[Peripheral arteriopathy in ESRD dialysed patients: when and how to intervene].

Critical limb ischemia secondary to chronic peripheral occlusive disease is common in chronically dialysed patients, with an incidence rate of 25-30%. Atherosclerotic lesions are more frequent in the infrainguinal arteries and long infrapopliteal occlusions often occur. Due to diabetes, hypertension and ischemic cardiopathy, the surgical prognosis is very poor in these patients; medical treatment should always be attempted associated with analgesia, without an excessive delay in surgical therapy if needed. Both spinal stimulation and lumbar simpaticectomy often fail; open and endovascular surgery are the best options before major amputation, which has a high incidence in this patient subgroup. Between 2000 and 2003, 23 chronically dialysed patients underwent surgery. Nine open and 13 endovascular procedures were performed, associated with four immediate and five late minor amputations. Despite an immediate mortality rate of 8.6%, we obtained immediate patency and limb salvage in all cases. In a medium follow-up of 25 months (range 3-36), five thromboses were found in subinguinal procedures; not one in iliac procedures. The five patients underwent major amputation. Another two patients underwent amputation despite arterious patency. Seven patients died due to cardiovascular diseases during the follow-up. Our experience confirms that the association between POAD and dialysis is a prediction factor for medium-term death and that the surgical risk is highly increased. It is important to select patients undergoing surgical treatment to check for the lowest invasivity.