Abstract
BackgroundPatients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients.ObjectiveThe aim is to conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization.MethodsWe will search electronic bibliographic databases (MEDLINE, EMBASE, the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review papers identified during the search, and included article bibliographies. We will include randomized and nonrandomized studies comparing the use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate the risk of bias. The primary outcome will be short-term (in-hospital or 30-day) mortality. Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, renal, and limb events; delirium; deep vein thrombosis or pulmonary embolism; neuraxial or regional anesthesia–related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios (ORs) and standardized mean differences (SMDs) using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using the Begg and Egger tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to make an overall rating of the quality of evidence in our effect estimates.ResultsThe protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30, 2021, and plan to complete the review of full-text papers by September 30, 2021. We will complete full-text study data extraction and the risk-of-bias assessment by November 15, 2021, and conduct qualitative and then quantitative data synthesis and GRADE assessment of results by January 1, 2022, before drafting the manuscript. We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022.ConclusionsThis study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial.Trial RegistrationProspero CRD42021237060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=237060International Registered Report Identifier (IRRID)PRR1-10.2196/32170
Highlights
BackgroundLower limb revascularization surgeries are commonly performed across North America [1,2,3,4]
We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022
This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for peripheral artery disease (PAD) results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay
Summary
BackgroundLower limb revascularization surgeries (ie, endarterectomy, patch angioplasty, and arterial bypass) are commonly performed across North America [1,2,3,4]. Patients undergoing lower limb revascularization surgery for PAD are typically older (average age of approximately 70 years), are current or past cigarette smokers, and have several comorbidities that place them at high risk for perioperative morbidity and mortality [2,3] These include diabetes and coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease [2,3]. Compared to adults with coronary artery or cerebrovascular disease, those with PAD have a higher risk of cardiovascular events, hospitalization, and hospitalization for coronary, carotid, or lower limb revascularization [8] Those patients undergoing lower limb revascularization surgery for PAD often require long postoperative (and sometimes preoperative) hospital stays and consume substantial health care system resources [9,10]. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients
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