER -