Long-term prognosis after bypass surgery versus endovascular therapy in chronic hemodialysis patients with peripheral artery disease -10-year follow-up study

Background Lower limb revascularization such as bypass surgery and endovascular therapy (EVT) has been commonly performed to treat peripheral artery disease (PAD) in chronic hemodialysis (HD) patients in spite of their very sever condition. However, it remains controversial which procedure should be optimized for better prognosis. The aim of this study was to compare bypass surgery and EVT in HD patients from the view point of long-term survival rate. Methods A total of consecutive 1,474 HD patients successfully undergoing lower limb revascularization were enrolled in this study. Of them, 464 patients underwent bypass surgery and 1014 patients underwent EVT. They were followed up to 10 years. To reduce the selection bias between two procedures, a propensity score-matching with all baseline characteristics was also performed. Results Diabetes was more prevalent in the EVT groupt than in the bypass group (69.6% vs. 62.6%, p=0.0081). In contrast, prevalence of chronic limb-threatening ischemia (CLTI) and below-knee artery disease were markedly higher in the bypass group than in the EVT group (84.4% vs. 53.5%, p<0.0001 and 61.3% vs. 28.8%, p<0.0001), respectively. Serum C-reactive protein (CRP) levels were also higher in the bypass group (median of 14.0mg/L vs. 4.0mg/L, p<0.0001). During follow-up period (median of 53 months), 138 patients (30.0%) and 261 (25.7%) patients died in the bypass and the EVT group, respectively. Kaplan-Meier survival rate for 10-year was lower in the bypass group than in the EVT group [42.6% vs. 36.8%, hazard ratio (HR) 1.30, 95% confidence interval (CI) 1.05-1.60, p=0.014]. On a landmark analysis, the bypass group had poorer prognosis within 1-year (HR 2.82, 95% CI 2.11-3.77, p<0.0001), however, inversely, had better prognosis after 1-year (HR 0.54, 95% CI 0.38-0.77, p=0.0056) compared to the EVT group. In addition, in a propensity-score matched cohort (n=351 in both group), Similar results were more clearly confirmed (HR 1.02, 95% CI 0.77-1.35, p=0.91 during 10-year, HR 1.80, 95% CI 1.22-2.66, p=0.0030 before 1-year, and HR 0.48, 95% CI 0.31-0.76, p=0.0014 after 1-year for the bypass group vs. the EVT group, respectively) (Figure). Conclusion During short-term (ex. 1-year after revascularization), prognosis after bypass surgery was inferior to that after EVT in chronic HD patients with PAD. However, it was superior as to long-term follow-up after lower limb revascularization. These results might be provided due to complete revascularization with bypass surgery.