Infrainguinal Lower Extremity Bypass Research Articles

Preoperative COVID-19 Vaccination is Associated with Decreased Perioperative Mortality after Major Vascular Surgery.

The objective of this study was to examine the effect of corona virus 2019 (COVID-19) vaccination on perioperative outcomes after major vascular surgery. COVID-19 vaccination is associated with decreased mortality in patients undergoing various surgical procedures. However, the effect of vaccination on perioperative mortality after major vascular surgery is unknown. This is a multicenter retrospective study of patients who underwent major vascular surgery between December 2021 through August 2023. The primary outcome was all-cause mortality within 30 days of index operation or prior to hospital discharge. Multivariable models were used to examine the association between vaccination status and the primary outcome. Of the total 85,424 patients included, 19161 (22.4%) were unvaccinated. Unvaccinated patients were younger compared to vaccinated patients (mean age 68.44 +/- 10.37y vs 72.11 +/- 9.20y, P<0.001) and less likely to have comorbid conditions, including hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dialysis. After risk factor adjustment, vaccination was associated with decreased mortality (OR 0.7, 95% CI 0.62 - 0.81, P<0.0001). Stratification by procedure type demonstrated that vaccinated patients had decreased odds of mortality after open AAA (OR 0.6, 95% CI 0.42-0.97, P=0.03), EVAR (OR 0.6, 95% CI 0.43-0.83, p 0.002), CAS (OR 0.7, 95% CI 0.51-0.88, P=0.004) and infra-inguinal lower extremity bypass (OR 0.7, 95% CI 0.48-0.96, P=0.03). COVID-19 vaccination is associated with reduced perioperative mortality in patients undergoing vascular surgery. This association is most pronounced for patients undergoing aortic aneurysm repair, carotid stenting and infrainguinal bypass.

Polyvascular disease is common in patients undergoing carotid endarterectomy and lower extremity bypass and is associated with worse outcomes

BackgroundPolyvascular 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 more than one 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 the χ2 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 (39.0% in 2 arterial beds, 7.6% in 3 arterial beds; n = 93,736) and 47% of LEB (41.0% in 2 arterial beds, 5.7% in 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 < .0001). Perioperative MI/death rates increased with increasing number of vascular beds affected following CEA (0.9% in 1 bed vs 1.5% in 2 beds vs 2.7% in 3 beds; P < .001) and LEB (2.2% in 1 bed vs 5.3% in 2 beds vs 6.6% in 3 beds; P < .001). Polyvascular disease was associated independently with perioperative MI/death after CEA (odds ratio, 1.59; 95% confidence interval [CI], 1.40-1.81;P < .0001) and LEB (odds ratio, 1.78; 95% CI, 1.52-2.08; P < .0001). Five-year survival was decreased in patients with polyvascular disease after CEA (82% in 3 beds vs 88% in 2 beds vs 92% in 1 bed; P < .01) and LEB (72% in 3 beds vs 75% in 2 beds vs 84% in 1 bed; P < .01) in a dose-dependent manner, with the lowest 5-year survival observed in those with three arterial beds involved. Polyvascular disease was independently associated with 5-year mortality after CEA (hazard ratio, 1.33; 95% CI, 1.24-1.40; P = .0001) and LEB (hazard ratio, 1.30; 95% CI, 1.20-1.41; P = .0001). ConclusionsPolyvascular disease is common in patients undergoing CEA and LEB and is associated with a higher risk of perioperative MI/death and decreased long-term survival. After revascularization, patients with polyvascular disease should be considered for more aggressive cardioprotective medications and closer follow-up.

Predictors of Early Graft Thrombosis During Index Admission for Lower Extremity Arterial Bypass

Early graft thrombosis following lower extremity bypass (LEB) has long served as a quality indicator of surgical management. A granular understanding of the risk factors for graft thrombosis might help mitigate the potentially avoidable sequelae of this complication. Our study utilized Vascular Quality Initiative (VQI) data to identify predictor variables associated with graft thrombosis during index admission following LEB. We queried the VQI database for patients receiving unilateral infrainguinal LEB between 2003 and 2022. Patients undergoing concomitant PVI or suprainguinal bypass were excluded from our analysis. We formed six procedural groups: femoral-above knee popliteal bypass, femoral-below knee popliteal bypass, femoral-tibial bypass, femoral-ankle bypass, popliteal-tibial bypass, and popliteal-ankle bypass. Among these six groups, we utilized multivariable logistic regression modeling to identify technical and perioperative characteristics that predicted early graft thrombosis. Of the 54,504 LEB procedures that met inclusion criteria, 11,906 (21.8%) underwent femoral-above knee popliteal, 17,541 (32.2%) femoral-below knee popliteal, 19,224 (35.3%) femoral-tibial, 1414 (2.6%) femoral-ankle, 2661 (4.9%) popliteal-tibial, and 1758 (3.2%) popliteal-ankle bypass procedures. At the time of discharge, 1012 (1.9%) required intervention for a thrombotic intervention, and 814 (1.5%) were occluded. After adjusting for patient characteristics and comorbidities, we identified the following independent predictors for early graft thrombosis: female gender, distal target, symptomatic indication (rest pain and tissue loss), urgent/emergent presentation, and anticoagulation therapy, specifically warfarin and rivaroxaban. Conversely, the use of preoperative statin, aspirin and clopidogrel was protective against early graft thrombosis (Table). There were 9.5% of patients not receiving one or several of the protective medications identified (25.9% not receiving statins, 69.1% not receiving clopidogrel, and 27.6% not receiving aspirin). With regard to type of conduit used for LEB, native vein conduits demonstrated the lowest odds of graft thrombosis (Table, Figure). In this large national contemporary study of LEB, we have identified several factors including distal target, urgent/emergent presentation, preoperative warfarin or rivaroxaban therapy and use of nonautologous conduits as independent predictors of graft thrombosis. Conversely, preoperative statin, antiplatelet therapy and the use of native vein conduits were protective against graft thrombosis. Despite their beneficial effect, we identified that 9.5% of the LEB population are not receiving statin and/or antiplatelet therapies, which serves as a potential quality improvement initiative. Our findings suggest that utilization of native vein when possible, and promoting aggressive preoperative medical optimization including statin, aspirin and P2Y12 inhibitors may help avoid early graft occlusion in patients requiring lower extremity revascularization.TableMultivariable logistic regression model indicating technical and perioperative characteristics associated with early graft thrombosis after lower extremity arterial bypass surgeryPerioperative characteristicsOdds ratio (95% confidence interval)P valueAge0.99 (0.98-0.99)<.001Female sex1.32 (1.20-1.45)<.001White race1.10 (1.00-1.22).059Diabetes0.83 (0.75-0.92)<.001Dialysis1.02 (0.93-1.13).638Congestive heart failure1.03 (0.89-1.18).731Prior coronary artery bypass grafting0.87 (0.79-0.96).008Chronic obstructive pulmonary disease0.94 (0.83-1.05).266Smoking0.82 (0.73-0.93).002Aspirin0.73 (0.66-0.81)<.001Statin0.85 (0.77-0.95).003Baseline hemoglobin0.92 (0.90-0.95)<.001BMI1.00 (0.99-1.01).835Bypass type Femoral to above knee popliteal1 (reference)- Femoral to below knee popliteal1.62 (1.30-2.03)<.001 Femoral to tibial vessel3.18 (2.58-3.90)<.001 Femoral to ankle vessel4.41 (3.28-5.93)<.001 Popliteal to tibial vessel2.58 (1.98-3.37)<.001 Popliteal to ankle vessel3.15 (2.32-4.28)<.001Urgency Elective1 (reference)- Urgent1.74 (1.54-1.97)<.001 Emergent3.45 (2.75-4.34)<.001Conduit Native vein1 (reference)- Dacron1.09 (0.56-2.11).810 Polytetrafluoroethylene1.36 (1.20-1.55)<.001 Nonautologous biologic2.41 (1.95-2.97)<.001Indication Asymptomatic1 (reference)- Claudication1.02 (0.53-1.97).953 Rest Pain2.44 (1.28-4.66).007 Tissue loss2.18 (1.16-4.11).016 Acute ischemia3.39 (1.77-6.49)<.001 Not treated2.53 (1.34-4.77).004Per hour procedure time1.00 (1.00-1.00)<.001Preoperative P2Y12 antagonist therapy None1 (reference)- Clopidogrel0.81 (0.73-0.91)<.001 Prasugrel1.14 (0.58-2.24).697 Ticagrelor0.93 (0.49-1.75).818 Other0.81 (0.30-2.16).668 No, for medical reasons0.69 (0.50-0.96).027 Noncompliant1.35 (0.75-2.45).314Preoperative anticoagulation therapy None1 (reference)- Warfarin1.38 (1.16-1.65)<.001 Dabigatran1.06 (0.49-2.31).874 Rivaroxaban1.42 (1.15-1.75).001 Other1.54 (1.29-1.85)<.001 No, for medical reasons1.14 (0.74-1.74).548 Noncompliant2.35 (1.27-4.35).007Presented are odds ratios (95% confidence interval) from a multivariable model adjusting for age, sex, race, diabetes, dialysis, congestive heart failure, prior coronary artery bypass grafting, chronic obstructive pulmonary disease, smoking, use of aspirin, statin, anticoagulation, body mass index, urgency, indication, and total procedural time. Boldface entries indicate statistical significance. Open table in a new tab

Investigating glycemic control in patients undergoing lower extremity bypass within an enhanced recovery pathway at a single institution

BackgroundEnhanced recovery pathways (ERPs) aim to lower perioperative stress to facilitate recovery. Limited fasting combined with carbohydrate loading is a common ERP element. The effect of limited fasting has not been elucidated in patients with diabetes. Given the known deleterious effects of poor glycemic control in the perioperative period, such as increased rates of surgical site infection, the associations of preoperative limited fasting with perioperative glycemic control and early outcomes after lower extremity bypass (LEB) were investigated. MethodsA single institutional retrospective review of patients who underwent infrainguinal LEB from 2016 to 2022 was performed. The ERP was initiated in May 2018. Patients were stratified by diabetes diagnosis and preoperative hemoglobin A1C (HbA1C) levels. Perioperative glycemic control was compared between the limited fasting and traditional fasting patients (nil per os at midnight). Limited fasting was defined as a clear liquid diet until 2 hours before surgery with recommended carbohydrate loading consisting of 400 cc of a clear sports drink (approximately 30 g of carbohydrates). All limited fasting patients were within the ERP. Early perioperative hyperglycemia (EPH) was defined as blood glucose of >180 mg/dL within the first 24 hours of surgery. Perioperative outcomes such as surgical site infection, readmission, reinterventions, and complications were also compared. ResultsA total of 393 patients were included (limited fasting patients N = 135; traditional fasting patients N = 258). A trend toward EPH was seen in all limited fasting groups. Evaluating limited fasting within diabetic patients revealed that 74.5% of limited fasting-diabetic patients had EPH compared with 49.6% of traditional fasting-diabetic patients (P = .001). When stratified by the HbA1C level, a significantly higher rate of EPH was seen in the HbA1c >8.0% groups, with 90.5% in the limited fasting patients compared with 67.9% in traditional fasting patients (P = .05). Limited fasting-diabetic patients experience a longer postoperative length of stay at 5.0 days (interquartile range: 3, 9) vs 4.0 days (2, 6) in nondiabetic patients (P = .016). ConclusionsERP limited fasting was associated with early perioperative hyperglycemia after LEB, particularly in patients with HbA1C >8.0%. Due to the high prevalence of diabetic patients undergoing LEB under ERP, the role of limited fasting and common glycemic elements of ERP may need to be re-evaluated in this subpopulation.

American Society of Anesthesiologists-Physical Status Classification As An Independent Risk Factor of Surgical Site Infection After Infra-Inguinal Arterial Bypass.

The present study aimed to assess whether high-risk American Society of Anesthesiologists (ASA)-Physical Status was an independent risk factor for the development of surgical site infection (SSI) after infra-inguinal lower extremity bypass (LEB). The ASA-Physical Status Classification System assesses the overall physical status preoperatively. ASA-Physical Status is associated with postoperative morbidity and mortality. However, limited data are available on how ASA-Physical Status Class affects the development of SSI after infra-inguinal LEB. Patients who had undergone infra-inguinal LEB from January 1, 2015 to December 31, 2018, for obliterative arteriopathy or popliteal aneurysm at our university hospital were included. SSI risk factors were identified using multivariable logistic regression. The length of hospital stay, major limb events (MALE), major adverse cardiovascular events (MACE), and all-cause mortality were compared for patients with SSI versus those without SSI 3 months and 1- year of follow-up after the index surgery. Among the 267 patients included, 30 (11.2%) developed SSI during the 3-month period and 32 (12%) at 1 year. ASA-Physical Status ≥3 [odds ratio (OR): 3.7, 95% confidence interval CI) 1.5-11.1], emergency surgery (OR: 2.7, 95% CI 1.2-6.0), general anesthesia (OR: 2.8, 95% CI 1.3-6.1), and procedure performed by a junior surgeon (OR: 2.7, 95% CI 1.3-6.0) were independently associated with SSI. At 3 months and 1 year, SSI was significantly associated with MALE (including surgical wound debridement, subsequent thrombectomy, major amputation), length of hospital stay, and all-cause mortality. The ASA-Physical Status should be considered in medical management when an infra-inguinal LEB is considered in frail patients, to prevent surgical complications.

Use of Direct Oral Anticoagulant and Associated Bleeding and Thrombotic Complication after Lower Extremity Bypass.

Therapeutic anticoagulation with either a vitamin K antagonist (VKA) or direct anticoagulant (DOAC) is often newly prescribed to patients undergoing lower extremity bypass (LEB) to aid in graft patency when risk factors for thrombosis are present or to treat postoperative venous thromboembolism or atrial fibrillation. There is a gap in knowledge as to how DOAC usage impacts postoperative outcomes compared with the standard-of-care VKAs. To determine temporal trends in DOAC prescription after infrainguinal LEB, impact on length of stay (LOS), and associated bleeding and thrombotic complications, patients undergoing elective LEB were identified from the Vascular Quality Initiative between January 2013 and May 2019. Postoperative bleeding, LOS, and graft occlusion for patients receiving VKA compared with DOAC were evaluated. A total of 24,459 LEBs were performed during the study period. Among 2,656 patients newly prescribed an anticoagulant, 78.0% (n = 2,072) received VKA and 22.0% (n = 584) received a DOAC, with DOAC use increasing throughout the study period. There was no significant difference in postoperative bleeding (VKA 2.3%, DOAC 1.7%, p = 0.413) or graft occlusion (VKA 1.2%, DOAC 1.4%, p = 0.762) between the anticoagulant classes. LOS was shorter in the DOAC group than in the VKA group (5.7 vs 6.8 days; p &lt; 0.001). This analysis demonstrates that DOAC use is increasing with time in Vascular Quality Initiative centers. DOACs are a safe and comparable alternative to VKAs in the postoperative setting with similar rates of bleeding complications and early graft patency and are associated with a reduced postoperative LOS.

Variability in Antithrombotic Therapy after Infrainguinal Lower Extremity Bypass

Antiplatelet monotherapy is recommended after infrainguinal lower extremity bypass (LEB). However, there is a paucity of high-quality data to guide therapy, and antiplatelet therapy is often prescribed in combination with anticoagulation. We therefore aimed to assess the variability in the use of antithrombotic therapy after infrainguinal LEB. The Vascular Quality Initiative dataset (2015-2021) was retrospectively reviewed to determine discharge patterns of antithrombotic therapy for all patients undergoing infrainguinal LEB. Monotherapy on discharge was defined as either single antiplatelet therapy (SAPT) or single anticoagulant (SAC). Combination therapy was dual antiplatelet therapy (DAPT), anticoagulant+antiplatelet (ACAP), or triple therapy. Hierarchical multivariable logistic regression with random effects for physician and center was used to identify predictors of combination therapy. Median odds ratios (MOR) were derived to quantify degree of variability in antithrombotic therapy. There were 29,507 patients undergoing infrainguinal LEB (monotherapy=10,634 vs. combination therapy=18,873). SAPT (90.6%) was the most common form of monotherapy, while DAPT (57.7%) and ACAP (34.6%) were the most common combination therapies. Patients undergoing LEB to popliteal targets were more likely to be prescribed monotherapy (SAC or SAPT) than to infra-popliteal targets (60.6% vs. 56.6%, P<0.001). Combination therapy (DAPT, ACAP, or triple therapy) was more often used in patients with tibial or plantar arteries as the bypass target. Patients undergoing bypass using autogenous vein were more likely to receive monotherapy compared with those receiving other conduits (64.8% vs. 52.9%, P<0.001), while patients with prosthetic grafts were more likely to receive combination therapy (37.9% vs. 28.2%, P<0.001). There were no significant differences in postoperative bleeding (P=0.491) or 30-day mortality (P=0.302) between the two groups. Prior peripheral vascular interventions (PVI) (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.79-1.99), concomitant PVI (OR: 1.83, 95% CI: 1.66-2.02), prosthetic graft use (OR: 1.74, 95% CI: 1.64-1.85), prior percutaneous coronary intervention (OR: 1.53, 95% CI: 1.43-1.65), plantar distal target (OR: 1.46, 95% CI: 1.29-1.65), alternative conduits (OR: 1.39, 95% CI: 1.25-1.53), and tibial distal targets (OR: 1.36, 95% CI: 1.28-1.44) were independent predictors of combination therapy in a multivariable regression model. Upon adjusting for patient-level factors, there was significant physician-level (MOR: 1.65, 95% CI 1.61-1.67) and center-level (MOR: 1.64, 95% CI 1.57-1.69) variability in the selection of antithrombotic therapy. Significant physician- and center-level variability in the use of antithrombotic regimens after infrainguinal bypass reflects the paucity of available evidence to guide therapy. Pragmatic trials are needed to assess antithrombotic strategies and guide recommendations aimed at optimizing cardiovascular and graft-specific outcomes after LEB.

Delirium Associated Adverse Events And Resource Use After Infrainguinal Lower Extremity Bypass

INTRODUCTION AND OBJECTIVES Delirium is common yet often underdiagnosed following vascular surgery. Infrainguinal bypass surgery patients are at particular risk for delirium, yet delirium's burden on other perioperative outcomes and resource utilization remains unclear. This study's objective was to identify delirium predictors and associated resource utilization. METHODS This single center retrospective analysis included all infrainguinal bypass cases from 2012-2020. The primary outcome was delirium development and severity. Secondary outcomes included length of stay, non-home discharge, readmission at 30 and 90 days, and survival. Regression analysis evaluated delirium risk factors and delirium's association with 2 year survival. RESULTS Overall, 420 patients underwent infrainguinal bypass of whom 115 (26%) developed postoperative delirium. Individuals with delirium were older, more likely to be women and have non-elective surgery (all P<0.05). On multivariable analysis, independent delirium predictors included age, CLTI, and non-elective procedure (Table 1). Consultations were performed in 25 cases (23%), 13 (52%) being to pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for the delirium group was higher (17 days vs 9 days; P<.001). Delirium was associated with increased non-home discharge (61.8% vs 22.1%; P<.001) and 90-day mortality (7.6% vs 2.9%; P=.033). Survival at 2 years was lower in those with delirium (89% vs 75%; P<.001). On cox multivariable analysis over 2 years, delirium was independently associated with poor survival (HR=2.0; 95% CI=1.15-3.38; P=0.014). CONCLUSIONS Delirium is associated with adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, non-home discharge, and 2-year mortality. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing lower extremity infrainguinal bypass. Delirium is common yet often underdiagnosed following vascular surgery. Infrainguinal bypass surgery patients are at particular risk for delirium, yet delirium's burden on other perioperative outcomes and resource utilization remains unclear. This study's objective was to identify delirium predictors and associated resource utilization. This single center retrospective analysis included all infrainguinal bypass cases from 2012-2020. The primary outcome was delirium development and severity. Secondary outcomes included length of stay, non-home discharge, readmission at 30 and 90 days, and survival. Regression analysis evaluated delirium risk factors and delirium's association with 2 year survival. Overall, 420 patients underwent infrainguinal bypass of whom 115 (26%) developed postoperative delirium. Individuals with delirium were older, more likely to be women and have non-elective surgery (all P<0.05). On multivariable analysis, independent delirium predictors included age, CLTI, and non-elective procedure (Table 1). Consultations were performed in 25 cases (23%), 13 (52%) being to pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for the delirium group was higher (17 days vs 9 days; P<.001). Delirium was associated with increased non-home discharge (61.8% vs 22.1%; P<.001) and 90-day mortality (7.6% vs 2.9%; P=.033). Survival at 2 years was lower in those with delirium (89% vs 75%; P<.001). On cox multivariable analysis over 2 years, delirium was independently associated with poor survival (HR=2.0; 95% CI=1.15-3.38; P=0.014). Delirium is associated with adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, non-home discharge, and 2-year mortality. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing lower extremity infrainguinal bypass.

The association of estimated glomerular filtration rate with outcomes following infrainguinal bypass for peripheral arterial disease

ObjectiveChronic kidney disease (CKD) is a recognized predictor of long-term survival, frequently coexisting with peripheral arterial disease (PAD). Estimated glomerular filtration rate (eGFR) is a more accurate marker of renal function than creatinine. This study sought to determine the graded impact of CKD, defined by eGFR, on infrainguinal lower extremity bypass (LEB) outcomes. MethodsThis retrospective study examined 44,332 patients from the Vascular Quality Initiative database who underwent LEB between January 2003 and November 2019. The GFR was estimated using the Modification of Diet in Renal Disease equation. Multivariable logistic regression was used to study perioperative mortality and Kaplan-Meier survival estimation and multivariable Cox regression were used to evaluate 5-year mortality, 1-year major amputation, and major amputation/death. ResultsThe 30-day mortality odds was increased for CKD 3 (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.32-1.91; P < .001) and CKD 5 (OR, 3.08; 95% CI, 2.45-3.87; P < .001) relative to CKD 1 to 2. Comparing CKD stages 3, 4, and 5 with CKD 1 and 2, there was a stepwise increase in the adjusted hazard of 5-year mortality (hazard ratio [HR], 1.18; 95% CI, 1.09-1.27; P < .001), (HR, 1.73; 95% CI; 1.47-2.03; P < .001) and (HR, 2.58; 95% CI, 2.33-3.84; P < .001), respectively. Although the risk of 1-year death or major amputation did not differ for CKD 3 compared with CKD 1, this was 50% higher for CKD 4 (HR, 1.50; 95% CI, 1.26-1.78; P < .001) and doubled for CKD 5 (HR, 2.07; 95% CI, 1.87-2.29; P < .001) compared with CKD 1 and 2. The adjusted HR for major amputation in 1 year was 0.81 (95% CI, 0.71-0.92; P = .002), 1.14 (95% CI, 0.84-1.54; P = .396) and 1.56 (95% CI,1.31-1.84; P < .001) for CKD 3, 4, and 5, respectively, compared with CKD 1 and 2. ConclusionsThe estimated GFR is a useful predictor of postoperative mortality, overall survival, and/or amputation after LEB in patients with PAD. It should be considered in the preoperative risk-benefit analysis process to guide patient selection in the population with concomitant PAD and CKD being considered for LEB.

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass

The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8kg/m2 vs. 28kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P<0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P<0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P<0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P>0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P>0.05). Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.

The impact of hemoglobin A1c on outcomes after lower extremity bypass

ObjectiveDiabetes has been shown to be associated with increased risk of postoperative complications after lower extremity bypass (LEB), although it is unclear whether medium-term glucose control affects outcomes. This study aimed to assess the association of perioperative hemoglobin A1c (HbA1c) level on perioperative outcomes after LEB. MethodsWe examined consecutive infrainguinal LEBs for chronic limb-threatening ischemia (CLTI) using the Vascular Quality Initiative database (2007-2018). Perioperative HbA1c levels were stratified into <5.7%, 5.7% to 6.5%, and >6.5%. Propensity score matching on demographics, medical history, and procedural characteristics was used to select comparable patients across HbA1c groups. The primary outcome was postoperative wound infection. Multivariable analyses were performed for matched and unmatched groups using Cox proportional hazards models for survival outcomes and logistic regression for binary outcomes with association expressed by adjusted hazard ratio (aHR) or adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CIs). ResultsThe CLTI cohort included 8171 infrainguinal LEBs: 631 (7.7%) had HbA1c <5.7%; 1691 (20.6%), 5.7% to 6.5%; and 5849 (71.6%), >6.5%. There was no difference in rates of wound infection in the CLTI cohort (HbA1c ≤5.7%, 3.8%; HbA1c 5.7%-6.5%, 3.7%; HbA1c >6.5%, 3.2%; P = .53) or matched cohort (4.3%, 4.5%, 3.4%; P = .62). There were no differences in perioperative mortality in the CLTI cohort (2.5%, 1.7%, 1.5%; P = .16) or the matched cohort (2.7%, 2.3%, 2.2%; P = .84). In multivariable analysis, there was no significant association between HbA1c and wound infection in the CLTI cohort (HbA1c 5.7%-6.5% vs <5.7%: aOR, 0.91 [95% CI, 0.56-1.50; P = .72]; HbA1c >6.5% vs <5.7%: aOR, 0.81 [95% CI, 0.52-1.26; P = .35]). There was, however, a significant association between decreased HbA1c and mortality (HbA1c 5.7%-6.5% vs <5.7%: aHR, 0.77 [95% CI, 0.61-0.97; P = .03]; HbA1c >6.5% vs <5.7%: aHR, 0.75 [95% CI, 0.61-0.93; P = .01]). ConclusionsOur study suggests no significant association of increased HbA1c level and perioperative complications. Additional investigation is required to further evaluate the impact of short-term glycemic control and long-term outcomes of patients undergoing LEB.

Use of Direct Oral Anticoagulants and the Associated Bleeding and Thrombotic Complications Following Lower Extremity Bypass in the Vascular Quality Initiative

Given the recent expansion of indications for direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) use in high-risk lower extremity bypass (LEB), we aimed to determine temporal trends in the use of DOACs following infrainguinal LEB, associated bleeding and thrombotic complications as well as length of stay. We hypothesized that DOAC utilization increased over time, had shorter length of stay and patients who received DOACs following LEB would have similar or lower bleeding rates and graft occlusion compared to those receiving VKA.

Hypoalbuminemia Predicts Increased Readmission and Emergency Department Visits After Lower Extremity Bypass.

Preoperative hypoalbuminemia is associated with poor outcomes across many surgical fields. However, the effects on outcomes after lower extremity bypass (LEB), particularly over the 90-day global surgical period, are unclear. Our goal was to analyze the effect of hypoalbuminemia within 90 days after LE bypass. We performed a single-center retrospective review of all infrainguinal LEBs from 2007 to 2017. Patients were categorized into 3 preoperative albumin groups: severe hypoalbuminemia (SH; albumin ≤2.8g/dL), mild-moderate hypoalbuminemia (MH; albumin >2.8-3.5g/dL), and normal albumin (albumin >3.5g/dL). Patient and procedural details were recorded. Outcomes analyzed included wound infection, myocardial infarction (MI), pulmonary complications, early graft occlusion (≤30 days), mortality, and emergency department (ED) presentation and readmissions within 30 and 90 days. Multivariable analysis was performed. We identified 313 patients undergoing LEB-45 (14.4%) with SH, 133 (42.5%) with MH, and 135 (43.1%) with normal albumin. Overall, the mean age was 65.7 years, and 63.3% were male. The SH group more frequently had tissue loss, diabetes, hypertension, end-stage renal disease, preoperative hematocrit <30%, and patients admitted preoperatively (all P < .05). There were no significant differences in wound complications, MI, pulmonary complications, early graft occlusion, 30-day or 90-day mortality, and 30-day ED presentation. Severe hypoalbuminemia compared to MH and normal albumin, respectively, had significantly higher rates of 30-day readmission (40% vs 30.8% vs 17.8%, P = .005), 90-day ED presentation (55.6% vs 33.8% vs 29.6%, P = .006), and 90-day readmission (66.7% vs 48.9% vs 35.6%, P = .001). Multivariable analysis showed that SH was independently associated with 90-day ED presentation (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.23-6.36, P = .014) and 90-day readmission (OR: 2.63, 95% CI: 1.21-5.71, P = .015). Our study suggests that patients with SH undergoing LEB had similar perioperative complication rates compared to normal albumin and MH groups, and SH was independently associated with 90-day ED presentation and readmission. Further studies are needed to assess other factors associated with ED visits and readmission.

Elective infrainguinal lower extremity bypass for claudication is associated with high postoperative intensive care utilization

BackgroundThe overall use of intensive care units (ICUs) in the United States has been steadily increasing and is associated with tremendous health care costs. We suspect that the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) procedures is high, despite relatively low risks of complications in the immediate postoperative period. We sought to identify the burden of ICU utilization after elective LEB in patients with claudication. MethodsWe queried the Premier Healthcare Database for all adult patients undergoing first recorded elective infrainguinal LEB for claudication from 2009 to 2015. Baseline characteristics and ICU utilization on postoperative day 0 (POD 0) were identified for each patient using Premier room and board chargemaster codes. A bivariate logistic regression was performed and postestimation concordance statistics were calculated to identify predictors of postoperative ICU vs regular surgical floor admission immediately after surgery. ResultsThere were 6010 patients who met the selection criteria, of whom 2772 (46.1%) were admitted to the ICU and 3238 (53.9%) to the regular surgical floor on POD 0. Whereas patient-level factors were responsible for minor differences found in postoperative admission to the ICU after elective LEB, hospital characteristics made up the majority of variation in admission practices. Specifically, patients undergoing elective infrainguinal LEB in rural, nonteaching, small hospitals and those in certain geographic regions were more likely to be admitted to the ICU than to the floor (all, P < .001). Patient-level factors were poorly predictive of admission to the ICU immediately postoperatively, with C statistics ranging from 0.50 to 0.53. In contrast, hospital-level factors had higher C statistics ranging from 0.51 to 0.66, with geographic location being the strongest predictor of post-LEB ICU admission. There were no significant differences in the incidence of postoperative wound complications, major adverse limb events, major adverse cardiac events, or in-hospital mortality between groups (all, P ≥ .32). The median total hospital cost was $2340 higher for ICU compared with floor admission ($13,273 [interquartile range, $10,136-$17,883] vs $10,927 [interquartile range, $8342-$14,523]; P < .001). ConclusionsNearly half of patients are admitted to an ICU directly after elective infrainguinal LEB for claudication. This practice is associated with significantly higher hospital cost and is predominantly influenced by hospital-level rather than by patient-level factors. Perioperative morbidity and mortality were similar regardless of postoperative disposition. To minimize ICU utilization, postoperative care intensity should be determined by clinical severity of the patient rather than by hospital routine.

Preoperative hemoglobin A1c levels and increased risk of adverse limb events in diabetic patients undergoing infrainguinal lower extremity bypass surgery in the Vascular Quality Initiative

BackgroundThe impact of preoperative glycemic control on the risk of adverse perioperative outcomes in diabetic patients undergoing lower extremity bypass (LEB) surgery is not well-understood. We determined whether higher preoperative hemoglobin A1c (HbA1c) levels are associated with an increased risk of major adverse limb events, major adverse cardiovascular events, and mortality in diabetic patients undergoing infrainguinal LEB. MethodsA retrospective review of all infrainguinal LEB surgeries in the Vascular Quality Initiative registry from January 2012 to February 2017 was performed. Only surgeries performed on diabetic patients with complete demographic and clinical data, including HbA1c value at the time of LEB, were included for analysis (n = 7727). Entries were stratified according to the following HbA1c levels: 6 or less (n = 1087), greater than 6 to 7 or less (n = 2137), greater than 7 to 8 or less (n = 1657), and greater than 8 (n = 2846). Multivariate logistic regression was used to determine the association of preoperative HbA1c levels on the risk of in-hospital major adverse limb events (above ankle amputation, loss of primary graft patency), major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiac arrhythmia), and mortality. ResultsThe number of surgeries complicated by adverse limb and cardiovascular events were 356 (4.6%) and 1314 (17.0%), respectively. There were 72 in-hospital deaths (0.9%). After adjustment for clinical and demographic variables, patients with high HbA1c values (≥8%) were at an increased risk of adverse limb events (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.01-1.86) compared with those with a normal HbA1c (>6% to ≤7%). High HbA1c values were not associated with an increased risk of cardiovascular events (OR, 1.07; 95% CI, 0.81-1.43) or mortality (OR, 1.57; 95% CI, 0.83-3.03). Patients with low HbA1c values (≤6%) did not experience a significantly higher risk for any of the three outcomes. In a stratified analysis, the association of high HbA1c values with adverse limb events was only present in those presenting without critical limb ischemia (OR 1.82; 95% CI, 1.05-3.16). ConclusionsPoor preoperative glycemic control in diabetic individuals undergoing infrainguinal LEB, particularly in those without critical limb ischemia, is associated with an increased risk of in-hospital limb events. Further study should evaluate whether improved efforts to identify individuals with poorly controlled diabetes and subsequent interventions to better optimize glycemic control during the preoperative period improve limb outcomes after LEB.

Outcomes for peripheral vascular intervention and lower extremity bypass in kidney transplant recipients are superior to outcomes of patients remaining on dialysis

BackgroundImproved survival is reported for patients with end-stage renal disease who are kidney transplant recipients (KTRs) compared with dialysis-dependent patients (DDPs). Whether amputation-free survival (AFS) and freedom from major adverse limb events (MALEs) after peripheral vascular intervention (PVI) or lower extremity bypass (LEB) are superior after renal transplantation remains incompletely defined. MethodsA retrospective cohort study was undertaken of KTRs and DDPs undergoing infrainguinal PVI or LEB for symptoms of limb-threatening ischemia recorded in the Vascular Quality Initiative from 2003 to 2017. Primary outcomes were AFS and freedom from MALEs along with their components of assisted primary patency, limb salvage, and patient survival. The χ2 tests and independent samples t-tests were used to compare demographic variables. Kaplan-Meier survival analyses were used to estimate outcomes, and Cox regression analyses were used to confirm independent predictors of outcome. ResultsThere were 2707 PVI (351 KTRs and 2356 DDPs) and 1444 LEB (198 KTRs and 1246 DDPs) procedures performed for limb-threatening ischemia. Chronic obstructive pulmonary disease, congestive heart failure, female patients, and African Americans were more common among the DDP group, as were lower preoperative hemoglobin values and older age. After PVI, KTRs had better AFS than DDPs (42% vs 66% at 1 year, 15% vs 26% at 2 years; hazard ratio [HR], 1.91; 95% confidence interval [CI], 1.38-2.64; P < .001) and fewer MALEs (53% vs 64% at 1 year, 35% vs 49% at 18 months; HR, 1.71; 95% CI, 1.25-2.34; P = .001). PVI outcomes, AFS, and freedom from MALEs were driven primarily by differences in limb salvage and patient survival but not assisted primary patency. After LEB, KTRs also displayed improved AFS compared with DDPs (44% vs 65% at 1 year, 10% vs 36% at 3 years; HR, 2.32; 95% CI, 1.41-3.81; P = .001), driven by patient survival but not limb salvage, whereas differences in freedom from MALEs did not attain statistical significance (67% vs 58%; P = .08). ConclusionsFor patients with end-stage renal disease, subsequent kidney transplantation was associated with better AFS and freedom from MALEs after PVI but only improved AFS after LEB. Open or endovascular revascularization can be advocated in patients with limb-threatening ischemia who have received kidney transplantation to a greater degree than in those who remain dialysis dependent.

NESVS10. Outcomes of Lower Extremity Bypass After Failed Endovascular or Open Revascularization Are Inferior to Bypasses Without Prior Intervention

Outcomes of lower extremity bypass (LEB) after failed lower extremity interventions have almost exclusively been studied in the short term, and the role of changes in runoff remains unclear. The goal of this study was to assess long-term outcomes of LEB after failed endovascular (peripheral vascular intervention [PVI]) or open (bypass graft [BPG]) revascularization and to determine the effect of PVI on distal bypass targets. Patients who underwent infrainguinal LEB for critical limb ischemia between 2010 and 2017 at our institution were included. Patients were stratified into three cohorts based on prior intervention: PVI, BPG, and none. Primary end points were major amputation, graft patency, and amputation-free survival (AFS). Univariate analysis was performed, and predictors of AFS were determined. In 148 patients, 160 procedures were stratified by previous intervention: 74 (46%) PVI, 25 (16%) BPG, and 61 (38%) none. Most patients were male (71%) and diabetic (56%). BPG patients were more likely to have compromised conduit (80%; P = .03), whereas PVI patients were more likely to be diabetic (68%; P = .01); 75% of LEB patients had a below-the-knee distal target, and there were no differences in above-knee vs below-knee targets between the cohorts (P = .15). There were no differences in 30-day complications. Overall major ipsilateral amputation rate was 14%. The none cohort had higher overall freedom from amputation (P = .045). The BPG cohort had decreased rates of primary patency (P = .03) and higher rates of graft occlusion (P = .03). The none cohort had better survival at 1 year and 2 years (85% and 79%). There was no difference in long-term AFS (5 years, 46%; P = .228). End-stage renal disease and conduit were negative predictors of AFS (P < .01). The number of prior PVIs did not affect 30-day or long-term outcomes. After PVI, 41 (55%) had either a runoff or distal target change at LEB. Patients who undergo LEB without prior intervention have better graft patency and amputation outcomes, but the demonstrated benefit for AFS is short-lived. More than half of patients who underwent PVI before LEB had either runoff or distal target change, which may be a contributor to the differences seen in graft patency and amputation outcomes.

The Impact of Perioperative Ankle-Brachial Index and Clinical Status on Outcomes following Lower Extremity Bypass

Ankle-brachial index (ABI) is a common method of graft surveillance after infrainguinal lower extremity bypass (LEB) surgery and is recommended by the Society for Vascular Surgery. Several studies failed to show the benefit of ABI surveillance but were limited by sample size, and the practice remains variable. We identified all patients who underwent LEB for occlusive disease from the Vascular Study Group of New England Registry (VSGNE) between 2003 and 2016. Postoperative changes were defined as follows: improvement for ABI >0.15 at discharge or clinical status improved (i.e., symptoms improved from rest pain to asymptomatic, and so forth), no change if ABI was within 0.15 or no change in clinical status, or worsened if ABI decreased >0.15 or clinical status deteriorated. We determined the independent effect of these changes on rates of mortality, reintervention, patency loss, amputation, and Major Adverse Limb Events (MALE-above ankle amputation, revision, thrombectomy, or lysis). In addition, we compared the practice of perioperative ABI to follow-up without ABI using propensity scores with inverse probability weights. We identified 7,994 patients undergoing their first intervention in the VSGNE, 2,251 of whom (29%) had both preoperative and discharge ABIs. Overall, 5,369 (67%) of the bypasses used vein, and 4,539 (57%) were femoropopliteal, with no difference in the rate of vein use or bypass type between those who had discharge ABIs and those who did not (P>0.05). Most bypasses were performed for chronic limb-threatening ischemia (59% in the ABI group, 65% in those without ABI data, P<0.01 for difference). At discharge, ABI remained stable in 22%, improved in 69%, and worsened in 9%, whereas clinical status remained stable in 12%, improved in 77%, and worsened in 12%. In univariate analysis, clinical status was associated with mortality, amputation, and MALE, but ABI change was only associated with mortality (all P<0.01). After multivariable adjustment, ABI change was no longer associated with mortality and remained unassociated with amputation and MALE (P>0.05), and the addition of ABI change to the models did not improve the fit of the model (likelihood ratio P>0.05). Forgoing perioperative ABI was associated with higher rates of patency loss (P=0.02), but not reinterventions (P=0.57), or untreated patency loss (P=0.17). A change in clinical status, but not a change in ABI, was associated with adverse outcomes after LEB. In this group of VSGNE patients with follow-up, perioperative ABI did not add incremental value to clinical status alone as a method of graft surveillance.

Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia

Patients with critical limb ischemia (CLI) utilize hospital resources at high rates. One major driver for resource utilization is emergency department (ED) visits. Our goal was to assess perioperative ED visits after lower extremity bypass (LEB) for CLI. All patients undergoing LEB for CLI from 2008 to 2017 at our institution were analyzed. ED visits and details of the visit within 30 and 90days of discharge from index admission were recorded. Multivariable analysis was performed to identify risk factors for any ED presentation and ED presentation without hospital admission. There were 317 patients identified who underwent infrainguinal LEB for CLI. Average age was 66 years, and 60.6% of patients were male. Within 30 and 90days, 24.3% and 36.3% presented to the ED overall, and 16.7% and 26.5% of all postoperative patients had an ED presentation without hospital admission, respectively. Most common reasons for any ED visits and for ED visits without admission within 30days were wound complications (22.1% and 20.8%), cardiac complications (16.9% and 17%), and ipsilateral leg pain (10.4% and 11.3%), respectively. Cryopreserved vein bypass (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.02-8.84, P=0.046) and index length of stay (LOS) (OR 1.09, 95% CI 1.04-1.15, P<0.001) predicted any 30-day ED visit. Active leg infection at the time of bypass (OR 2.35, 95% CI 1.21-4.58, P=0.012) and index LOS (OR 1.05, 95% CI 1.004-1.09, P=0.033) predicted 30-day ED presentation without hospital admission. Most common reasons for any ED visit and for ED visits without admission within 90days were surgical wound complications (15.8% and 14.3%), cardiac complications (14.9% and 14.3%), and nonsurgical wounds (9.6% and 9.5%), respectively. Chronic renal insufficiency (CRI) (OR 2.73, 95% CI 1.52-4.93, P=0.001) and index LOS(OR 1.07, 95% CI 1.01-1.12, P=0.017) predicted any 90-day ED visit. CRI (OR3.34, 95% CI 1.81-6.17, P=0.001) predicted 90-day ED presentation without hospital admission. For multiple ED visits within 90days, there were 5 patients each with 5 ED visits, 12 each with 4 ED visits, 26 each with 3 ED visits, and 47 each with 2 ED visits. There is a high rate of ED utilization in CLI patients after LEB. Targeting these patients with closer follow-up and improved outpatient ambulatory access could assist in decreasing the frequency of postoperative ED visits. Particular areas of targeted improvement are those patients who presented to the ED and were not admitted.

Active smoking in claudicants undergoing lower extremity bypass predicts decreased graft patency and worse overall survival

ObjectivePerforming lower extremity bypass (LEB) in actively smoking claudicants remains controversial. Whereas some surgeons advocate a strict nonoperative approach to active smokers, citing perceived inferior outcomes, others will proceed with surgical bypass if the patient is anatomically suited and medical management has failed. The purpose of this study was to determine the impact of active smoking on LEB outcomes among claudicants. MethodsAll patients undergoing infrainguinal LEB for claudication in the Vascular Study Group of New England from 2003 to 2016 were analyzed. Smoking was defined as active tobacco use within 1 month of surgery. End points included in-hospital outcomes; long-term primary, assisted primary, and secondary patency; and mortality. Univariate, Cox multivariable, and Kaplan-Meier methods were used to determine the impact of smoking. Propensity score matching was performed to control for intergroup differences. ResultsOf 1789 LEBs, 971 (54%) were performed in nonsmokers and 818 (46%) in smokers. The follow-up rate was 87% at a mean of 382 days (standard error, ±6.8 days). Smokers were younger (60 vs 68 years; P < .001) and were less likely to have multiple comorbidities, including hypertension, coronary artery disease, congestive heart failure, diabetes, and chronic renal insufficiency (P ≤ .05); they were more likely to have an above-knee popliteal bypass target (52% vs 43%; P = .001). Smokers also had lower rates of postoperative major cardiac events (2.4% vs 5.3%; P = .002) and perioperative blood transfusion (5.6% vs 11%; P < .001) compared with nonsmokers, but there was no difference in respiratory complications, wound complications, or mortality. At 2-year follow-up, smokers demonstrated inferior primary patency (48% vs 61%; P = .03) and assisted primary patency (59% vs 74%; P = .01), with comparable rates of secondary patency and overall mortality. Propensity matching yielded two similar groups (n = 450 for each). Propensity-matched smokers had significantly decreased 2-year primary patency (43% vs 58%; P = .02), assisted primary patency (54% vs 71%; P = .03), and 10-year survival (69% vs 76%; P < .01). Cox multivariable analysis confirmed that smoking was an independent predictor of diminished primary patency (hazard ratio [HR], 1.3; 95% confidence interval [CI], 1.0-1.6; P = .03), assisted primary patency (HR, 1.4; 95% CI, 1.1-1.8; P = .004), and overall survival (HR, 1.3; 95% CI, 1.1-1.5; P < .001). ConclusionsDespite the fact that smokers are younger and have fewer comorbidities than nonsmokers, active smoking at the time of LEB for claudication is associated with decreased long-term patency and decreased overall survival. Surgeons should consider smoking an important risk factor for worse LEB outcomes in smokers compared with nonsmokers.