Realistic expectations for pedal bypass grafts in patients with end- stage renal disease

Purpose: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging clinical problem. Multiple series have shown the inferior limb salvage rate for femoropopliteal or femorotibial bypass grafts in this group. This outcome study is restricted to those patients with ESRD who require pedal bypass grafts for attempted limb salvage. Methods: Between December 1, 1990, and December 31, 1997, 34 patients with ESRD underwent pedal bypass grafting on 41 limbs. This review explores the patient and bypass graft outcomes and their relationships to typical risk factors. Results: The average age in the study was 64 years (range, 39 to 85 years). Twenty patients (59%) were men, 31 (91%) had diabetes, 32 (94%) were hypertensive, and 28 (82%) had coronary artery disease, but only 10 patients (29%) were smokers. All the patients were undergoing dialysis except 2 patients with functioning renal transplants. All bypass grafting procedures were performed for limb salvage. The follow-up periods ranged from 1 to 84 months (average, 13,5 months). With life-table analysis, the cumulative assisted primary patency rate was 62% at 1 year and 62% at 2 years. The limb salvage rate was 56% and 50% at 1 and 2 years, respectively. All the patients who were seen with heel gangrene had early limb loss or died. Seven of the 16 amputations (44%) were performed despite patent bypass grafts. Ten of the 16 amputations (63%) occurred within 3 months of the surgery. The survival rate was 64% at 1 year and 52% at 2 years. After the bypass graft procedure, the mean ankle brachial index and the toe pressure rose from 0.48 to 1.05 and 18 to 86, respectively. Conclusion: Modest success can be expected with pedal bypass grafts in patients with ESRD, with most failures occurring in the first 3 months. Limb salvage rates lag behind graft patency rates because of progressive necrosis despite a hemodynamically functioning bypass graft. Heel gangrene is a strong predictor for a negative outcome. Lastly, overall patient survival rates are poor but comparable with the rates of other patients with ESRD.