Polyvascular Disease is Common in Patients Undergoing Carotid Endarterectomy and Lower Extremity Bypass and is Associated With Worse Outcomes

Abstract

IntroductionPolyvascular disease is strongly associated with increased risk of cardiovascular morbidity and mortality. However, its prevalence in patients undergoing carotid and lower extremity surgical revascularization and its impact on outcomes are unknown. MethodsThe Vascular Quality Initiative was queried for carotid endarterectomy (CEA) or infrainguinal lower extremity bypass (LEB), 2013-2019. Polyvascular disease was defined as presence of atherosclerotic occlusive disease in > 1 arterial bed: carotid, coronary, and infrainguinal. Primary outcomes were: (1) composite perioperative myocardial infarction (MI) or death and (2) 5-year survival. Patient characteristics and perioperative outcomes were evaluated using chi-square test and multivariable logistic regression. Survival was analyzed using Kaplan-Meier method and Cox proportional hazards multivariable models. ResultsPolyvascular disease was identified in 47% of CEA (39% 2 arterial beds, 7.6% 3 arterial beds; n = 93,736) and 47% of LEB (41% 2 arterial beds, 5.7% 3 arterial beds; n=25,223). For both CEA and LEB, patients with polyvascular disease had more comorbidities including hypertension, congestive heart disease, chronic obstructive pulmonary disease, smoking, diabetes mellitus, and end-stage renal disease (P<0.0001). Perioperative MI/death rates increased with increasing number of vascular beds affected following CEA (0.9% 1 bed vs 1.5% 2 beds vs 2.7% 3 beds, P<0.001) and LEB (2.2% 1 bed vs 5.3% 2 beds vs 6.6% 3 beds, P<0.001). Polyvascular disease was independently associated with perioperative MI/death after CEA (OR 1.59 (95% CI 1.40-1.81), P<.0001) and LEB (OR 1.78 (95% CI 1.52-2.08), P<.0001). Five-year survival was decreased in patients with polyvascular disease after CEA (82% 3 beds vs 88% 2 beds vs 92% 1 bed, P<0.01) and LEB (72% 3 beds vs 75% 2 beds vs 84% 1 bed, P<0.01) in a dose-dependent manner, with the lowest 5 year survival observed in those with 3 arterial beds involved. Polyvascular disease was independently associated with five-year mortality following CEA (HR 1.33 (95% CI 1.24-1.40), P=0.0001) and LEB (HR 1.30 (95% CI 1.20-1.41), P=0.0001). ConclusionPolyvascular disease is common in patients undergoing CEA and LEB and is associated with higher risk of perioperative MI/death and decreased long-term survival. Following revascularization, polyvascular disease patients may be considered for more aggressive cardioprotective medications and closer follow up.