Postdischarge Events After Lower Extremity Revascularization

Abstract

Outcome studies using hospital discharge data likely underestimate postoperative morbidity and mortality after lower extremity revascularization because they fail to capture postdischarge events. However, the degree of underestimation and the timing of postdischarge complications are not well characterized. We used the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted databases from 2011 to 2014 to tabulate 30-day adverse events (in the hospital and after discharge) for lower extremity bypass (LEB) and endovascular interventions (ENDO) performed for claudication and chronic limb-threatening ischemia (CLTI). A total of 9165 patients underwent lower extremity revascularization (63% female; mean age, 68 years; 64% CLTI; 39% LEB). For CLTI, total 30-day mortality was 2.5% for ENDO (41% after discharge) and 3% for LEB (29% after discharge). Cardiac events occurred in 2.8% of ENDO patients (44% after discharge) and 3.9% of LEB patients (29% after discharge). Thirty-day reoperation rates were 13.2% for ENDO (49% after discharge) and 16.4% for LEB (41% after discharge). For claudication, total 30-day mortality was 0.4% (33% after discharge) for ENDO and 0.7% (17% after discharge) for LEB. Thirty-day reoperation rates were 4.1% for ENDO (60% after discharge) and 6.9% for LEB (52% after discharge; Table). As many as 41% of deaths, 44% of cardiac events, and 31% of wound infections after lower extremity revascularization occur after discharge, emphasizing the need for close surveillance after hospital discharge. The morbidity and mortality benefit of ENDO over LEB may be exaggerated by solely evaluating in-hospital data because ENDO patients have higher rates of postdischarge events as a result of shorter hospital stays. These data demonstrate the importance of reporting 30-day rather than in-hospital outcomes when evaluating postoperative adverse events.TablePostdischarge events after lower extremity revascularizationDays from operation to adverse event, mean ± SDNo. of 30-day eventsIn-hospital rate, %Postdischarge rate, %Proportion of events after discharge, %Endovascular for CLTI2037 Mortality12.9 ± 10.2511.51.041 Cardiac event6 ± 9.6571.61.244 Renal failure261.00.323 Reoperation11.9 ± 9.22686.76.549Bypass for CLTI3837 Mortality13.6 ± 9.01152.10.929 Cardiac event5 ± 6.61523.40.513 Renal failure641.40.319 Wound infection4156.63.028 Reoperation11.1 ± 9.26329.76.741Endovascular for claudication1460 Mortality14 ± 6.260.30.133 Cardiac event4.4 ± 5.680.40.125 Renal failure20.10.00 Reoperation12.2 ± 10.4601.62.560Bypass for claudication1711 Mortality6.1 ± 6120.60.117 Cardiac event3.7 ± 4.4251.30.212 Renal failure100.50.110 Wound infection1334.92.431 Reoperation11.4 ± 9.01173.33.65%CLTI, Chronic limb-threatening ischemia; SD, standard deviation. Open table in a new tab