Infrainguinal bypass revascularization failures in African American and White patients with end-stage kidney disease and chronic limb-threatening ischemia
Michael Yi Ming Wang, Zdenek Novak, Stephanie L Rakestraw, Emily L Spangler, Adam W Beck, Danielle C Sutzko
University of Alabama Heersink School of Medicine, Birmingham, AL
Background
End-Stage Kidney Disease (ESKD) is a risk factor for the development and progression of Chronic Limb-Threatening Ischemia (CLTI), with African American (AA) patients being more likely to undergo amputation than White patients. Previous studies have explored these disparities, but few specifically investigate these differences among patients with both CLTI and ESKD. This study aimed to compare outcomes by race among patients with both CLTI and ESKD undergoing infrainguinal bypass, our hypothesis being that AA patients would experience significantly worse postoperative outcomes than White patients.
MethodsUsing the Vascular Quality Initiative (VQI), we examined graft occlusion, reintervention, amputation, and mortality among infrainguinal bypass patients within the index hospitalization and 2-year follow-up between 2007 and 2020. AA and White patients with both ESKD and CLTI aged 18 to 80 were included, while patients with any history of ipsilateral revascularization or aneurysmal disease were excluded. Index hospitalization outcomes were evaluated using chi-square or t-tests, and Mann-Whitney tests where appropriate. Kaplan-Meier plots and Cox regressions were used to examine graft occlusion, reintervention, amputation, and death during follow-up. Among the variables included in multivariable model were sex, diabetic status, smoking history, aspirin use, prosthetic vs. vein graft placement, body mass index, and ankle brachial index.
ResultsA cohort of 1,475 patients was identified, consisting of 18.3% (537) AA and 8.2% (938) White patients. White patients were more likely to be male (69.3 vs 60.0%, p<.001), have a smoking history (W-73.2 vs AA-66.7%, p=.008) and to have diabetes (W-63.0 vs AA-53.8%, p=.001). AA patients had higher rates of tibioperoneal trunk and tibial artery disease (AA-54.7 vs W-61.5%, p<.011). No difference was found in the use of prosthetic vs vein grafts (AA-41.8 vs W-38.4%, p=.195). AA patients had longer median lengths of stay(LOS) (AA-13 [IQR 6-20] vs W-10.5 days [IQR 6-18], p=.019). There was no difference in perioperative graft occlusion (AA-3.4% vs. W-3.7%, p=.766), reintervention, (AA-22.2% vs. W-21.6%, p=.804), amputation (AA-4.8% vs. W-3.9%, p=.362), or mortality (AA-3.5 vs. W-4.9%, p=.220). At 2 years, AA patients had significantly higher adjusted rates of amputation (Figure 1; p=.001) but had lower adjusted mortality rates (Figure 2; p<.001). There was no statistically significant difference in long term graft occlusion or reintervention.
ConclusionsDuring index hospitalizations, only median LOS was found to be different between the groups, with no significant differences in graft occlusion, reintervention, amputation, or mortality. Racial disparities, however were seen during 2 year follow-up: AA patients with ESKD and CLTI were associated with higher amputation rates, but lower mortality rates than White patients over 2 years. Further study to determine the etiology of these disparities is needed to ensure equitable care. 
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