Infrainguinal Bypass Research Articles

Immediate postoperative hyperglycemia after peripheral arterial bypass is associated with short-term and long-term poor outcomes

ObjectiveAlthough the impact of poorly controlled diabetes on surgical outcomes of patients undergoing lower extremity revascularization is well-known, it is not clear if immediate postoperative hyperglycemia (IPH) itself can be used as a surrogate for poor outcomes after peripheral arterial bypass. We sought to examine the effect of IPH in this patient population with its impact on short-term and long-term outcomes. MethodsRetrospective review was completed for 505 patients who underwent either suprainguinal bypass surgery or infrainguinal bypass surgery between July 2002 and April 2018 for the treatment of peripheral arterial disease. All patients were undergoing first-time open bypass grafting. Patients were stratified into those who were normoglycemic or hyperglycemic (glucose ≥ 140 mg/dL) within 24 hours after surgery. A comparative analysis was performed on comorbidities and outcomes. ResultsOf 505 patients who underwent bypass grafting, 255 patients (50.5%) were hyperglycemic. The mean age of patients was 63.5 ± 14.1 years. The median follow-up was 5.2 years (range, 0.0-15.2 years). The distribution of procedures was as follows: femoral to popliteal bypasses (29%), femoral to femoral bypasses (17%), femoral to tibial bypasses (12%), aortobifemoral bypasses (10%), iliofemoral bypasses (9%), and axillofemoral bypasses (7%). At 30 days, hyperglycemic patients had an increased incidence of limb loss (8.3% vs 4.0%) and myocardial infarction (4.8% vs 0.8%) and incurred higher costs of hospital stay ($27,701 vs $22,990) (all P < .05). At 10 years, these patients had a higher incidence of needing major amputations (15.4% vs 9.4%; P = .025). Hyperglycemia after infrainguinal bypass was associated with nearly twice the risk of limb loss at 5 years (hazard ratio, 1.91; P = .034). Among the cohort of patients who required major amputations, the time duration between index revascularization and amputation was significantly shorter as compared with normoglycemic patients (P = .003). ConclusionsIn this single-institution study with long-term follow-up, IPH was associated with increased rates of 30-day amputation and myocardial infarction, as well as an increased cost of hospital stay. In the long term, postoperative hyperglycemia was associated with greater major limb loss. Among the cohort of patients who required major amputations, the time period between revascularization and amputation was shorter for those patients who had IPH. IPH is an independent marker for poor outcomes after lower extremity revascularization procedures.

The association between preoperative length of stay and surgical site infection after lower extremity bypass for chronic limb-threatening ischemia

ObjectiveSurgical site infection (SSI) is an important complication of lower extremity bypass (LEB) and the rate of SSI after LEB varies widely in the existing literature, ranging from 4% to 31%. Prolonged length of stay (LOS) has been implicated in the occurrence of SSI across multiple surgical disciplines. The impact of preoperative LOS in patients with chronic limb-threatening ischemia (CLTI) undergoing LEB is unknown. We examined the association of preoperative LOS on SSI after LEB. MethodsA retrospective analysis of the Society for Vascular Surgery Vascular Quality Initiative Infrainguinal Bypass Registry identified patients undergoing elective LEB for chronic limb-threatening ischemia from 2003 to 2019. Patients undergoing LEB for acute limb ischemia, urgent/emergent procedures, aneurysm, or who had concomitant suprainguinal bypass were excluded. The primary outcome measure was postoperative SSI. Multivariable forward stepwise logistic regression was then performed including all variables with a P value of less than .10 in both matched and unmatched cohorts to evaluate for demographic and perioperative predictors of SSI. Propensity score matching was used to create matched cohorts of patients for each LOS group. ResultsA total of 17,883 LEB procedures were selected for inclusion: 0 days (12,362 LEB), 1 to 2 days (1737 LEB), and 3 to 14 days (3784 LEB). Patients with the greatest preoperative LOS were more likely to have vein mapping (0 days preoperative LOS, 66.3%; 1-2 days, 65.2%; 3-14 days, 73.2%; P < .01) or computed tomography angiography/magnetic resonance angiography (0 days, 32.1%; 1-2 days, 34.4%; 3-14 days, 38.4%; P < .01). Patients with 3 or more days of preoperative LOS had longer procedure lengths (0 days, 244 minutes; 1-2 days, 243 minutes; 3-14 days, 255 minutes; P < .01) and were more likely to have completion angiogram (0 days, 27.1%; 1-2 days, 29.5%; 3-14 days, 31.6%; P = .02). Multivariable logistic regression demonstrated that preoperative LOS of 3 to 14 days was associated with increased rate of SSI (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.20-3.07; P = .01). Transfusion of 3 or more units (OR, 2.87; 95% CI, 1.89-4.36; P < .01) and prolonged procedure length (>220 minutes; OR, 1.86; 95% CI, 1.26-2.73; P < .01) were also significantly associated with postoperative SSIs. ConclusionsMany factors including preoperative comorbidities and operative complexity covary with preoperative LOS as risk factors for SSI. However, when patients are matched based on comorbidities and factors that would predict overall clinical complexity, preoperative LOS remains important in predicting SSI.

Patient and Institutional Costs of Failure of Angioplasty of the Superficial Femoral Artery

Debate surrounds the optimal management of superficial femoral artery (SFA) disease. Randomized trial data rarely reflect real world findings, specifically the consequences to the patient of angioplasty failure. We observed the effect of a failed SFA angioplasty on the need for repeated clinic visits, hospital readmissions, imaging requirements, and reinterventions. We reviewed a consecutive series of 148 patients (94 men, median age 72years) undergoing solely SFA angioplasty over a 2-year period. Patient preangioplasty demographics and 2-year post-PTA follow-up data were collated, including hospital attendances (inpatient/outpatient), further imaging (including radiation exposure) and revascularization attempts. We defined "failed angioplasty" as presence of clinical symptoms with radiological evidence of significant restenosis after an initial successful primary SFA angioplasty. Fifty-four patients represented with a failed angioplasty (median time of 4months after index PTA). In this group, failure of index angioplasty resulted in a further 185 restenosis-related clinic visits and a total of 537 bed days of inpatient stay. This group underwent a further 149 imaging events and required a further 34 endovascular revascularization procedures and 12 infrainguinal bypass procedures. These interventions and investigations corresponded to overall effective radiation dose across all patients of 190.69mSv. Of the cohort of 99 patients who did not have a "failed angioplasty," they required 100 clinic visits, 21 further scans (total radiation dose 6.42mSv), and 36 bed days of inpatient admission. Failed angioplasty results in significant additional consequences for patients and health-care systems. Further work should focus on refining decision-making, providing the right procedure to the right patient at the right time.

Medicare reimbursement of lower extremity bypass does not cover cost of care for most patients with critical limb ischemia

ObjectiveLower extremity bypass surgery remains an important treatment option for patients with critical limb ischemia (CLI), but is resource intensive. We sought to evaluate the cost and Medicare reimbursement for lower extremity bypass surgery in patients with CLI. MethodsHospital cost accounting systems were queried for total technical and professional costs incurred and reimbursement received for patients with CLI undergoing lower extremity bypass at our center between 2011 and 2017. Patients were identified by assignment to Diagnosis-Related Group (DRG) 252, 253, or 254 (other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity, respectively). Additional clinical data were incorporated from the Vascular Quality Initiative clinical registry. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by DRG. We compared technical, professional, and total costs; reimbursement; and contribution margins across DRGs using univariate statistics and evaluated factors associated with total contribution margin using median quantile regression. ResultsWe analyzed 68 patients with hemodynamically confirmed CLI (46% rest pain, 54% tissue loss), of whom 25% received a prosthetic graft. Mean age was 66.1 ± 11.6 years, 69% were male, 49% diabetic, 44% current smokers, and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex DRG 252 (median, $2490; interquartile range [IQR], −$1,621 to $10,080). In the majority of patients with less complex DRG 253 (median, −$3,100; IQR, −$8499 to $109) and DRG 254 (median, −$4902; IQR, −$9259 to $1059), reimbursement did not cover the cost of care. Both technical costs and professional costs varied significantly with the complexity of DRG. Although reimbursement from technical services increased alongside increasing complexity of DRG, there was insignificant variation in professional reimbursement as DRG complexity increased. On multivariable modeling, longer length of stay (−$2547 per additional day) and preoperative dialysis (−$5555) were significantly associated with negative margins. ConclusionsFor the majority of patients with CLI, current Medicare reimbursement does not adequately cover the cost of providing care after open bypass surgery. As commercial insurers move toward Medicare reimbursement rates, more granular risk stratification profiles are needed to ensure open surgical care for patients with CLI remains financially sustainable.

Effect of Perioperative Blood Transfusion in Anemic Patients Undergoing Infrainguinal Bypass

Patients who present with lower extremity ischemia are frequently anemic, and the optimal transfusion threshold for this cohort has remained controversial. We sought to evaluate the effect of blood transfusion on major adverse cardiac events (MACE), including myocardial infarction, dysrhythmia, stroke, congestive heart failure, and 30-day mortality for these patients. All consecutive patients who had undergone infrainguinal bypass at our institution from 2011 to 2020 were included. The primary outcome was MACE, and blood transfusion was the primary exposure. Univariate and multivariable analyses were performed to assess the effects of patient and procedural variables, including red blood cell transfusion, stratified by hemoglobin (Hb) nadir (<7, 7-8, >8 g/dL). Of the 287 patients reviewed for analysis, 146 (50.9%) had required transfusion (mean, 1.6 ± 3 U). The patients who had received a transfusion had had a mean nadir Hb of 8.3 ± 1.0 g/dL compared with 10.1 ± 1.7 g/dL for those without transfusion. The overall incidence of MACE was 15.7% (45 of 287 patients). Univariate analysis demonstrated that MACE was associated with blood transfusion (P = .009), lower Hb nadir (P = .02), higher blood loss (P = .003), higher baseline creatinine (P = .02), previous coronary revascularization (P = .002), nonambulatory status (P = .03), American Society of Anesthesiologists classification 4 or 5 (P < .0001), and preoperative P2Y12 antagonist therapy (P = .049). Transfusion was independently associated with MACE for patients with a Hb nadir >8 (odds ratio [OR], 3.09; P = .006) but not for patients with a Hb nadir of 7 to 8 (OR, 0.818; P = .77). The effect in the Hb nadir <7 group was inconclusive (Fig). The only other variables independently associated with MACE were previous coronary revascularization (OR, 2.58; P = .01) and higher blood loss (OR, 1.05; P = .02). The hospital length of stay for patients with MACE was significantly longer than that for patients without MACE (14.8 vs 8.2 days; P < .001). For patients undergoing infrainguinal bypass, receiving a transfusion with a Hb nadir >8 was associated with a threefold increase in MACE, with a length of stay twice as long. For patients with a Hb of 7 to 8, transfusion did not increase or reduce the incidence of MACE. These findings suggest no benefit of blood transfusions for patients with a Hb nadir >7 and harm for those with a Hb nadir >8.

Influence of Operative Time in the Results of Infrainguinal Bypass for Chronic Limb Threatening Ischemia.

An increased operative time (OT) has been associated with a higher rate of adverse outcomes after several surgical procedures although scarce evidence exists for infrainguinal bypass surgery (IBS) and its impact beyond the postoperative period. The aim of this study was to define surgical characteristics related to a prolonged OT in IBS for chronic limb threatening ischemia and its influence on postoperative and 1-year outcomes. Retrospective study of 249 consecutive patients (mean age 72.4years, 73.1% male) undergoing IBS for CLI between 2008 and 2018. The characteristics related to the duration of surgery and its impact on outcome were assessed with a multiple linear regression and a multivariate logistic regression, respectively. Interventions associated with a prolonged OT included the bypass to a below-the-knee artery (additional 36min, p = 0.002), the need for an alternative vein or a hybrid PTFE-vein graft (additional 37min, p = 0.02) and inflow associated procedures (additional 47min, p < 0.001). OT was associated with a higher rate of postoperative complications (OR for each additional 30min 1.123, 95% CI 1.021-1.234) and need for a sociosanitary facility at discharge (OR 1.143, 95% CI 1.033-1.265). At 1-year of follow-up, OT was related to a higher major amputation rate (OR 1.201, 95% CI 1.036-1.393) and non-significantly to mortality (OR 1.125, 95% CI 0.999-1.268). A prolonged OT is a risk factor for adverse outcomes after IBS that extends beyond the immediate postoperative period. Further research is needed to evaluate how an expected high OT might influence decision-making.

Endoluminal interventions versus surgical interventions for stenosis in vein grafts following infrainguinal bypass

Background Bypass surgery using a large saphenous vein graft, or another autologous venous graft, is a well-recognised treatment option for managing peripheral arterial disease of the lower limb, including chronic limb-threatening ischaemia (CLTI) and intermittent claudication, peripheral limb aneurysms, and major limb arterial trauma. Bypass surgery has good results in terms of limb preservation rates and long-term graft patency but is limited by the possibility of vein graft failure due to stenoses of the graft. Detection of stenoses through clinical and ultrasonographic surveillance, followed by treatment, is used to avoid graft occlusion. The conventional approach to treatment of patients with graft stenosis following infrainguinal bypass consists of open surgical repair, which usually is performed under general anaesthesia. Endoluminal treatment with angioplasty is less invasive and uses local anaesthesia. Both methods aim to improve blood flow to the limb. Objectives To assess the effectiveness of endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to 25 August 2020. Selection criteria We aimed to include all published and unpublished randomised controlled trials (RCTs) that compared endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. Data collection and analysis Two review authors independently assessed all identified studies for potential inclusion in the review. We aimed to use standard methodological procedures in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The main outcomes of interest were primary patency, primary assisted patency, and all-cause mortality. Main results We identified no RCTs that met the inclusion criteria for this review. Authors' conclusions We found no RCTs that compared endoluminal interventions versus surgical intervention for stenosis in vein grafts following infrainguinal bypass. Currently, there is no high-certainty evidence to support the use of one type of intervention over another. High-quality studies are needed to provide evidence on managing vein graft stenosis following infrainguinal bypass.

Failed Prior Endovascular Interventions Do Not Affect 30-day Cardiovascular or Limb-related Outcomes of Infrainguinal Bypasses for Chronic Limb Threatening Ischemia

It is often hypothesized that failed prior endovascular intervention could adversely affect the outcome of subsequent infrainguinal bypass in the corresponding limb. However, this perception is not well supported in the literature because of conflicting data. The aim of this study is to address this controversial issue via analysis of a multicenter prospectively collected database. Patients who underwent infrainguinal bypass for chronic limb threatening ischemia (CLTI) were identified in the targeted American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2017. These patients were stratified into 4 groups: first time femoral-popliteal bypass, femoral-popliteal bypass after failed prior endovascular revascularization, first time femoral-tibial bypass, and femoral-tibial bypass after failed prior endovascular revascularization. Thirty-day outcomes including mortality, graft patency, major amputations, and major organ dysfunction were measured. We identified 7,044 patients who underwent surgical bypasses for CLTI. Patients were mostly well matched among the 4 groups except for differences in sex, hypertension, and preoperative renal function. In terms of major adverse cardiovascular events and major adverse limb events, femoral-popliteal or femoral-tibial bypasses after failed prior endovascular intervention had comparable 30-day outcomes to first-time bypasses. However, patients with failed prior endovascular intervention had increased rates of postoperative wound infection, required significantly more blood transfusions, and had longer operative time. Failed prior endovascular intervention does not adversely affect 30-day outcomes of subsequent infrainguinal bypass surgery in mortality, limb salvage, or other major cardiovascular complications.

An Endovascular-First Approach for Aortoiliac Occlusive Disease is Safe: Prior Endovascular Intervention is Not Associated with Inferior Outcomes after Aortofemoral Bypass

Although prior endovascular intervention is a risk factor for inferior outcomes after infrainguinal bypass, there are few studies evaluating the effect of prior aortoiliac endovascular intervention (AIEI) on outcomes after aortofemoral bypass (AFB). We sought to determine if prior AIEI was predictive of adverse events after AFB. The Vascular Quality Initiative was queried for all patients who underwent AFB form 2009 to 2019. Urgent/emergent cases and repeat procedures were excluded. Primary outcomes were major perioperative complications, major adverse limb event (MALE)-free survival, and long-term survival. Multivariable logistic regression identified predictors of major complications. Predictors of MALE-free survival were identified with Cox proportional hazards modeling. There were 3,056 patients who underwent AFB; 618 had a prior AIEI. Mean age was 60.3±8.7years, and 58.7% of patients were men. There was no difference in major complications between the 2 groups (AIEI: 23.8%, no AIEI: 24.5%; P-value=0.70). Factors associated with major complications were chronic obstructive pulmonary disease (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.07-1.54; P=0.008), simultaneous lower extremity intervention (endarterectomy, bypass, or transluminal intervention, OR 1.41, 95% CI: 1.18-1.69; P<0.001), congestive heart failure (CHF) (OR 1.58, 95% CI: 1.15-2.16; P=0.004), increased age (OR 1.03 per year, 95% CI: 1.02-1.04; P<0.001), increasing operative blood loss (OR 1.35 per liter, 95% CI: 1.21-1.50; P<0.001), increasing operative time (OR 1.07 per hour, 95% CI: 1.02-1.13; P=0.008), and end-to-side proximal anastomosis (OR 1.23, 95% CI: 1.03-1.46; P=0.022). One-year MALE-Free survival was 88.2% (95% CI: 85.2-90.7%) for the prior AIEI group and 89.7% (95% CI: 88.3-90.7%) for the group without prior AIEI (logrank P-value=0.201). Predictors of MALEs/death were history of a bypass (hazard ratio [HR] 1.51, 95% CI: 1.16-1.96; P=0.002), increasing degree of ischemia on presentation (HR 1.28 per increasing level of ischemia, 95% CI: 1.16-1.41; P<0.001), diabetes (HR 1.29, 95% CI: 1.05-1.59; P=0.014), simultaneous peripheral vascular intervention (HR 2.06, 95% CI: 1.02-4.15; P=0.044), CHF (HR 1.60, 95% CI: 1.18-2.18; P=0.002), end-stage renal disease on hemodialysis (HR 5.07, 95% CI: 2.45-10.48; P<0.001), and presenting hemoglobin<9g/dl (HR 1.76, 95% CI: 1.02-3.02; P=0.041). One-year survival for the prior AIEI group was 94.5% (95% CI: 92.2-96.1%) and 94.0% (95% CI: 92.9-94.9%) for the group with no prior AIEI (logrank P=0.486). Prior AIEI did not predict any of the primary outcomes in multivariable analysis. An endovascular-first approach for aortoiliac occlusive disease appears to be safe and does not portend to inferior results after AFB.

Long-Term Impact of Vascular Surgery Stress on Frail Older Patients

Frailty is a syndrome where the ability to cope with acute physiological stress is compromised, although it is unclear what impact this stress has on long-term outcomes. Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity is a validated method for calculating levels of stress associated with vascular procedures. We designed this study to evaluate the long-term impact of different levels of surgical stress among frail older patients undergoing vascular surgery procedures. We identified all independently living patients who underwent prospective frailty assessment followed by an elective vascular surgery procedure captured in the Vascular Quality Initiative registry (endovascular abdominal aortic aneurysm [AAA] repair, thoracic endovascular aortic repair, suprainguinal and infrainguinal bypass, peripheral vascular intervention, carotid endarterectomy, and open AAA) at an academic institution between January 2016 and July 2018. Patient- and procedure-level data were obtained from our institutional data warehouse and Vascular Quality Initiative database, and used to calculate Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity scores. The association between frailty and composite outcome of any major complications (surgical site infection; graft thrombectomy; major amputation; adverse cardiac, pulmonary, or neurologic event; acute renal insufficiency; and/or reoperation related to the index procedure), nonhome living status, or death within 1year after low-, medium-, and high-stress vascular procedures was evaluated using bivariate and logistic regression models. A total of 163 patients were identified (70% male, mean age 67.8years) who underwent open AAA repair (6%), endovascular AAA repair (21%), thoracic endovascular aortic repair (7%), suprainguinal bypass (5%), infrainguinal bypass (18%), carotid endarterectomy (18%), or peripheral vascular interventions (25%), which included 44 (27%) patients diagnosed with frailty before surgery. Overall, frail patients had significantly higher rates of the 1-year composite outcome (48% frail versus 27% nonfrail; P=0.012) when compared with nonfrail patients, with a significant dose-dependent effect as the level of stress increased. In comparison, increasing levels of surgical stress had a negligible effect on long-term outcomes among nonfrail patients. The interaction between frailty and high surgical stress was found in adjusted regression models to be a significant predictor of adverse outcomes within 1year after vascular surgery (odds ratio, 3.3; 95% confidence interval, 1.3-8.6; P<0.01). Frail patients who undergo high-stress vascular procedures have a significantly higher rate of complications leading to loss of functional independence and mortality within the year after their surgery. These data suggest that estimates of surgical stress should be incorporated into clinical decision making for frail older patients before and after surgery.

Frailty Increases Reinterventions for Surgical Site Infections After Infrainguinal Bypass Procedures

Surgical site infection (SSI) contributes to a high burden of vascular morbidity, particularly in lower limb revascularizations. While frailty has been associated with higher mortality and readmission rates after surgery, less is known about frailty’s relationship with SSI. Thus, we sought to explore the association of frailty with SSI after infrainguinal bypass.

Contemporary Results of In Situ Versus Reversed Autologous Saphenous Vein Infrainguinal Bypass for the Management of Lower Extremity Arterial Disease

The objective was to retrospectively assess early and long-term results in patients undergoing infrainguinal vein bypass for peripheral artery obstructive disease (PAOD) using either in situ or reversed grafts in a single-center experience.

Femorotibial Bypass Versus Popliteal-tibial Bypass—The Impact of Choosing a More Distal Inflow

The outcomes following any surgical bypass are in part impacted by the inflow, conduit, and outflow of the bypass. There are limited data on how choosing a more proximal inflow during lower extremity infrainguinal bypass will impact outcomes. Additionally, fewer studies have assessed outcomes of the popliteal-tibial bypass.

Preoperative d-ROMs as a Biomarker for Predicting Graft Failure After Distal Bypass Surgery in CLTI Patients

Autologous vein graft is one of reliable conduit; however, intimal hyperplasia (IH) is the main cause of vein graft failure after bypass surgery. If we can predict the IH before bypass surgery, we may perform appropriate revascularization, and serve better life prognosis for patients with chronic limb-threatening ischemia (CLTI). The aim of this study was to clarify the biomarker for predicting IH development preoperatively. This prospective study included 69 patients (73 limbs) who underwent infrainguinal bypass surgery for CLTI between April 2016 and June 2018 in single center (73% diabetes and 46% dialysis). Various factors associated with graft failure due to IH development were analyzed by the Cox proportional hazard model. IH was defined by angiogram (computed tomography scan or digital subtraction angiography; >75% stenosis) or peak systolic velocity of greater than 3.0 m/s by duplex ultrasound surveillance. There were 43 (59%) patients with WIfI stage 4 disease and there was significant difference in d-ROMs (as oxidative stress marker) by WIfI stage (stage 3, n = 295 vs stage 4, n =346; P = .034). Fifty-two (71%) grafts were patent (P group) and IH was occurred in 21 (29%) grafts (IH group). Forty-eight grafts (65%) were of poor quality and primary graft patency was 69% at 1 year and 63% at 2 years. There were significant differences in d-ROMs (P, n = 308 vs IH, n = 366; P = .027) and poor graft quality (P, n = 29 vs IH, n = 19; P = .041) between the two groups. Multivariate analysis demonstrated two statistically significant predictors of high d-ROMs in IH group (cut off, 316; area under the curve, 0.63): female (odds ratio, 0.152; 95% confidence interval, 0.041-0.569; P = .005), poor graft quality (odds ratio, 5.195; 95% confidence interval, 1.33-20.25; P = .018). This study suggested that oxidative stress and graft quality strongly correlates graft patency in patients with CLTI and d-ROMs may become a biomarker for predicting IH development preoperatively.

The Comorbidity-Polypharmacy Score is an Objective and Practical Predictor of Outcomes and Mortality after Vascular Surgery

The comorbidity-polypharmacy score (CPPS) was developed to quantify the severity of comorbidities of patients with geriatric trauma. CPPS is the sum of the number of medications and comorbidities, and is thus objective, user-friendly, and potentially adaptable to many clinical situations. We sought to understand if CPPS associates with outcomes and mortality after common vascular surgery procedures. This is a retrospective single-center study. A total of 466 patients who underwent carotid endarterectomy, infrainguinal bypass, percutaneous lower extremity revascularization, or endovascular abdominal aortic aneurysm repair at a single medical center were included. CPPS were classified as mild, moderate, severe, and morbid based on scores of 0-7, 8-15, 15-21, and ≥21, respectively. End points were reinterventions, 30-day readmission, and mortality. We used chi-squared tests to analyze differences in categorical variables; Kruskal-Wallis tests to analyze differences in continuous variables; Kaplan-Meier estimation and Cox proportional hazard modeling to examine survival data; and receiver operator characteristic (ROC) curve analyses to assess sensitivity and specificity. The mean preoperative CPPS was 14.1±6.1. Higher CPPS were associated with longer hospital and postoperative length of stay (P<0.001). Severe and morbid CPPS categories had higher rates of ICU admission, reintervention, and 30-day readmission which did not reach statistical significance after correction for multiple comparisons. CPPS was independently associated with 1- and 5-year mortality in a multivariable Cox model (hazard ratio=2.2, 95% confidence interval: 1.3-3.3). ROC analysis revealed C-statistics of 0.81 and 0.72 for 1-year and 5-year all-cause mortality, respectively (P<0.001). CPPS is a simple and pragmatic clinical tool for quantifying risk of postoperative outcomes and mortality after common vascular surgery procedures. Further investigation is needed to validate the use of CPPS in enhancing existing predictors of patient outcomes and in serving as an adjunctive tool for determining resource allocation and discharge planning in patients who underwent vascular surgery.

Predictors and Consequences of Loss to Follow-up after Vascular Surgery

Loss to follow-up (LTF) after surgery impacts quality of care and can adversely affect short- and long-term clinical outcomes. This study identifies modifiable factors contributing to LTF after vascular surgery and the factors' effect on short- and long-term clinical outcomes. This is a retrospective single-center cohort study of 440 consecutive adult patients who underwent carotid endarterectomy, infrainguinal bypass, percutaneous lower extremity revascularization, or endovascular aortic aneurysm repair at Northwestern Memorial Hospital between November 2011 and November 2013. Twenty-six patients who died within 9months after surgery were excluded because of competing risks with the study end points. Demographics, medical history and medications, hospitalization and procedure-related factors, and postoperative complications were collected from the medical record. The primary end point was LTF 1month after surgery (LTF1M), defined as lack of an in-person outpatient visit with a vascular surgeon 1month after the index procedure. Secondary outcomes were LTF 1year after surgery (LTF1Y), defined as lack of an in-person outpatient visit with a vascular surgeon between 9 and 22months after discharge, and overall 5-year survival. Overall LTF1M and LTF1Y rates were 27.3% and 46.8%, respectively. Kaplan-Meier analysis revealed no difference in survival based on the LTF1M status (P=0.72), but patients who were LTF1Y had significantly worse survival at 5years (P<0.001). Seeing a nonvascular surgeon specialist at our institution (odds ratio (OR) 0.58, 95% confidence interval (CI): 0.35-0.94, P=0.03) and having a reintervention (OR 0.17, 95% CI: 0.08-0.37, P<0.001) were associated with decreased LTF1Y in a multivariable model. Overall mortality was more likely with LTF1Y (hazard ratio (HR) 3.27, 95% CI: 1.86-5.76, P<0.001) and less likely with seeing another specialist at our institution (HR 0.38, 95% CI: 0.20-0.75, P=0.005). LTF rates after vascular surgery are high and associated with poor long-term outcomes. Patients who did not see a nonvascular surgeon specialist at our institution had higher rates of LTF1Y and worse overall mortality, suggesting that improved integration of care can improve LTF and survival.

Antithrombotic Therapy in Lower Extremity Artery Disease.

Lower extremity artery disease (LEAD) is a marker of a more advanced atherosclerotic process often affecting multiple vascular beds beyond the lower limbs, with a consequent increased risk for all-cause and cardiovascular mortality. Antithrombotic therapy is the cornerstone of management of these patients to prevent ischaemic cardiovascular and limb events and death. In patients with symptomatic LEAD, the efficacy of aspirin has been established long ago for the prevention of cardiovascular events. In the current guidelines, clopidogrel may be preferred over aspirin following its incremental ability to prevent cardiovascular events, while ticagrelor is not superior to clopidogrel in reducing cardiovascular outcomes. Dual antiplatelet therapy (DAPT, aspirin with clopidogrel) is currently recommended for at least 1 month after endovascular interventions irrespective of the stent type. Antiplatelet monotherapy is recommended after infra-inguinal bypass surgery, and DAPT may be considered in below-the-knee bypass with a prosthetic graft. In symptomatic LEAD, the addition of anticoagulant (vitamin K antagonists) to antiplatelet therapy increased the risk of major and life-threatening bleeding without benefit regarding cardiovascular outcomes. In a recent trial, low dose of direct oral anticoagulant rivaroxaban plus aspirin showed promising results, not only to reduce death and major cardiovascular events, but also major limb events including amputation. Yet, this option should be considered especially in very high risk patients, after considering also the bleeding risk. Despite all the evidence accumulated since >40 years, many patients with LEAD remain undertreated and deserve close attention and implementation of guidelines advocating the use of antithrombotic therapies, tailored according to their level of risk.

Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing

ObjectiveCardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing. MethodsWe reviewed all patients who underwent elective open abdominal aortic aneurysm repair, suprainguinal bypass, endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), and infrainguinal bypass within the Vascular Study Group of New England from 2003 to 2017. We excluded patients with positive stress test results (n = 3312) and studied two mutually exclusive groups: elective surgery patients with a negative stress test result and elective surgery patients with no stress test (total n = 26,910). The primary outcome was a composite of in-hospital postoperative cardiac events (dysrhythmia, heart attack, heart failure) or death. ResultsA preoperative stress test was obtained in 66.3% of open repairs, 42.8% of suprainguinal bypasses, 37.1% of EVARs, 36.0% of CEAs, and 31.2% of infrainguinal bypasses. The proportion of patients receiving a preoperative stress test varied widely across centers, from 37.1% to 80.0%. The crude odds ratio of in-hospital postoperative cardiac event or death was 1.37 (95% confidence interval [CI], 1.07-1.76) for open repair and 1.52 (CI, 1.13-2.03) for suprainguinal bypass, indicating that patients with negative stress test results before these procedures were 37% and 52% more likely to suffer a postoperative event or die compared with patients selected to proceed directly to surgery without testing. Conversely, the crude odds ratio was 0.92 (CI, 0.66-1.29) for EVAR, 0.92 (CI, 0.70-1.21) for CEA, and 1.13 (CI, 0.90-1.40) for infrainguinal bypass, indicating that patients undergoing these procedures had a similar likelihood of sustaining an event whether they had a negative stress test result or proceeded directly to surgery without a stress test. ConclusionsThe use of cardiac stress testing before vascular surgery varies widely throughout New England. Whereas patients are often appropriately selected to proceed directly to surgery, a negative preoperative stress test result should not assuage the concern for an adverse outcome as these patients retain a substantial likelihood of cardiac events, especially after large-magnitude procedures.

Intraoperative Diagnostik in der offenen Gefäßchirurgie

Intraoperative imaging diagnostics during open vascular surgical procedures aim to enhance diagnostic certainty during the operation, ensure quality control documentation and reduce avoidable complications; however, the evidence for the various diagnostic imaging procedures with respect to improvement of perioperative outcome is not confirmed for carotid endarterectomy or for infrainguinal bypass surgery. Nevertheless, an intraoperative diagnostic control is principally recommended. The advantage of intraoperative imaging is confirmed and essential for the surgical reconstruction of bypass occlusions and acute thromboembolic occlusions.

Zinc Deficiency and Clinical Outcome After Infrainguinal Bypass Grafting for Critical Limb Ischemia.

Background: The aim of this study was to identify a relationship between zinc (Zn) deficiency and clinical outcome in patients with critical limb ischemia (CLI).Methods and Results: Forty-five limbs from 44 patients with CLI who underwent de novo infrainguinal bypass grafting (IBG) were retrospectively reviewed. The patients were divided into a Zn deficiency group (ZD group: Zn <60 µg/dL) and a Zn sufficiency group (ZS group: Zn ≥60 µg/dL). Graft patency, limb salvage (LS), amputation-free survival (AFS), and wound healing were compared between the groups. LS and AFS were examined to identify whether Zn deficiency was an independent predictor. The preoperative factors potentially predictive of Zn deficiency were also analyzed. Twenty-four limbs were categorized into the ZD group. Patients in the ZD group were more likely to have undergone hemodialysis (HD) and have lower serum albumin. The surgical procedures were not significantly different between the groups. Patency, LS, AFS, and complete wound healing rates were significantly lower in the ZD group. Zn deficiency was a negative predictor of LS. Age >75 years and HD were identified as predictors of Zn deficiency.Conclusions: Zn deficiency was associated with poor clinical outcome. Zn supplementation may improve clinical outcomes during IBG for CLI.