Why does a patient on peritoneal dialysis need an intervention on the superficial femoral artery?

Why Patients on Peritoneal Dialysis May Need Superficial Femoral Artery Intervention

Patients on peritoneal dialysis requiring SFA intervention most commonly present with peripheral artery disease causing either critical limb ischemia (rest pain, non-healing ulcers, gangrene) or lifestyle-limiting claudication, as dialysis patients have accelerated atherosclerosis and increased risk of limb-threatening ischemia. 1, 2

Primary Clinical Indications

Critical Limb Ischemia (Most Common and Urgent)

• Dialysis patients with PAD have significantly higher rates of critical limb ischemia compared to non-dialysis patients, presenting with ischemic rest pain, non-healing ulcerations, or gangrene 1
• Mortality rates reach 20% within 6 months and exceed 50% at 5 years if left untreated, making revascularization critical for reducing morbidity and mortality 1
• The SFA (extending from the common femoral artery bifurcation to the adductor canal) is frequently affected by atherosclerotic disease, particularly at the proximal bifurcation and distal adductor canal where compression occurs 1, 3, 4

Lifestyle-Limiting Claudication

• Patients with intermittent claudication affecting vocation or lifestyle who have failed conservative management (supervised exercise 30-45 minutes, 3 times weekly for minimum 12 weeks, plus cilostazol for ≥3 months) require intervention 1
• SFA stenosis or occlusion is the most common lesion causing intermittent claudication, typically manifesting as calf discomfort with ambulation that resolves with rest 1

Why Dialysis Patients Are at Higher Risk

Accelerated Atherosclerosis

• Chronic hemodialysis (and by extension, dialysis in general) is associated with high prevalence of PAD and accelerated atherosclerotic disease 2
• Dialysis patients present at significantly younger ages with more symptomatic limb ischemia compared to non-dialysis patients, despite similar lesion severity 2

Prognostic Factors

• Hemodialysis status is specifically identified as a comorbidity affecting two-year survival estimates in patients with lower extremity PAD 1
• This places dialysis patients in a higher-risk category requiring more aggressive limb salvage strategies 1

Treatment Approach for PD Patients with SFA Disease

For Critical Limb Ischemia

• Both endovascular and surgical revascularization are appropriate (median score 8/9) for all anatomic subsets in CLI, as revascularization is critical for reducing high morbidity and mortality 1
• Endovascular stent placement in the SFA is feasible, safe, and effective in dialysis patients, with primary patency, assisted primary patency, and limb salvage rates comparable to non-dialysis patients 2
• Primary stent placement may be offered as first-choice therapy for dialysis patients with SFA lesions 2

For Claudication

• Intervention is appropriate only after documented failure of supervised exercise therapy (minimum 12 weeks) and pharmacotherapy (cilostazol ≥3 months) 1
• For short lesions (≤10 cm), percutaneous transluminal angioplasty is the preferred endovascular option 5
• Self-expanding nitinol stents appear to improve mid-term results for SFA interventions 3

Critical Pitfalls to Avoid

• Do not intervene for claudication without documented failure of conservative therapy (exercise and cilostazol for specified durations) 1
• Do not delay revascularization in CLI, as mortality and limb loss rates are extremely high without intervention 1
• Recognize that isolated SFA occlusion rarely causes advanced ischemia due to collateral circulation through the deep femoral artery, but combined inflow/outflow disease causes more severe symptoms 1
• Hemodialysis status (and likely PD status) increases baseline risk, warranting consideration of more aggressive limb salvage strategies 1, 2

Additional Consideration: Vascular Access Facilitation

• In rare circumstances, peripheral artery procedures may be needed to facilitate arterial access for life-saving cardiovascular procedures (e.g., large-diameter catheter placement for hemodynamic support devices) 1
• This indication applies when alternate vascular access has been considered and peripheral artery access is deemed the best option 1
• These revascularizations are not undertaken for PAD management per se, but to facilitate necessary care dependent upon suitable vascular access 1