Elective Infrainguinal Bypass Research Articles

Association of anaesthesia technique with 30-day primary graft patency after open lower limb revascularization: retrospective cohort study.

BackgroundThe relationship between anaesthetic technique and graft patency after open lower limb revascularization is unclear. The aim of this study was to evaluate the association between 30-day graft patency after elective infrainguinal bypass and anaesthetic technique (regional anaesthesia (RA, i.e. neuraxial and/or peripheral nerve blockade) compared with general anaesthesia (GA)).MethodsPatients who underwent elective infrainguinal bypass in the 2014–2019 National Surgical Quality Improvement Program Vascular Procedure Targeted Lower Extremity Open data set were included. Excluded patients were those under 18 years old, those who did not receive RA or GA, and/or had an international normalized ratio of 1.5 of greater, a partial thromboplastin time more than 35 s, or a platelet count less than 80 × 109/L. The primary outcome was primary graft patency without reintervention. The relationship between anaesthetic technique and patency was analysed with multivariable logistic regression.ResultsIncluded were 8893 patients with a mean(s.d.) age of 68(11) years and 31.5 per cent female. Within the cohort, 7.7 per cent (n = 688) patients received RA only, 90.4 per cent (n = 8039) GA only, and 1.9 per cent (n = 166) both GA and RA. In the RA-only group, 91.7 per cent (631 of 688) received neuraxial anaesthesia. The primary patency rate was 93.2 per cent (573 of 615) for RA only, and 91.5 per cent (6390 of 6983) for GA only (standardized mean difference, 0.063). RA was not associated with a higher rate of patency compared with GA (adjusted OR, 1.16; 95 per cent c.i., 0.83 to 1.63; P = 0.378).ConclusionThere was no association between anaesthetic technique and 30-day graft patency after elective infrainguinal bypass surgery. Further prospective studies would be useful to study the impact of anaesthesia technique on important patient-centred outcomes such as long-term patency and non-home discharge.

Abstract P105: Bypasses To Below-Knee Arteries May Expedite Amputation In Patients With Claudication

Objective: Claudication is an early-stage subtype of peripheral artery disease that may result in surgical intervention. The purpose of this study was to compare the types of elective bypass in a population of Black and White patients with claudication and to identify actionable areas that may explain the higher limb amputation rates observed in Black patients. Methods: We identified Black and White patients undergoing elective infrainguinal bypass for claudication using data from the Vascular Quality Initiative registry (2011-2018). Distal bypass target was classified as 1) at or above the popliteal artery (above-knee) or 2) below the popliteal, including all tibial, peroneal, dorsalis pedis and tarsal/plantar arteries (below-knee). Graft conduit was categorized as vein or prosthetic. We calculated one-year risk of major lower limb amputation with 95% confidence intervals (CI) for all combinations of target and conduit, stratified by race. We then forced an intervention on the data to estimate the post-intervention incidence of amputation and the proportion of racial disparity eliminated and 95% CI if everyone received the gold standard treatment (above-knee, vein). Results: We identified 8,401 infrainguinal bypass revascularizations for claudication (12% Black/88% White); 82% were performed above-knee and 44% of those used a vein conduit. The remaining 18% of bypasses were to below-knee arteries, of which 78% used a vein conduit. The remaining 1,534 (18.3%) bypasses were to below-knee arteries, including 1,197 (78.4%) using vein and 330 (21.6%) using prosthetic material. One-year incidence of major limb amputation was 1.6% (1.3%,1.9%) among all grafts, 1.2% (1.0%,1.5%) in above-knee grafts, and 3.3% (2.4%,4.2%) in below-knee grafts. Black patients had higher incidence of amputation across bypass target/conduit groups compared to White patients; the difference was greatest for below-knee revascularizations (8.9%, 95% CI: 4.8%,12.3% v 2.1%, 95% CI: 0.9%,2.9%). Pre-intervention amputation incidence was 1.3% (1.0%,1.5%) in White patients and 3.6% (1.9%,5.2%) in Black patients. Overall amputation incidence decreased significantly after our gold standard intervention was applied for both White (1.0%; 0.7%,1.2%) and Black (2.0%; 0.7%,3.2%) patients. The risk difference (i.e. the disparity gap) between Black and White patients was lessened post-intervention by 56.8% (31.9%,116.3%). Conclusions: We observed risk of amputation higher than would be expected based on other studies of the natural history of claudication without bypass surgery; future work should identify the mechanisms that alter the natural history of claudication via open bypass surgery. Interventions below-knee or using a prosthetic graft were particularly harmful and their harm was concentrated in Black patients.

Prospective Study of Postoperative Glycemic Control with a Standardized Insulin Infusion Protocol after Infrainguinal Bypass and Open Abdominal Aortic Aneurysm Repair

The aim of this study is to examine the effect of moderate postoperative glycemic control in diabetic and nondiabetic patients undergoing infrainguinal bypass (INFRA) or open abdominal aortic aneurysm (OAAA) repair. In a single center prospective study, we investigated postoperative glycemic control using a standardized insulin infusion protocol after elective INFRA bypass (n=53, 62%) and OAAA repair (n=33, 38%) between January 2013 and March 2015. The primary end point was optimal glycemic control, defined as having ≥85% of blood glucose values within the 80-150mg/dL target range. Suboptimal glycemic control was defined as <85% of blood glucose values within the blood glucose target range. Secondary end points included in-hospital and 30-day surgical site infection (SSI) rates, composite adverse events, length of stay (LOS), and hospital cost. Optimal glycemic control was achieved more commonly after OAAA repair than INFRA bypass (85% vs. 64%, P=0.04). Moderate hypoglycemia (<70mg/dL) was observed in 32 (37%) patients, while severe hypoglycemia (<50mg/dL) was observed in 6 (7%) patients. SSI at 30 days was more common after INFRA bypass (n=15, 29%) than OAAA repair (n=2, 6%) (P=0.01). In-hospital (6% vs. 6%, P=1.0) and 30-day (24% vs. 22%, P=1.0) SSI rates were similar for optimal versus suboptimal glycemic control patients after INFRA bypass. In-hospital (4% vs. 0%, P=1.0) and 30-day (4% vs. 0%, P=1.0) SSI rates were similar for optimal versus suboptimal glycemic control patients after OAAA repair. The percentage of blood glucose > 250mg/dL was similar for patients with and without SSI (3% vs. 2%, P=0.36). Adverse cardiac and pulmonary events after INFRA bypass were similar between groups (9%vs. 21%, P=0.23; 0% vs. 5%, P=0.36, respectively). Adverse cardiac and pulmonary events after OAAA repair were similar between groups (2% vs. 0%, P=1.0; 4% vs. 0%, P=1.0, respectively). Mean LOS was significantly lower in patients with optimal glycemic control after INFRA bypass (4.2 vs. 7.3days, P=0.02). Mean LOS was similar after OAAA repair for patients with optimal and suboptimal control (5.8 vs. 6.4days, P=0.46). Inpatient hospital costs after INFRA bypass were lower for the group with optimal (median $25,012, interquartile range [IQ] range $21,726-28,331) versus suboptimal glycemic control (median $28,944, IQ range 24,773-41,270, P=0.02). Postoperative hyperglycemia is common after INFRA bypass and OAAA repair and can be effectively ameliorated with an insulin infusion protocol. The protocol was low risk with reduced LOS and cost after INFRA bypass. Complications including SSI were not reduced in patients with optimal perioperative glycemic control.