Liver Disease is Associated with Increased Mortality and Major Morbidity After Infra-Inguinal Bypass but not After Endovascular Intervention

Abstract

Liver disease increases mortality after abdominal surgery, including endovascular aortic aneurysm repair. However, its effect on mortality and morbidity after endovascular and open management of peripheral vascular disease has not been widely evaluated. The National Surgical Quality Improvement Program was used to evaluate patients undergoing infra-inguinal bypass and endovascular intervention (2005 - 2016). Aspartate aminotransferase to platelet ratio (APRI score) is a non-invasive tool recommended by the World Health Organisation to identify liver disease and was calculated for all patients. A ratio of > 0.5 was used to identify patients with liver fibrosis. Demographics, comorbidities, and 30 day outcomes were evaluated for patients with and without liver fibrosis. A subgroup analysis was completed in patients with APRI scores > 0.5, to evaluate the effect of increasing Model for End-Stage Liver Disease (MELD) scores on outcomes. Multivariable regression was used to account for differences in baseline factors. In total, 17 603 patients underwent infra-inguinal bypasses. Fibrosis was associated with higher mortality (3.8% vs. 2.4%; p < .001), major complications (23% vs. 20%; p= .020), pulmonary (5.1% vs. 2.9%; p < .001), and renal complications (1.9% vs. 1.1%; p= .007) after bypass. These differences persisted following multivariable adjustment. Altogether, 7 830 patients underwent endovascular intervention. Fibrosis was also associated with higher mortality (4.7% vs. 2.2%; p < .001), pulmonary (3.9% vs. 2.5%; p= .022), and renal complications (1.9% vs. 0.8%; p= .003) after endovascular intervention. After adjustment, only renal complications persisted. In a subgroup analysis of patients with liver fibrosis, morbidity (31% vs. 17%; p < .001) and mortality (7.2% vs. 1.8%; p < .001) increased after bypass among those with MELD scores > 15 but not after endovascular intervention. Liver fibrosis was associated with higher 30 day mortality and major complications after infra-inguinal bypass, with outcomes worsening as MELD scores increased. Surgeons may consider an endovascular first approach in managing peripheral arterial disease among those with liver fibrosis.