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One in four patients with peripheral arterial disease (PAD) who require surgical vascular intervention are patients with chronic kidney disease (CKD).1 There is a 24–37% prevalence of PAD in patients with CKD, which is three-fold higher than the general population.2 This prevalence reaches 35.7% in those patients in the United States who have CKD and are on hemodialysis.1 All-cause mortality in patients with PAD and CKD is higher for both those who do and do not undergo renal transplantation.3

Patients with CKD tend to have higher perioperative complication rates with limb salvage procedures, including cardiac death, overall mortality, and failure of intervention, even when an operation is technically successful. The aforementioned is true for both endovascular and open surgical techniques.1

Although CKD patients make up a large percentage of patients with PAD, they appear to be offered fewer surgical interventions for revascularization or limb salvage and are more likely to undergo amputation despite revascularization.1


The Ankle-Brachial Index (ABI), according to the TASC II consensus, is the standard initial evaluation of patients who are suspected of having PAD. Table 25-1 describes the potential findings of an ABI and what these measurements imply.

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TABLE 25-1 Ankle-Brachial Index (ABI)




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Indicates global arterial stiffness/noncompressible arteries. Often seen in diabetic patients and those with long-standing chronic kidney disease (CKD), especially those on dialysis.

Toe-brachial index can be helpful in this situation, because it gives a more accurate reading. Pulse volume recordings may also give a better picture of the amount of blood flow to the distal lower extremity.



Seen in patients with mild to no peripheral arterial disease. If a patient does have PAD, they will be asymptomatic.

Lifestyle modifications to slow progression of disease.

  • Initiate statin therapy

  • Smoking cessation

  • Supervised walking program



Diagnostic of PAD. Patients can be symptomatic with claudication, i.e., leg cramping when walking, which improves with rest. There should not be any tissue loss seen in these patients.

Lifestyle modifications to slow worsening of the disease.

  • Initiate statin therapy

  • Smoking cessation

  • Supervised walking program


Critical limb ischemia

Patients will have rest pain or tissue loss: ulceration of skin on toes, dry gangrene, or wet gangrene.

Endovascular or open intervention for revascularization. Possible need for amputation.

PAD is usually described via the Rutherford and Fontaine classification systems, which can be found in Tables 25-2A and 25-2B.

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TABLE 25-2A Fontaine Classification System of Peripheral Arterial Disease


Stage I

Mild claudication

Stage IIa

Moderate to severe claudication

Stage IIb

Rest pain

Stage III

Tissue loss (ulceration, gangrene)

Stage IV

Adapted with permission from Norgren L, Hiatt WR, Dormandy JA, ...

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