Balancing Days at Home and Major Adverse Limb Events After Surgical Versus Endovascular Lower-Extremity Revascularization in Chronic Kidney Disease.

BACKGROUND

The risk-benefit trade-offs after lower-extremity revascularization among older patients with chronic kidney disease remain unclear. We compared how surgical versus endovascular lower-extremity revascularization associates with clinical outcomes that may be valued differently by patients.

METHODS

We selected adults aged ≥66 years with chronic kidney disease who underwent lower-extremity revascularization from January 1, 2008, to December 31, 2017, with ≥12 months Medicare Parts A and B before the procedure. The primary outcome was days at home at 30, 180, and 365 days after revascularization. The secondary outcome was major adverse limb events (ie, lower-extremity revascularization or major amputation). We report outcomes as the difference in survived days at home and days lost due to major adverse limb events by restricted mean time lost.

RESULTS

Among 87 446 patients, 15.3% underwent surgical and 84.7% underwent endovascular revascularization. Surgical revascularization was associated with fewer days at home at 30 days (difference, -8.4 [95% CI, -8.6 to -8.2]), 180 days (difference, -21.2 [95% CI, -22.1 to -20.4]) and 365 days (difference, -31.9 [95% CI, -33.5 to -30.6]) compared with endovascular. Surgical revascularization was associated with fewer days lost to major adverse limb events at 180 days (difference, -6.9 [95% CI, -7.6 to -5.8]) and at 365 days (difference, -17.3 [95% CI, -19.3 to -14.7]).

CONCLUSIONS

In this study of older patients with chronic kidney disease, surgical lower-extremity revascularization was associated with fewer survived days at home, but also with fewer days lost to major adverse limb events compared with an endovascular approach. Considering different risk-benefit profiles when planning for lower-extremity revascularization is essential to facilitate shared decision making.