Performance of the Emergency Surgery Score for Nonelective Aortoiliac Endovascular Reconstructions

Abstract

The Emergency Surgery Score (ESS) has been previously validated as a reliable tool to predict postoperative outcomes in emergency general surgeries and some vascular surgeries. The purpose of this study was to assess the performance of the ESS for endovascular aortoiliac revascularization procedures in the nonelective setting (neAER). The American College of Surgeons’ National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing neAER between 2015 and 2019. The performance of the ESS in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. A total of 838 patients underwent neAER with a median age of 65 (+11.99 standard deviation), with 400 females (47.7%). The 30-day mortality rate was 5.0%. The ESS correlated with 30-day mortality (area under the curve [AUC] was 0.786). The score gradually and accurately predicted 30-day mortality; 0%, 0.81%, 11.48%, 25%, and 100% of patients with ESS of 0, 4, 8, 12, and 16 died within 30 days after surgery, respectively. ESS was also used to calculate risk of death/discharge to hospice (AUC: 0.790), discharge to rehab (AUC: 0.686), renal failure (AUC: 0.715), reintubation (0.681), postintervention ventilation requirement (0.735), deep venous thrombosis (0.660), cardiopulmonary arrest (0.733), and septic shock (0.796). A cumulative frequency table of mortality with ESS was used to partition patients into quartiles of ESS <5, ESS of 6 or 7, ESS of 8 or 9, and ESS >10. A Cochran-Armitage test showed a linear trend toward increased 30-day mortality among the quartiles with increasing ESS (P < .001), with quartile 4 (ESS >10) having 76 times odds of increased 30-day mortality compared with reference quartile 1 (ESS <5) (Table). The correlation between the increasing ESS and observed 30-day mortality is displayed in the Fig. ESS performance accurately predicts mortality for neAER procedures. Its use may be useful for preoperative risk stratification and has the potential to be used for national benchmarking after these endovascular procedures.TableMultivariate analysis showing effects of predictors on 30-day mortalityVariableOdds ratioP valueSex (ref male)2.769.176Hispanic (ref not)0.000.998Preoperative ABI 0.9 or less (ref preoperative ABI >0.9)0.601.677Aortic stent1.808.638External iliac stent0.069.019CLTI (ref asx/claudicant)0.901.932High-risk anatomic factors1.715.485High-risk physiological factor1.642.517ESS score (ref score ≤5) 6 ≤ ESS ≤ 716.220.02 8 ≤ ESS ≤ 914.392.054 10 ≤ ESS76.252<.001C-statistic0.891Boldface type indicates statistical significance.ABI, Ankle-brachial index; CLTI, chronic limb-threatening ischemia; ESS, Emergency Surgery Score. Open table in a new tab