Chronic kidney disease and outcomes after transcatheter aortic valve replacement in patients with severe peripheral arterial disease: insights from the Hostile registry

Chronic kidney disease (CKD) often coexists with aortic stenosis and worsens outcomes after transcatheter aortic valve replacement (TAVR). CKD is also associated with peripheral artery disease (PAD), but its impact in severe PAD patients undergoing TAVR remains unclear.

To evaluate the effect of CKD on PAD severity and outcomes after TAVR.

The HOSTILE registry included patients with severe PAD undergoing TAVR via transfemoral access (TFA, 30%) after iliofemoral revascularization, transalternative access (32%), or transthoracic access (38%). Patients were stratified by estimated glomerular filtration rate (eGFR) into low (≤48.0 mL/min/1.73 m²; n = 565) and intermediate/high (>48.0 mL/min/1.73 m²; n = 1130) groups. The primary endpoint was major adverse events (MAEs) at 30 days and 12 months, adjusted using propensity score and overlap weighting.

PAD characteristics were comparable across eGFR strata. Low eGFR was associated with higher 30-day MAEs (aHR 1.24, P = .018), mainly driven by major vascular complications (aHR 1.32, P = .006). At 1 year, MAEs (aHR 1.28, P = .003) and mortality (aHR 1.53, P = .002) remained increased, although landmark analysis suggested predominantly peri-procedural risk. Using an eGFR cut-off of 30 mL/min/1.73 m² confirmed worse 30-day and 1-year MAEs, mortality, and cardiac death, with increased 1-year bleeding. In TFA patients, low eGFR predicted higher 30-day MAEs (aHR 1.77, P = .002) and mortality (aHR 2.83, P = .025), and 1-year MAEs (aHR 1.77, P = .001) and mortality (aHR 2.31, P = .003), with significant access–eGFR interaction.

In severe PAD patients undergoing TAVR, CKD amplifies peri-procedural risk, especially early vascular complications. Although TFA remains associated with better outcomes, its benefit appears attenuated in patients with renal dysfunction.