The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease

Pooria Nakhaei; Mohammed Hamouda; Mahmoud B Malas

doi:10.1016/j.avsg.2023.12.102

The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease

Ann Vasc Surg. 2024 Apr 9:S0890-5096(24)00151-1. doi: 10.1016/j.avsg.2023.12.102. Online ahead of print.

Authors

Pooria Nakhaei¹, Mohammed Hamouda¹, Mahmoud B Malas²

Affiliations

¹ Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
² Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA. Electronic address: mmalas@ucsd.edu.

PMID: 38599491
DOI: 10.1016/j.avsg.2023.12.102

Abstract

Background: Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages.

Methods: This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD.

Results: CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates.

Conclusions: The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.