Infrainguinal Bypass Research Articles

Alternative Conduits Have Worse Outcomes Than Prosthetic Grafts for Infrainguinal Bypass

Single-segment great saphenous vein (ssGSV) is the preferred conduit for infrainguinal bypass. Alternative autologous conduits (AACs) and nonautologous biologic conduits (NABCs) are thought to be a better alternative to traditional prosthetic conduits (PCs) in the absence of the ssGSV. We analyzed the outcomes of these alternative conduits in lower extremity bypass (LEB) in patients with chronic limb threatening ischemia. The Vascular Quality Initiative LEB database from 2003 to 2020 was queried to identify LEB in patients with chronic limb threatening ischemia. The primary outcomes were graft patency, major adverse limb events (MALE), and MALE-free survival at 1 year. Standard statistical methods were used as appropriate. We identified 22,671 LEB procedures (12,810 ssGSVs, 6002 PCs, 1907 AACs, and 1952 NABCs). Compared with the ssGSV group, the other conduit patients were significantly older, had more comorbidities, had an increased rate of prior lower extremity interventions, had a higher rate of infrageniculate bypass targets, and had been less ambulatory at baseline. The PC, AAC, and NABC groups had significantly higher rates of postoperative morbidity compared with the ssGSV group. The PC group had higher 30-day mortality compared with the ssGSV, AAC, and NABC groups (3% PC vs 2% ssGSV, 2% AAC, and 2% NABC; P = .049). The PC and NABC groups had higher 1-year mortality compared with the ssGSV and AAC groups (13% PC and 13% NABC vs 10% ssGSV and 10% AAC; P = .02). In an adjusted Cox regression model (Fig; stratified by infrageniculate target and adjusted for age, comorbidities, and prior vascular interventions), AAC (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.19-1.67; P < .001) and NABC (HR, 1.9; 95% CI, 1.61-2.25; P < .001) were associated with an increased risk of loss of primary patency compared with PC. A similar association with MALE was observed: both AAC (HR, 1.35; 95% CI, 1.15-1.58; P < .001) and NABC (HR, 1.8; 95% CI, 1.53-2.11; P < .001) were associated with an increased risk of MALE compared with PC. However, PC was not significantly different from ssGSV. In the absence of ssGSV, alternative autologous or nonautologous biologic materials do not confer a benefit with regard to graft patency or MALE compared with PCs. The increased operating time or costs associated with the use of these conduits was not justified from the results from the present study.

Primary Patency of Infrainguinal Bypass is Correlated to the Quality of the Profunda Femoral Artery

Primary Patency of Infrainguinal Bypass is Correlated to the Quality of the Profunda Femoral Artery

Can concomitant above-knee femoropopliteal bypass with artificial graft affect the outcome of femorofemoral bypass with artificial graft?

Few have studied the effect of concomitant femoropopliteal (FEM-POP) bypass surgery on the outcome of femorofemoral (FEM-FEM) bypass in patients with peripheral arterial disease (PAD). This study was aimed to analyze the risk relationship of concomitant FEM-POP bypass on the patency of FEM-FEM bypass. From March 2009 to April 2020, a total of 27 patients who underwent FEM-FEM bypass surgery using polytetrafluoroethylene grafts were retrospectively analyzed according to concomitant FEM-POP bypass surgery. The mean follow-up duration was 38.20 ± 34.56months. The overall primary patency of the FEM-FEM bypass grafts in all 27 patients was 83.7, 78.5, and 72.0 at one, two, and 3years, respectively. The overall limb salvage rate was 100, 94.1, and 86.9 at one, two, 3years, respectively. Among them, ten patients underwent FEM-FEM bypass only (group 1). The other 17 patients needed a concomitant FEM-POP bypass and these patients were classified into three groups (group 2, ipsilateral FEM-POP, n = 5; group 3, crossover FEM-POP, n = 6; and group 4, bilateral FEM-POP, n = 6) The comparison of the primary patency of group 1 with the concomitant FEM-POP groups (sum of groups 2, 3, and 4, that is, group 5, n = 17) revealed a statistically significant improved patency for FEM-FEM bypasses not requiring concomitant infra-inguinal bypass (p = .036). Among the concomitant FEM-POP groups, group 2 had the lowest primary patency of the FEM-FEM bypass significantly (p = 0.07). The limb salvage rate of group 4 was significantly low. A concomitant FEM-POP bypass influenced the outcome of FEM-FEM bypass surgery. In conclusion, compromised infra-inguinal runoff at either extremity requiring concomitant FEM-POP bypass significantly worsens long-term FEM-FEM bypass patency. In addition, a concomitant bilateral FEM-POP bypass is a risk factor affecting the limb salvage rate in FEM-FEM bypass.

Increasing Chronic Opioid Usage Despite Reduced Prescriptions After Vascular Surgery

Perioperative narcotics confer an increased risk of chronic opioid use (COU), but optimal prescribing in vascular surgery is undefined. The study goal was to identify current practices in perioperative opioid prescription and COU in opioid-naïve patients undergoing vascular surgery. The Optum Clinformatics Data Mart is a deidentified commercial and Medicare Advantage claims database with beneficiaries across the United States. From 2004 to 2018, adult patients undergoing vascular surgery within a 3-year continuous enrollment period were queried. Common procedural terminology codes for amputation, thoracic and abdominal endovascular aortic repair, arteriovenous fistula, carotid endarterectomy, supra- and infra-inguinal bypass, open abdominal aortic repair, peripheral endovascular intervention, and venous procedures were used. Opioid-related definitions were derived from prior literature: patients were considered opioid-naïve if they did not fill a narcotic prescription within 1 year to 14 days prior to surgery. Perioperative prescriptions were those filled between 14 days prior and 7 days after surgery, and chronic opioid use was defined as filling 10 prescriptions or a 120-day supply within the postoperative year. Morphine milligram equivalents (MME) were calculated, with perioperative totals exceeding 50 MME/day as an indicator of increased overdose risk. Multivariate logistic regression was performed to identify patient factors associated with COU. Of 119,491 patients, 66,637 (53.3%) were female, with a mean age of 64.0 ± 14.2 years. Procedures were most commonly venous (44.6%), followed by peripheral endovascular interventions (14.7%) and carotid endarterectomy (14.0%). Perioperative MME/day varied significantly by procedure (P < .0001), ranging from 40.0 in supra-inguinal bypass to 23.8 MME/day in venous procedures (Fig 1A). Rates of postoperative COU varied significantly by procedure (P < .0001) and were highest following amputation (7.62%), peripheral endovascular intervention (6.95%), and infra-inguinal bypass (6.94%) (Fig 1A). Although the percentage of perioperative prescriptions greater than 50 MME/day decreased from 2004 to 2018 (27.11% to 13.98%; P < .0001), rates of COU increased (2% to 5.8%; P < .0001) (Fig 1B). In a multivariate logistic regression for factors associated with chronic opioid use, increased age (P < .001), prior substance abuse (P < .001), and a history of diabetes (P = .002) were independently associated with COU. Supra-inguinal bypass, infra-inguinal bypass, and amputations are associated with increased perioperative opioid prescriptions and postoperative COU. Despite reductions in perioperative opioid prescriptions, the incidence of COU following vascular surgery in opioid-naïve patients has increased in the last 15 years. Comorbidities including increased age, prior substance abuse, and diabetic history are independently associated with COU risk.

Alternative Autologous and Biologic Conduits Have Worse Outcomes Than Prosthetic Grafts for Infrainguinal Bypass

Single segment great saphenous vein (ssGSV) is the preferred conduit in infrainguinal bypass. Alternative autologous conduits (AAC) and nonautologous biologic conduits (NABC) are thought to be a better alternative to traditional prosthetic conduits (PC) in the absence of ssGSV. In this study, we analyzed the outcomes of these alternative conduits in lower extremity bypasses (LEB).

Narcotic Use and Poor Inflow Are Associated With a Higher Risk of Amputation After Infrainguinal Bypass

Narcotic Use and Poor Inflow Are Associated With a Higher Risk of Amputation After Infrainguinal Bypass

The Impact of Frailty on Outcomes in Patients Undergoing Infrainguinal Arterial Bypass—Insights From Vascular Quality Initiative Database

Frailty has been used as a prognostic indicator and is increasingly linked to adverse postoperative surgical outcomes. The aim of this study was to understand the effect of frailty on mortality, amputation, and revision in patients undergoing infrainguinal bypass and identify risk factors within this population associated with each outcome.

Female Sex Is Associated With Higher Risk of Reintervention After Endovascular Interventions and Infrainguinal Bypass for Intermittent Claudication

Intermittent claudication (IC) is a commonly treated vascular condition. Patient sex has been shown to influence the outcomes of interventions for other vascular disorders; however, whether the outcomes of interventions for IC vary by sex is unclear. We sought to assess the association of biological sex with the outcomes after open and endovascular interventions for IC.

Direct Oral Anticoagulants Started After Infrageniculate Bypass Reduce Three-Year Mortality When Compared With Warfarin

Despite numerous studies looking at antiplatelet/anticoagulation regimens after lower extremity bypass, there has been no consensus on optimal regimen for a particular combination of conduit and target. A 2017 Vascular Quality Initiative study found that anticoagulation had no effect on primary patency of infrainguinal bypass grafts but had some benefit in secondary patency of infrageniculate targets. Clinically, many patients who receive below-knee bypasses are started on anticoagulation, which historically has been with warfarin.

Systematic Review and Meta-Analysis of Cryopreserved Venous Conduits for Infrainguinal Bypass Grafting

Cryopreserved vein grafts (CVGs) are used as alternative conduits for infrainguinal bypass when autologous veins are not available. This study aims to determine short- and long-term outcomes of CVGs for infrainguinal bypass grafting through a meta-analysis of existing literature.

Graft Patency and Determinants of Outcome in Infrainguinal Bypasses - A Retrospective Study

Context: Chronic lower limb ischemia, an important marker of atherosclerosis, is a common clinical problem prevalent in all socioeconomic groups in our country and across the globe. Infrainguinal bypass is mandated in a subset of patients with critical limb ischemia to provide immediate limb salvage as well as excellent long-term results. Aim: The purpose of our retrospective study is to elucidate the effect of various known factors on the long term patency of infrainguinal bypass grafts performed in our patient population at a tertiary referral hospital. Methods: We retrospectively reviewed follow up data of 110 patients who had undergone infrainguinal bypass grafting over a period of ten years in our Institutional vascular registry. Graft patency rates and factors affecting thereof over this period were studied and the data statistically analysed. Overall cumulative patency rates were calculated by the life table survival method and compared with that of the patency rates of above-knee bypass procedures in the world literature. Patency rates in a different subset of patients were calculated and compared using the Wilcoxon (Gehan) test and Fisher's exact test to assess the influence of various factors in the long term outcome of the procedure. Results: Cumulative patency in terms of graft survival probabilities based on the life table analysis was 0.84, 0.80, and 0.64 at 30, 60, and 90 months respectively. Grafts in patients who had continued to smoke post-operatively had failed when compared with those who did not smoke (P = 0.01). Cumulative patency rates of non- diabetics were higher as compared to non-diabetics (0.70 vs 0.44; P = 0.04). Conclusion: Our study shows that continued smoking and diabetes are the determinant factors associated with graft occlusion. Strict avoidance of smoking and optimal control of diabetes is likely to improve graft function and long-term patency in patients undergoing infra-inguinal bypass grafting.

Omniflow II biosynthetic grafts versus expanded polytetrafluoroethylene grafts for infrainguinal bypass surgery. A single-center retrospective analysis.

The aim of this study is to evaluate the outcome of Omniflow II biosynthetic vascular grafts as compared to synthetic expanded polytetrafluoroethylene (ePTFE) grafts in infrainguinal bypass surgery. A single-center, retrospective, observational study was performed reviewing patients with critical limb ischemia who underwent infrainguinal bypass surgery between 2014 and 2018. Patients characteristics, graft characteristics, and treatment outcomes were collected. Patency rates were compared using Kaplan-Meier estimates. Sixty bypasses were performed in 57 patients. For above-knee surgery, six were Omniflow and 13 were synthetic. For below-knee surgery, 19 were Omniflow and 22 were synthetic. Patient characteristics between groups were similar. However, American Society of Anesthesiologists (ASA) classification scores were higher in the Omniflow group as compared to ePTFE (88% was ASA 3 or higher versus 60%; p = 0.018). Furthermore, wound, ischemia, and foot infection (WIfI) composite scores were higher in the Omniflow group (p = 0.0001). There was a trend toward more active infection at time of surgery in the Omniflow group (40 vs 22.9%, p = 0.15). At 1year, primary patency rates were 60.0% versus 46.9% for above-knee Omniflow versus ePTFE grafts, respectively (p = 0.72). Secondary patency rates were 80.0% versus 82.5% (p = 0.89), and limb salvage rates were 83.3% versus 100% (p = 0.14). For below-knee surgery, 1- and 2-year primary patency rates in Omniflow versus ePTFE grafts were 36.0% versus 41.8% (p = 0.60) and 36.0% versus 31.1% (p = 0.87). Secondary patency rates were 66.8% versus 75.2% at 1year (p = 0.53) and 58.8% versus 48.3% (p = 0.77) at 2years. Below-knee limb salvage rates for Omniflow versus ePTFE after 2years were 88.0% versus 68.3% (p = 0.28), respectively. Aneurysmal degeneration occurred in 2/25 (8%) in the Omniflow group and 0/35 (0%) in the ePTFE group. Bypass infections occurred in 2/25 (8%) in the Omniflow group and 0/35 (0%) in the ePTFE group (p = 0.09). Omniflow bypasses were more commonly implanted in patients with higher limb infection rate as confirmed with a higher adapted WIfI score. A trend toward a higher infection rate of Omniflow grafts was observed but not statistically significant. Graft infection rates were relatively low and treatable with antibiotics. No significant difference in graft performance was observed. The choice between the two studied grafts remains based on surgeon's preference.

Outcomes of bypass and endovascular interventions for advanced femoropopliteal disease in patients with premature peripheral artery disease

ObjectivePatients with premature peripheral artery disease (PAD), defined as age ≤50 years at presentation, have had poor outcomes with open and endovascular lower extremity revascularization. It is unclear whether either strategy is associated with better outcomes because comparative studies have been limited to case series in this patient population. The aim of the present study was to compare the outcomes of patients with premature PAD who had undergone bypass or endovascular revascularization for advanced femoropopliteal disease. Our hypothesis was that open bypass would provide superior long-term outcomes compared with endovascular intervention for patients with premature advanced femoropopliteal PAD. MethodsAll the patients with premature PAD who had undergone isolated femoropopliteal lower extremity revascularization and included in the Vascular Quality Initiative infrainguinal bypass and peripheral vascular intervention files were reviewed from 2003 through 2019. Propensity score matching (1:1) was performed between patients who had undergone femoropopliteal bypass and endovascular interventions for isolated femoropopliteal Trans-Atlantic Classification System C or D lesions. The 1-year outcomes, including reintervention, patency, major amputation, and mortality, were analyzed. ResultsOf the 2538 included patients, 902 had undergone isolated femoropopliteal endovascular intervention and 1636 had undergone femoropopliteal bypass. The endovascular intervention group were more likely to have diabetes (68.9% vs 54.0%; P < .001), coronary artery disease (31.0% vs 23.0%; P < .001), renal failure requiring dialysis (14.2% vs 7.2%; P < .001), and claudication (45.1% vs 36.6%; P < .001) compared with the bypass group. After propensity score matching, 466 patients were in each group with no significant differences in the baseline characteristics. Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention (12.0% vs 7.9%; P = .038); however, the rates of major amputation and mortality were not different. At 1 year, patients who had undergone femoropopliteal bypass were less likely to require reintervention (17.0% vs 25.2%; P = .012). However, no differences were found in major amputation (7.7% vs 7.9%; P = .928) or mortality (5.2% vs 5.2%; P = 1.00). Propensity score matching was also performed between femoropopliteal bypass with the great saphenous vein and isolated femoropopliteal endovascular interventions, and the outcomes were similar. ConclusionsFor patients with premature PAD and advanced femoropopliteal disease, bypass surgery decreased the reintervention rate at 1 year but was associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy. No differences were found in major amputation or mortality between the two strategies.

Surgeon experience versus volume differentially affects lower extremity bypass outcomes in contemporary practice

BackgroundCalls for minimum case thresholds to guide surgeon credentialing paradigms are increasing in contemporary practice. To date, the volume–outcome relationship and the role of surgeon experience as a proxy for quality have remained primarily focused on nonvascular extirpative surgery and aneurysm repair. However, it is unclear whether these data can be rightly extrapolated to predict lower extremity bypass (LEB) outcomes. Thus, the purpose of the present study was to examine whether the annualized case volume vs surgeon experience is more consequential in predicting for successful LEB reconstruction. MethodsA total of 25,852 procedures with sufficient 1-year follow-up data from the Society for Vascular Surgery Vascular Quality Initiative infrainguinal bypass registry (2003-2019) were reviewed for chronic limb threatening ischemia among patients undergoing infrageniculate reconstruction. The procedures were categorized according to surgeon years of practice experience at surgery (ie, 0-5, 6-10, 11-15, >15 years) and the number of LEB procedures performed by the surgeon during the year of surgery (volume quartiles: 1-8, 9-14, 15-21, and >21). Mixed effects logistic and Cox regression models were used to assess the effects of experience, volume, and their interaction on outcomes. ResultsIncreasing practice experience was more significantly associated with a reduction of in-hospital complications (odds ratio, 0.97; 95% confidence interval [CI], 0.96-0.99; P = .002) and the risk of major adverse limb events (odds ratio, 0.94; 95% CI, 0.92-0.97; P < .0001) compared with the volume. Increasing experience and volume were both associated with increased freedom from thrombosis (hazard ratio, 0.95; 95% CI, 0.93-0.98; P = .001). In contrast, neither experience nor volume had any significant association with early mortality. However, a higher volume was associated with diminished long-term survival (hazard ratio, 1.04; 95% CI, 1.0-1.1; P = .01). The most experienced surgeons (>15 years' experience) were significantly more likely to perform LEB for rest pain (P < .0001). No significant differences were found in the bypass rates among patients with tissue loss. The most experienced and highest volume surgeons were more likely to use an autogenous and/or composite conduit, in situ reconstruction, and/or pedal targets (P < .05). Similarly, more experienced and higher volume surgeons had less blood loss and shorter procedure times (P < .0001). Overall, the most experienced surgeons (>15 years' experience) were significantly more likely to have a higher volume with a diminished risk for all LEB outcomes. ConclusionsSurgeon experience appears to have the most important role in predicting for overall LEB performance with improved in-hospital outcomes and major adverse limb events. The more experienced surgeons performed more complex reconstructions with fewer complications. These findings have significant clinical and educational implications as our most experienced surgeons approach retirement. Mentorship strategies to facilitate ongoing technical development among less experienced surgeons are imperative to sustain optimal limb salvage outcomes and have significant ramifications regarding expectations for regulatory and credentialing paradigms.

Infrainguinal bypass under triple nerve block in patients with severely compromised left ventricular ejection fraction and chronic limb-threatening ischemia

A severely compromised left ventricular ejection fraction (LVEF) is a major limitation for lower extremity bypass reconstruction both under general anesthesia or neuraxial anesthesia (NA). A series of eight infrainguinal bypass procedures were performed under peripheral nerve block in five patients (three males and two females; median age, 67 years) with chronic limb-threatening ischemia and a preoperative LVEF of 35% or less (median, 27%; range, 20%-35%). There were no conversions to neuraxial anesthesia/general anesthesia or early postoperative complications. This study showed that open infrainguinal reconstructions can be performed safely under peripheral nerve blockade in this vulnerable category of patients.

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

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. To assess the effectiveness of endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. 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. 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. 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. We identified no RCTs that met the inclusion criteria for this review. 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.

Effect of infrainguinal bypass tunneling technique on patency and amputation in patients with limb ischemia

ObjectiveWe investigated the association of tunneling technique on patency and amputation in patients undergoing lower extremity bypass for limb ischemia. MethodsThe National Vascular Quality Initiative database infrainguinal bypass module from 2008 to 2017 was queried for analysis. We excluded cases with non–great saphenous vein grafts, grafts using multiple segments, aneurysmal disease indications, bypass locations outside the femoral to below the knee popliteal artery or tibial arteries, and missing data on tunneling type and limb ischemia. The main exposure variable was the tunneling type, subcutaneously vs subfascially. Our primary outcomes were primary patency and amputation. The secondary outcomes included primary-assisted patency and secondary patency. Univariate and multivariate logistic regression models were used. ResultsA total of 5497 bypass patients (2835 subcutaneous and 2662 subfascial) were included. Age, race, graft orientation (reversed vs not reversed), bypass donor and recipient vessels, harvest type, end-stage renal disease, smoking, coronary artery bypass graft, congestive heart failure, P2Y12 inhibitor at discharge, surgical site infection at discharge, and indication (rest pain vs tissue loss vs acute ischemia) were analyzed for an association with the tunneling technique (P < .05). Multivariate analyses demonstrated that the tunneling type was not associated with primary patency, primary-assisted patency, secondary patency, or major amputation (P > .05). ConclusionsCompared with subfascial tunneling, the superficial tunneling technique was not associated with primary patency or major amputation in limb ischemia patients undergoing infrainguinal bypass with a single-segment great saphenous vein.

Performance of the AUB-HAS2 Cardiovascular Risk Index in vascular surgery patients.

The American University of Beirut (AUB)-HAS2 risk index is a recently published tool for preoperative cardiovascular evaluation. It is based on six data elements: history of Heart disease, symptoms of Heart disease (angina or dyspnea), Age ⩾ 75 years, Anemia (hemoglobin < 12 mg/dL), emergency Surgery, and vascular Surgery. This study analyzes the performance of a modified AUB-HAS2 index (excluding the vascular surgery element) in a broad spectrum of vascular surgery procedures. The study population consisted of 90,476 vascular surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. The performance of the AUB-HAS2 index was studied in seven groups: carotid endarterectomy (CEA), open abdominal aortic aneurysm surgical repair (OAAA), endovascular aortic aneurysm repair, supra-inguinal bypass, infra-inguinal bypass, lower extremity thrombo-endarterectomy, and lower extremity angioplasty. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. Each patient was given an AUB-HAS2 score of 0, 1, 2, or > 2 depending on the number of data elements s/he has. The AUB-HAS2 index was able to stratify risk in the majority of patients into low (< 3%, score 0), intermediate (3-10%, score 1-2), and high (> 10%, score > 2) (p < 0.0001). The receiver operating curve had an area of 0.71 in the overall group and it ranged from 0.60 in CEA patients to 0.75 in OAAA patients. In conclusion, the AUB-HAS2 index is a simple tool that can quickly and effectively stratify the risk of patients undergoing a broad spectrum of vascular surgeries into low, intermediate, and high.

Sarcopenia in Patients Undergoing Lower Limb Bypass Surgery is Associated with Higher Mortality and Major Amputation Rates

BackgroundSarcopenia is adversely associated with survival in several diseases. Vasculopathy is often associated with multimorbidity and consequent deconditioning with poor long-term outcomes. This study examined the impact of sarcopenia on clinical outcome in patients with and without critical limb-threatening ischaemia who underwent infrainguinal bypass surgery. MethodsAll patients undergoing infra-inguinal surgical revascularisation in 2016–2018 were retrospectively reviewed. Sarcopenia was defined as a skeletal muscle area at the L3 vertebral level (defined as L3 muscle area < 114cm2 for men or <89.8cm2 for women) on CT angiography. The primary outcome was overall survival by analysed by time to event analysis. Secondary outcomes included ipsilateral major lower-limb amputation, length of hospital stay, myocardial infarction and surgical-site infection. ResultsA total of 116 patients with a mean age of 66.9 years were included, with a mean follow-up of 21 months. 14 (12%) of patients were sarcopenic; there were more patients with diabetes (40% vs 7%) in the sarcopenic group, p=0.018. Age, gender, Rutherford grade at presentation, other co-morbidities, other laboratory tests, conduit material and Rutherford grade at presentation were similar in those with and without sarcopenia and were statistically insignificant upon testing.Overall survival was worse for sarcopenic patients (Log Rank P=0.001) and Hazard Ratio for death 5.8; 95%CI 1.8–19.1; P=0.001. Major lower-limb amputation occurred more frequently in patients with sarcopenia (7/14 [50%] vs 23/102 [23%]; P=0.046). There was no difference in other secondary outcomes including rates of graft occlusion, myocardial infarction, surgical site infection and length of stay.Adding SMA measurement to a multivariate generalised linear model including age, sex, diabetes, and haemoglobin improved the AUROC from 0.75–0.85. ConclusionIn this cohort of patients undergoing vascular surgery, sarcopenia defined using L3 muscle area was significantly associated with overall mortality and major lower-limb amputation.

Liver Disease is Associated with Increased Mortality and Major Morbidity After Infra-Inguinal Bypass but not After Endovascular Intervention

Liver disease increases mortality after abdominal surgery, including endovascular aortic aneurysm repair. However, its effect on mortality and morbidity after endovascular and open management of peripheral vascular disease has not been widely evaluated. The National Surgical Quality Improvement Program was used to evaluate patients undergoing infra-inguinal bypass and endovascular intervention (2005 - 2016). Aspartate aminotransferase to platelet ratio (APRI score) is a non-invasive tool recommended by the World Health Organisation to identify liver disease and was calculated for all patients. A ratio of > 0.5 was used to identify patients with liver fibrosis. Demographics, comorbidities, and 30 day outcomes were evaluated for patients with and without liver fibrosis. A subgroup analysis was completed in patients with APRI scores > 0.5, to evaluate the effect of increasing Model for End-Stage Liver Disease (MELD) scores on outcomes. Multivariable regression was used to account for differences in baseline factors. In total, 17 603 patients underwent infra-inguinal bypasses. Fibrosis was associated with higher mortality (3.8% vs. 2.4%; p < .001), major complications (23% vs. 20%; p= .020), pulmonary (5.1% vs. 2.9%; p < .001), and renal complications (1.9% vs. 1.1%; p= .007) after bypass. These differences persisted following multivariable adjustment. Altogether, 7 830 patients underwent endovascular intervention. Fibrosis was also associated with higher mortality (4.7% vs. 2.2%; p < .001), pulmonary (3.9% vs. 2.5%; p= .022), and renal complications (1.9% vs. 0.8%; p= .003) after endovascular intervention. After adjustment, only renal complications persisted. In a subgroup analysis of patients with liver fibrosis, morbidity (31% vs. 17%; p < .001) and mortality (7.2% vs. 1.8%; p < .001) increased after bypass among those with MELD scores > 15 but not after endovascular intervention. Liver fibrosis was associated with higher 30 day mortality and major complications after infra-inguinal bypass, with outcomes worsening as MELD scores increased. Surgeons may consider an endovascular first approach in managing peripheral arterial disease among those with liver fibrosis.