Comparison of limb outcomes between bypass surgery and endovascular therapy in dialysis-dependent and-independent patients with chronic limb-threatening ischemia

Objective: To examine limb salvage (LS) and wound healing in dialysis -dependent and -independent patients with chronic limb -threatening ischemia (CLTI) after infrainguinal bypass surgery or endovascular therapy (EVT). Methods: We retrospectively analyzed the multi -center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) stage 2 to 4 between 2015 and 2020. The primary endpoint was LS. The secondary endpoint included wound healing, amputation -free survival (AFS), periprocedural complications, and 2 -year survival. Comparison of these outcomes were made after propensity score matching. Results: We analyzed 252 dialysis -dependent (318 limbs) and 305 dialysis -independent (354 limbs) patients. Propensity score matching extracted 202 pairs with no significant differences in characteristics. The LS rate in bypass surgery was better than that in EVT in dialysis -dependent patients (P < .001). There was no significant difference in the LS rates between bypass surgery and EVT in dialysis -independent patients (P = .168). The wound healing rate of bypass surgery was better than that of EVT both dialysis -dependent and -independent patients with CLTI. The AFS rate of bypass surgery was better than that of EVT in dialysis -dependent patients (P < .001). There was no significant difference in the AFS rates between bypass surgery and EVT in dialysis -independent patients (P = .099). There was no significant difference in the occurrence of Clavien-Dindo >= IV and V between bypass surgery and EVT in dialysis -dependent and -independent patients. Age >= 75 years, serum albumin levels <3.5 g/dL, and non -ambulatory status were risk factors for 2 -year mortality in dialysis -dependent patients. The 2 -year survival rates in dialysis -dependent patients with risk factors of 0, 1, 2, and 3 were 82.5%, 67.1%, 49.5%, and 10.2%, respectively (P < .001). Conclusions: For LS and wound healing, bypass surgery was preferred for revascularization in dialysis -dependent patients with WIfI stage 2 to 4. Although dialysis dependency was one of the risk factors for 2 -year mortality, dialysis -dependent patients, who have 0 to 1 risk factors, may benefit from bypass surgery, as 2 -year survival of >50% is expected. (J Vasc Surg 2024;79:316-22.)