Comparison of Limb Outcomes between Bypass Surgery and Endovascular Therapy in Dialysis-dependent and -independent Patients with Chronic Limb Threatening Ischemia

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). We retrospectively analyzed the multi-center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) stage 2–4 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 (PSM). We analyzed 252 dialysis-dependent (318 limbs) and 305 dialysis-independent (354 limbs) patients. PSM 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 dialysis-independent patients. Age ≥ 75 years, serum albumin levels < 3.5g/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). For LS and wound healing, bypass surgery was preferred for revascularization in dialysis-dependent patients with WIfI stage 2–4. Although dialysis dependency was one of the risk factors for 2-year mortality, dialysis-dependent patients, who have 0-1 risk factor, may benefit from bypass surgery, as 2-year survival of ≥ 50% is expected. •Type of Research: Multicenter retrospective cohort study•Key Findings: Bypass surgery was superior to endovascular therapy for wound healing and limb salvage in 557 patients with CLTI and 672 limbs. Dialysis dependency was a poor prognostic factor. Age ≥ 75 years, serum albumin level