Objective: While there have been a number of studies suggesting poor outcomes of lower extremity revascularization in patients with end-stage renal disease (ESRD), little is known about results in patients with renal transplants (RT). We analyzed 1-year primary patency and limb salvage outcomes and associated risk factors in RT patients compared to a non-RT cohort. The results here are aimed at helping guide health care providers in decisions about the appropriateness of infrainguinal revascularization procedures in transplant patients.

Methods: The Vascular Quality Initiative database was used to identify all renal transplant patients who underwent infrainguinal bypass procedures from 2003-2015. Patients with dialysis requirements were excluded. Multivariable Cox regression analysis and coarsened exact matching with many-to-one were employed to identify predictors of primary patency and limb salvage at 1 year.

Results: A total of 21,420 non-RT and 178 RT patients underwent infrainguinal bypass procedures. RT patients were more likely to have critical limb ischemia (87.6% vs. 69.3%, P<0.001), and a more distal level of outflow artery (popliteal-tibial: 19.4% vs. 7.3%, femoral-tibial: 38.9% vs. 35.0%, femoral-popliteal: 41.7% vs. 57.7%, P<0.001). RT patients were more likely to receive a greater saphenous vein conduit (67.2% vs. 57.8%, P=0.03). Compared to non-RT patients, RT patients had significantly higher primary patency rates at one year (86.9% vs. 75.8%, P=0.01) and similar 1-year primary-assisted patency (93.1% vs. 87.9%, P=0.07) and 1-year limb salvage rates (82.9% vs. 88.4%, P=0.08.) Risk factors associated with loss of primary patency included critical limb ischemia and history of prior bypass, while African American race, history of contralateral limb amputation, critical limb ischemia, use of prosthetic conduit, and more distal bypass were associated with increased risk of limb loss. There was no difference in survival between RT and non-RT patients at 4 years follow-up (74.2% vs. 76.7%, P=0.59.)

Conclusion: This is the largest series to date of infrainguinal revascularization in transplant patients. Although studies have shown poor outcomes for ESRD patients who undergo lower extremity bypass for limb-threatening ischemia, we demonstrate here that outcomes for transplant patients are not inferior to those of non-transplant patients. Aggressive approaches at limb salvage are justifiable in appropriately selected renal transplant patients.

CITATION INFORMATION: Craig-Schapiro R, Nejim B, Malas M. Outcomes of Infrainguinal Revascularization in Renal Transplant Patients. Am J Transplant. 2017;17 (suppl 3).

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