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Patients with end-stage renal disease (ESRD) whether on dialysis therapy (DT) or who received a kidney transplant (KT) have previously shown unfavorable surgical outcomes. Little is known about the comparative efficacy and durability of lower extremity bypass (LEB) in those patients. The Vascular Quality Initiative database was explored to identify DT or KT recipients (2003-2016) who had LEB. We included 1,714 bypass procedures; DT: 1,512 (88.2%). Primary patency (PP) at 2 year was comparable between KT and DT groups (PP [95% confidence interval {CI}]: 77.0% [69.7%-82.8%] vs. 80.5% [77.8%-82.9%]; P = 0.212), and the risk-adjusted hazard was similar (adjusted hazard ratio [aHR] [95% CI]: 0.89 [0.61-1.30]; P = 0.540). Amputation-free survival (AFS) at 2 year was more favorable in KT group (AFS [95% CI]: 73.1% [66.3%-78.8%] vs. 48.0% [45.4%-50.6%]; P < 0.001), (aHR [95% CI]: 2.29 [1.62-3.23]; P < 0.001). Patients on DT exhibited a higher risk of mortality than KT recipients (aHR [95% CI]: 2.94 [2.07-4.17]; P < 0.001). This study demonstrated superior limb outcomes in KT recipients than patients on DT after LEB. Despite the comparable PP, the risk of amputation or death was doubled in patients on DT compared with KT recipients. Because both groups were similar in several baseline characteristics, the difference in outcome is likely driven by the positive effect of KT on the physiological milieu of these patients., (Copyright © 2019. Published by Elsevier Inc.)

Background: Drug abuse may affect lower extremity vessels due to ischemia following intra-arterial injections, vasospasm, arterial and venous pseudoaneurysms, arteriovenous fistulae, vasculitis, and complicated abscesses. Little is known about the outcomes of lower extremity bypass (LEB) for peripheral arterial disease (PAD) in patients with a history of drug abuse disorder. The aim of this study is to evaluate the outcomes of LEB in this patient population., Methods: A retrospective study of the Premier Healthcare Database 2009-2015 was performed. In-hospital complications, mortality, and hospitalization costs were assessed in patients with a history of drug abuse disorder (opioids, cannabis, cocaine, sedatives/hypnotics/anxiolytics, and hallucinogens/methamphetamine/psychoactive drugs) who underwent LEB for PAD. Multivariable logistic and generalized linear models were utilized to study the association between drug use/misuse and in-hospital outcomes after LEB., Results: Our cohort included 50,976 patients, of which 967 (2%) had a history of drug abuse disorder on admission. The majority of drugs were cannabis (38.5%), followed by opioids (21.5%) and cocaine (14.5%). Patients with a history of drug use/misuse were significantly at a higher risk of developing complications during their hospital stay (71.9% vs. 64.2%, P < 0.001) including acute renal failure (11.8% vs. 9.1%), stroke (1.6% vs. 0.6%), respiratory complications (pneumonia and respiratory failure) (15.0% vs. 9.6%), hemorrhage/shock (36.2% vs. 31.8%), vascular or graft-related complications (29.8% vs. 26.4%), wound complications (9.1% vs. 6.3%), cellulitis (8.5% vs. 6.8%), and sepsis (2.1% vs. 1.2%, all P < 0.001). In addition, drug users were found to have higher risk of concomitant major amputations compared to nondrug users (2.0% vs. 0.9%, P < 0.001). On multivariable analysis, no difference was noted between the 2 groups in terms of in-hospital mortality and concomitant major amputations. However, drug use/misuse was associated with 57% higher odds of overall in-hospital complications (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.34-1.83, P < 0.001), a prolonged length of hospital stay (median: 7 days vs. 5 days in nonabusers, P < 0.001), and higher hospitalization costs compared to nonusers (adjusted mean difference: OR $3,075, 95% CI $2,096-$4,055, P < 0.001)., Conclusions: Drug use/misuse is significantly associated with increased odds of in-hospital complications, longer hospital stays, and higher hospitalization costs following LEB. Vascular surgeons need to pay special attention to this patient population and explore interventions to decrease the morbidity and economic burden associated with drug use., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Studies of infrainguinal bypass surgery (IBS) in patients with end-stage renal disease have focused on hemodialysis (HD) patients. Little is known of the applicability of their outcomes to patients with renal transplants (RTs). In this study, we sought to compare perioperative and long-term outcomes of IBS in a large population-based cohort of HD and RT patients., Methods: A retrospective review of all HD and RT patients who underwent IBS between January 2007 and December 2011 in the U.S. Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate 30-day postoperative (graft failure, limb loss, conduit infection, death) and long-term (primary patency [PP], primary assisted patency [PAP], secondary patency [SP], limb salvage, mortality) outcomes., Results: There were 10,787 IBSs performed in 9739 (90%) HD patients and 1048 (10%) RT patients who presented predominantly with critical limb ischemia (72%). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). Comparing HD vs RT patients, PP, PAP, and SP were 18% vs 33%, 23% vs 38%, and 30% vs 48%, respectively, at 5 years among autogenous conduit recipients (all P < .001) and 20% vs 28% (P = .02), 23% vs 31% (P = .02), and 33% vs 53% (P < .001) among prosthetic conduit recipients. Limb salvage and patient survival were 39% vs 56% and 19% vs 48%, respectively, at 5 years (all P < .001). Risk-adjusted analyses demonstrated higher PP (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 1.20-1.45; P < .001), PAP (aHR, 1.32; 95% CI, 1.19-1.45; P < .001), SP (aHR, 1.47; 95% CI, 1.31-1.65; P < .001), limb salvage (aHR, 1.48; 95% CI, 1.30-1.67; P < .001), and patient survival (aHR, 2.42; 95% CI, 2.17-2.71; P < .001) for RT compared with HD patients., Conclusions: The HD-dependent state is associated with elevated bypass and patient-level risks after IBS compared with patients with RTs. These results show that the benefits of renal transplantation likely extend to infrainguinal bypass-specific outcomes. The estimates of risk reported herein should inform the patient's and provider's expectations at the point of care., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare conduit use and surgical outcomes of hemodialysis-dependent men and women after open lower extremity bypass surgery., Methods: Using the United States Renal Data System, we studied all hemodialysis patients in the United States who underwent infrainguinal bypass surgery between January 1, 2006, and December 31, 2011. Univariate methods (χ 2 , analysis of variance) were employed to compare patient and bypass characteristics between men and women. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were employed to evaluate outcomes that included patency, graft failure, and mortality at 30 days. In addition, we compared limb salvage and patient survival rates between men and women., Results: There were 9739 bypasses performed in 5927 (61%) men and 3812 (39%) women who presented most commonly with critical limb ischemia (men, 73%; women, 71%; P = .04). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). The prevalence of autogenous conduits was higher for men (61 vs 55%; P < .001), and they were associated with higher patency compared with prosthetics (adjusted hazard ratio [aHR], 1.10; 95% confidence interval [CI], 1.01-1.19; P = .03). The risk-adjusted analyses revealed higher odds of acute graft failure for women compared with men who received prosthetic conduits (adjusted odds ratio, 1.23; 95% CI, 1.03-1.46; P = .021) but not among patients who received autogenous conduits (adjusted odds ratio, 1.07; 95% CI, 0.91-1.25; P = .41). Despite the difference in choice of conduit, there was no significant difference in primary patency (aHR, 1.00; 95% CI, 0.95-1.06; P = .90), primary assisted patency (aHR, 1.03; 95% CI, 0.97-1.10; P = .28), secondary patency (aHR, 1.01; 95% CI, 0.95-1.08; P = .75), limb salvage (aHR, 0.97; 95% CI, 0.90-1.04; P = .41), and survival (aHR, 0.97; 95% CI, 0.92-1.03; P = .45) for women compared with men., Conclusions: We found lower use of autogenous conduits in women than in men. In patients who received prosthetic conduit, acute graft failure was higher for women than for men. The benefits of autogenous conduits over prosthetic grafts underscore the need to improve the selection of appropriately sized autogenous conduits for bypass irrespective of gender., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Lower extremity bypass (LEB) remains the gold standard revascularization procedure in patients with peripheral arterial disease. The cost of LEB substantially varies based on patient's characteristics and comorbidities. The aim of this study was to assess regional variation in infrainguinal LEB cost and to identify the specific health care expenditures per service that are associated with the highest cost in each region., Methods: We identified adult patients who underwent infrainguinal LEB in the Premier database between June 2009 and March 2015. Generalized linear regression models were used to report differences between regions in total in-hospital cost and service-specific cost adjusting for patient's demographics, clinical characteristics, and hospital factors., Results: A total of 50,131 patients were identified. The median in-hospital cost was $13,259 (interquartile range, $9308-$19,590). The cost of LEB was significantly higher in West and Northeast regions with a median cost of nearly $16,000. The high cost in the Northeast region was driven by the fixed (indirect) cost, whereas the driver of the high cost in the West region was the variable (direct) cost. The adjusted total in-hospital cost was significantly higher in all regions compared with the South (mean difference, West, $3752 [95% confidence interval (CI), 3477-4027]; Northeast, $2959 [95% CI, 2703-3216]; Midwest, 1586 [95% CI, 1364-1808])., Conclusions: In this study, we show the marked regional variability in LEB costs. This disparity was independent from patient clinical condition and hospital factors. Cost inequality across the US represents a financial burden on both the patient and the health system., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hemodialysis dependence confers unique physiologic conditions. Prior reports of outcomes after infrainguinal open bypass operations in patients on hemodialysis have been based on relatively small sample institutional series. In this study, we evaluate long-term outcomes after open bypass operations in a large contemporary population-based cohort of hemodialysis patients. We studied all hemodialysis patients who underwent infrainguinal open operation using autogenous versus prosthetic conduits in the United States Renal Data System between January 2007 and December 2011., Methods: Univariate methods (χ 2 , analysis of variance) were used to compare the characteristics of the patient and type of bypass. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were used to evaluate 30-day postoperative outcomes as well as patency, limb salvage, and mortality in the long term., Results: There were 9,739 (autogenous: 59%, prosthetic: 49%) infrainguinal open bypass operations performed in this cohort. Of these, 4,717 (48%) were femoral-popliteal, 3,321 (34%) were femoral-tibial, and 1,701 (18%) were popliteal-tibial bypasses. Bypass operations were performed most commonly for critical limb ischemia (72%). Primary patency was 18% for both types of conduits at 5 years (P = .16). Comparing autogenous versus prosthetic conduits, primary-assisted patency was 23% vs 20% at 5 years (P = .98), while secondary patency was 30% for both conduits at 5 years (P = .05). Limb salvage was 35% vs 41% at 5 years (P < .001). Multivariable analyses demonstrated greater patency (adjusted hazard ratio [aHR]: 1.16; 95% confidence interval, 1.05-1.28; P = .003) and limb salvage (aHR: 1.12; 95% confidence interval, 1.01-1.24; P = .03) for autogenous compared to prosthetic bypasses. The advantage conferred by autogenous conduits was most clinically relevant for femoral-tibial (aHR: 1.34; 95% confidence interval, 1.17-1.55; P < .001) and popliteal-tibial (aHR: 1.55; 95% confidence interval, 1.09-2.21; P = .014) configurations., Conclusion: This large study evaluated the long-term outcomes of open bypass operations in patients on hemodialysis. The data confirm the long-term benefits of autogenous conduits compared with prosthetic conduits in this high-risk population of patients, especially for the treatment of distal lesions. Individual patient life expectancy, availability of adequate autogenous conduit options, indication for operation, level of disease, as well as potential need for future options for additional access for dialysis should be taken into consideration when deciding to construct an open bypass in a hemodialysis patient., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Peripheral arterial disease poses a significant burden in the hemodialysis (HD)-dependent population. Race is a known modifier of outcomes after surgical treatment of peripheral arterial disease. A comprehensive evaluation of the effect of race on infrainguinal bypass surgery (IBS) outcomes in HD patients is lacking. In this study, we evaluated the effects of race on long-term IBS outcomes in a large, nationally representative cohort of HD patients., Methods: We studied all HD patients who underwent IBS between January 2007 and December 2011 in the United States Renal Disease System-Medicare matched database. Univariate methods were used to compare patients' demographic and medical characteristics. Kaplan-Meier, univariate and multivariable logistic, and Cox regression analyses were used to evaluate long-term graft patency, limb salvage, and mortality., Results: There were 9305 IBSs performed in 5188 white (56%), 3354 black (36%), and 763 Hispanic (8%) patients. Of these, 4531 (49%) were femoral-popliteal, 3173 (34%) were femoral-tibial, and 1601 (17%) were popliteal-tibial bypasses. Comparing whites vs blacks vs Hispanics, acute graft failure was 14% vs 16% vs 15% (P = .03), with no statistical difference on multivariate analyses. Primary patency was 52% vs 45% vs 48% at 1 year and 24% vs 21% vs 26% at 4 years (P < .001). Primary assisted patency was 56% vs 48% vs 53% at 1 year and 29% vs 25% vs 32% at 4 years (P < .001); secondary patency was 65% vs 56% vs 60% at 1 year and 40% vs 33% vs 40% at 4 years (P < .001). Limb salvage was 68% vs 60% vs 62% at 1 year and 45% vs 42% vs 40% at 4 years (P < .001). Black patients had higher long-term graft failure (adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 1.05-1.24; P = .001) and limb loss (aHR, 1.27; 95% CI, 1.15-1.40; P < .001) compared with white patients. No differences in graft failure (aHR, 0.99; 95% CI, 0.89-1.11; P = .89) and limb loss (aHR, 1.08; 95% CI, 0.94-1.23; P = .28) were found in Hispanics vs whites. All-cause mortality was lower among blacks (aHR, 0.65; 95% CI, 0.60-0.71; P < .001) and Hispanics (aHR, 0.67; 95% CI, 0.59-0.75; P < .001) compared with whites., Conclusions: This large study confirms the presence of multidirectional racial disparities in graft durability, limb salvage, and mortality after IBS in HD patients. Black patients had lower graft patency and higher limb loss than white and Hispanic patients, whereas perioperative and long-term mortality was higher in white patients. These results should inform further granular root cause analyses and subsequent action to eliminate these disparities., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)