Infrainguinal Bypass Research Articles

Isolated Common Femoral Endarterectomy (without Infrainguinal Bypass) for the Treatment of Chronic Limb-threatening Ischemia

Isolated Common Femoral Endarterectomy (without Infrainguinal Bypass) for the Treatment of Chronic Limb-threatening Ischemia

National VQI Initiative Associated With Improved Prescription of Statin and Antiplatelet Medications Across Racial and Ethnic Groups

In 2017, the Vascular Quality Initiative announced the first national initiative intended to improve prescription of antiplatelets and statins. We hypothesized that this national quality initiative would be associated with an increase in prescription of these medications and a decrease in previously noted racial disparities in evidence-based medical management. A retrospective analysis using VQI data from the suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention modules from January 2015 through July 2022 was performed. Inclusion criteria were center participation during the entire study period, age over 18 years, and no documented contraindication to statin or antiplatelet therapy. Exclusion criteria were acute limb ischemia or inpatient death. Frequency of statin prescription by racial group prior to and following announcement of the national initiative were compared. Multivariable logistic regression was performed separately for statin and antiplatelet prescription at discharge. Finally, a time series analysis was performed to assess changes in disparities over time. Overall, 202,900 patients were included, of whom 149,059 identified as White, 35,871 identified as Black or African American, 11,039 identified as Latinx/Hispanic, 2015 identified as Asian, 1031 identified as Indigenous (including American Indian, Alaskan Native, Native Hawaiian, or other Pacific Islander), and 3861 were designated unknown or other, including patients who identified with more than one race. Almost all racial and ethnic groups had a statistically significant improvement in the frequency of any statin prescription and new statin prescription (Table). Moreover, while the difference between groups was statistically significant prior to announcement of the national quality improvement initiative (P < .001), there was no statistically significant difference between groups after (P = .05). On adjusted analysis, following the national quality improvement initiative, patients had an increased odds of both statin (odds ratio [OR], 1.5; P < .001; 95% confidence interval [CI], 1.4-1.6), new statin (OR, 1.4; P < .001; 95% CI, 1.4-1.5), nonaspirin antiplatelet (OR, 1.5, P < .001; 95% CI, 1.5-1.6), and new nonaspirin antiplatelet prescription (OR, 1.5, P < .001; 95% CI, 1.5-1.6). There was no statistically significant difference in the odds of new aspirin prescription. A time series analysis demonstrated continued improvement of statin prescription for all racial and ethnic groups, with a convergence around 90% (Figure). The first national VQI quality initiative was associated with a reduction in the disparities in statin prescription and nonaspirin antiplatelet prescription across all ethnic groups. These findings highlight the impact VQI-based national quality initiatives may have on racial and ethnic disparities in medical management.TableStatin prescription at dischargeAny statin prescriptionNew statin prescriptionPre-Post-DifferenceP valuePre-Post-DifferenceP valueWhite80.5%88.2%+7.8%.00126%37.8%+11.8%.001Black or African American79.7%88.2%+8.6%.00129.8%42.2%+12.4%.001Latinx/Hispanic82%87.7%+5.7%.00131.9%38.9%+7%.001Unknown or other77.6%86.6%+9%.00127.2%38.7%+11.5%.001Asian83.8%87%+3.2%.0527.9%37.9%+10%.05Indigenous (including American Indian, Alaskan Native, Native Hawaiian, or other Pacific Islander)77.2%86.5%+9%.00133.3%39.5%+6.2%.33 Open table in a new tab

Adherence to Society for Vascular Surgery Guidelines for Claudication in the Society for Vascular Surgery Vascular Quality Initiative

Current Society for Vascular Surgery (SVS) guidelines recommend 51 specific factors related to the management of intermittent claudication as quality measures. It was the objective of this study to assess rates of adherence to these guidelines for patients treated with suprainguinal or infrainguinal bypass or percutaneous vascular intervention and to determine if this was associated with a difference in the periprocedural outcomes. All patients from the SVS Vascular Quality Initiative (VQI) undergoing infrainguinal bypass (INFRA), suprainguinal bypass (SUPRA), and percutaneous vascular intervention (PVI) for claudication from 2018 were included. Nonelective procedures for other than chronic atherosclerotic disease were excluded. The rates of adherence to each assessable guideline were evaluated. For outcomes analysis, individuals were classified as “adherent” to the guidelines vs not and compared. Of the 51 SVS recommendations, 12 could be evaluated using VQI registries; these included first-line ankle-brachial index, smoking cessation, statin therapy, antiplatelet therapy with aspirin, optimal medical therapy after intervention, anatomic imaging studies before intervention, optimizing diabetes control, Plavix as second-line antiplatelet, adjunct stenting in intermediate superficial femoral artery lesions, annual follow-up, covered stents for the treatment of aortoiliac disease, and no recommended endovascular treatment for isolated infrapopliteal disease. The rates of overall “adherence” were 38.2% for INFRA, 17.1% for SUPRA, and 32.2% for PVI. There were a surprising number of isolated tibial (n = 1431, 3.1%) and pedal (n = 12, 0.03%) endovascular interventions performed for claudication. There were 784 tibial bypasses (19.3%), 30 (0.7%) at the ankle, 2 of which were tarsal/plantar bypasses for claudication. It appears that for the most part, there do not seem to be important clinical differences in outcomes based on the study definition of adherence for all outcomes assessed. Among factors such as survival (Fig 1), time to amputation (Fig 2), primary patency (Fig 3), and time to reoperation/reintervention for occlusion (Fig 4) for INFRA, SUPRA, and PVI, there were no differences between individuals meeting the study definition of adherence vs those not adherent for all outcomes was assessed. Overall adherence rates to SVS guidelines for the management of intermittent claudication are low and may be an opportunity for improvement in patient outcomes. An absence of differences noted in this study may reflect unmeasured factors in patient selection or in outcomes. Adding more of the SVS recommendations for the management of intermittent claudication to the VQI registry may serve as a future focus for quality improvement projects.

8mm Conduit Outperforms 6mm Conduit in Extra-anatomic Bypass

Extra-anatomic bypass is an important tool in relieving supra-inguinal occlusive disease. These bypasses are frequently conducted with prosthetic material, commonly available in 6-mm and 8-mm sizes. Previous studies have demonstrated infra-inguinal bypass has improved patency when graft size is 6 mm or greater. This study aimed to examine outcomes of 6-mm vs 8-mm prosthetic graft use in extra-anatomic bypasses. A retrospective analysis of the Vascular Quality Initiative supra-inguinal database (2010-2022) was conducted. Patients undergoing either axillary-femoral or femoral-femoral prosthetic bypass with available conduit size data were included. Primary endpoints included graft patency and major adverse limb events (MALE). A logistic regression analysis was performed of demographic and operative variables to determine if any factors contributed to the selection of graft size. Then, multivariable Cox regression analysis was conducted in groups based on prosthetic diameter (6 mm vs 8 mm), controlling for these factors. Seven mm was excluded from formal regression analysis due to small sample size but included in survival curves to demonstrate the stepwise impact of graft size. A total of 6463 patients were included for analysis; 2355 axillary-femoral bypasses and 4128 femoral-femoral bypasses. Of these, 1071 patients underwent bypass with 6-mm graft, and 5392 patients underwent bypass with 8-mm graft. Significant predictors (P < .05) of 8-mm graft use in both types of extra-anatomic bypass included male gender, body mass index (BMI) of 25-35 kg/m2, and common femoral as distal target when compared to profunda, superficial femoral artery, and other distal vessels. The most significant predictor (P < .001) of improved primary patency in both types of extra-anatomic bypass examined was larger conduit diameter (8 mm vs 6 mm axillary-femoral hazard ratio [HR], 0.5; femoral-femoral HR, 0.66). Cox regression curves by graft size were generated for both axillary-femoral and femoral-femoral bypasses (Figs 1 and 2), which demonstrated significantly higher primary patency in patients with 8-mm bypasses over time. Improved performance in 8-mm graft compared with 6-mm graft was additionally demonstrated in primary-assisted patency, secondary patency, and MALE regression curves with P < .001 for both axillary-femoral and femoral-femoral bypasses. In this retrospective analysis of extra-anatomic bypasses, 8-mm grafts had significantly improved patency rates and fewer MALE when compared with 6-mm grafts over time. Male sex and body mass index were associated with larger diameter bypass use; after controlling for these preoperative factors, 8-mm grafts still outperformed 6-mm grafts. Vascular surgeons should be cognizant of the potential implications in limb salvage when selecting prosthetic graft for extra-anatomic bypass.Fig 2Primary patency of axillary-femoral bypass over time by graft size.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Sex Disparities in Infra-inguinal Vein Bypass for Peripheral Artery Disease

Although studies demonstrate sex-based differences in peripheral arterial disease (PAD), contemporary outcomes in surgically managed PAD remains largely under-characterized. We sought to discern the differences in perioperative outcomes between males and females with PAD who received infra-inguinal vein bypasses. The infra-inguinal bypass Vascular Quality Initiative (VQI) registry was queried between 2010 and 2020. We evaluated patients with infra-inguinal vein bypasses for occlusive disease, excluding non-occlusive disease, asymptomatic, acute limb ischemia, and emergent procedures. Baseline demographics, comorbidities, prior medical and surgical management, and perioperative outcomes were compared between men and women using the χ2 analysis and t test. Socioeconomic status was defined using Distressed Community Index (DCI). Bypass patency at 1 year was compared between single-segment vein bypasses of the same inflow and outflow targets, using Kaplan-Meier analysis. We identified 28,845 infra-inguinal vein bypasses; 30.6% of patients were female. Female patients were older and had a higher portion of black race, non-ambulatory status, and disadvantaged socioeconomic DCI (Table I). Males had higher rates of smoking, chronic obstructive pulmonary disease, cardiac disease, and coronary percutaneous/bypass interventions. More women were on more likely to be taking P2Y inhibitors, possibly related to a significantly higher rate of prior lower extremity endovascular interventions (P < .001). Alternatively, males had higher rates of prior ipsilateral bypass. Men presented with less clinical disease severity, with a higher proportion of claudication in men vs rest pain in women. Females had a higher rate of popliteal bypass targets suggestive of proximal disease, whereas more males had tibial bypass targets suggestive distal disease (Table II). Women had a higher utilization of non-reversed GSV compared with men (24.2% vs 22.6%; P < .001). No significant differences were seen in total procedure time, blood loss, or postoperative infection. More males underwent postoperative amputation. Fewer women returned home or were ambulatory on discharge. Males were also more likely to be on aspirin and statin both prior to intervention and on discharge (P < .001). There was no significant differences between men and women in 5-year survival (74.6% vs 74.2%; P = .98) or 1-year primary patency in femoral-above knee popliteal (58.6% vs 58.0%; P = .720), femoral-below knee popliteal (57.2% vs 56.7%; P = .816), femoral-tibial (56.5% vs 57.7%; P = .520), or popliteal-tibial (58.0% vs 55.7%; P = .950) bypass. Females present with a unique demographic, socioeconomic, and PAD disease pattern, with diminished perioperative medical management and advanced clinical disease. Acknowledgment of these differences should guide increasing attention to screening programs, medical optimization, and post intervention disposition planning. Although less women were discharged on optimal medical management, bypass patency was similar to men at 1 year.Table ICategorical variables for patients receiving infra-inguinal vein bypassMaleFemaleP-valueDemographics Age, years66 ± 1067 ± 12<.001 Body mass index, kg/m227.7 ± 5.728.0 ± 6.9.042 Race<.001White82.2%76.7%Black13.8%19.7%Others4.0%3.6% Ambulatory status<.001Ambulatory95.5%93.5%Non-ambulatory4.5%6.5% DCI<.001Prosperous23.1%20.8%Comfortable21.3%20.3%Mid-tier20.7%19.4%At-risk18.3%19.6%Distressed16.7%19.9% Smoking history87.0%76%<.001 Chronic obstructive pulmonary disease24.6%26.3%<.001 Hypertension87.8%89.6%<.001 Diabetes mellitus52.6%49.0%.008 Coronary disease31.2%27.1%<.001 Heart failure17.1%16.9%.018 Peripheral endovascular42.9%47.9%<.001 Peripheral bypass25.3%23.6%.015 Minor amputation10.7%8.6%<.001 Percutaneous coronary22.6%20.1%<.001 Coronary bypass19.1%16.9%<.001 Aspirin74.3%73%.071P2Y inhibitor28.9%32.9%<.001 Statin75.1%71.7%<.001 Claudication26.6%21.0%<.001 Rest pain24.3%28.6% Tissue loss49.2%50.4%DCI, Disadvantaged Community Index. Open table in a new tab Table IIPerioperative outcomes for patients receiving infra-inguinal vein bypassMale, %Female, %P-valueBypass category<.001 Femoral-above knee popliteal13.319.8 Femoral-below knee popliteal31.635.1 Femoral-tibial42.235.3 Popliteal-tibial12.89.8Perioperative antibiotics82.779.7<.001SSI3.03.9<.002Postoperative amputation12.111.9<.001Discharge medications Aspirin86.684.7<.001 P2Y inhibitor41.645.1<.001 Statin83.979.2<.001Discharge status<.001 Home72.364.6 Rehab16.019.8 Nursing home10.914.5 Other0.81.1Discharge graft patency.002 Primary95.093.5 Primary-assisted2.53.1 Secondary1.72.2 Occluded0.81.2SSI, Surgical site infection. Open table in a new tab

Location of Venous Infrainguinal Bypass Stenosis Is Associated with Reverse/nonreverse Orientation and Responds Differently to Endovascular vs Open Revision

Location of Venous Infrainguinal Bypass Stenosis Is Associated with Reverse/nonreverse Orientation and Responds Differently to Endovascular vs Open Revision

Differences in Long-Term Outcomes in End-Stage Kidney Disease Patients with Chronic Limb-Threatening Ischemia

End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI). CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves. The ESKD cohort was younger (66.4±11.8 vs. 71.6±12.1years, P<0.001) with higher rates of diabetes (82.2 vs. 60.9%, P<0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N=2,128 procedures) of ESKD patients and 60.8% (N=13,075 procedures) of non-ESKD patients. At 21months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P<0.001) and a higher amputation rate (22.3 vs. 7.1%, P<0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P<0.001). CLTI patients with ESKD have worse long-term outcomes at 2years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage.

O007 Glycaemic variability is a predictor of graft failure following infra-inguinal bypass for peripheral arterial disease (PAD). A retrospective cohort study

Abstract Introduction Many factors influence graft patency following infra-inguinal bypass (IIB). Glycaemic variability (GV) is associated with increased risk of multiple adverse outcomes. However, the impact of GV on outcomes following IIB is unknown. Methods A 3-year single centre retrospective case notes analysis of all people undergoing IIB between 2017–2019. Rutherford stage, graft conduit, bypass level, procedure details, baseline demographics, co-morbidities, mean HbA1c and GV (HbA1c SD) were assessed. Time to re-intervention, ipsilateral amputation or death were recorded to determine primary (PP). Results Were reported as hazard ratios (HR) following multivariate adjustment.193 IIB outcomes were analysed: mean (±SD) age 68.9(9.2) years; 135(69.9%) male. 156 (80.8%) had pre-operative HbA1c for analysis and 88(45.6%) had DM; 87(45.1%) were current smokers; 107(55.4%) underwent emergency procedures. Those without diabetes were more likely to smoke (P=0.011), but those with DM were more likely to have IHD (0.007), had higher Rutherford stage (p=0.0006), underwent more distal bypasses (p=0.004) and more emergency procedures (p=0.04). GV&amp;gt;9.1% was associated with significantly lower PP than GV&amp;lt;9.1%, 198 [105–377] vs. 713 [313-1287] days (p=0.02). Univariate predictors of PP included Rutherford stage 4 vs 3 (p=0.01), level of bypass, (p=0.0003), DM (p=0.04) and GV&amp;gt;9.1% (p=0.02). On multivariate adjustment, GV &amp;gt;9.1% and level of bypass remained independent predictors of primary patency, HR 1.96 (95% CI:1.12-3.42, p=0.018) and HR 2.54 (95%CI:1.24-5.22, p=0.038) respectively. Conclusion We have demonstrated GV and level of bypass as independent predictors of graft failure on multivariate analysis. Therefore, optimising GV should be a therapeutic target to improve outcomes.

O062 Female gender is associated with increased length of hospital stay following infra-inguinal bypass for peripheral arterial disease (PAD). A retrospective cohort study

Abstract Introduction Women have previously been found to have longer post-operative stays following coronary artery bypass. However, impact of gender on length of stay following infra-inguinal bypass (IIB) surgery for PAD is unknown. Methods A 3-year single centre retrospective case notes analysis of all people undergoing IIB between 2017-2019. Rutherford stage, graft conduit, urgency of bypass, level of bypass, procedure details, baseline demographics, length of stay (LoS), co-morbidities were collected and univariate associations with LoS were reported. Factors associated with increased LoS on univariate analysis were entered into a multivariate model and reported as hazard ratios (HR). Results :193 IIB outcomes on 176 patients were analysed on: mean(±SD) age 68.9(9.2) years; 135(69.9%) male; 88(45.6%) had DM; 87(45.1%) were current smokers and 107(55.4%) underwent emergency procedures. On univariate analysis, LoS for female patients was significantly longer than for male patients (9.5 [6-21] vs. 7[5-15] days, p=0.016). Other factors associated with increased LoS were emergency vs. elective (13[7-22] vs. 5 [4-9] days, p&amp;lt;0.0001, Rutherford stage (p&amp;lt;0.0001), bypass level (p=0.001) and diabetes (9 [5-21] vs. 7[4-15] days, p=0.017) After multivariate adjustment, female gender (RR 1.56 95% CI: 1.12-2.18) was associated with increased LoS. As was elective bypass (RR 0.50 95% CI:0.36-0.71) and lower Rutherford stage (3 vs. 5: RR 0.32 95% CI: 0.2-0.52) (4 vs 5:0.46 95% CI: 0.31-0.68). Conclusion We have demonstrated that female gender is independently associated with significantly longer hospital stays. With further investigation into causation, this could potentially inform pre- and post-operative management to reduce risks to women undergoing IIB.

Characteristics and Outcomes of Patients Undergoing Infrainguinal Bypass in the Endovascular Era

The Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) for lower extremity bypass (LEB) in chronic limb-threatening ischemia (CLTI) based on studies that included patients who were at good risk for open revascularization. In the endovascular era, many LEB patients have had prior interventions, and most would be considered high-risk by the original SVS OPG standards. The goal of this study is to characterize a contemporary patient population undergoing LEB for CLTI and determine if outcomes remain commensurate with the parameters established by the SVS OPG. All patients who underwent LEB for CLTI over a 10-year period (2012-2021) were identified. Patients were stratified into low- and high-risk categories based upon the clinical, conduit, and anatomic parameters used in the SVS OPG. Limb salvage at 1year and amputation-free survival, a composite outcome of major amputation and mortality, at 1 year were compared with the SVS OPG cohort. Primary, assisted, and secondary patency at 1 and 3years were also evaluated using Kaplan-Meier survival analysis. There were 169 LEBs performed for CLTI. One hundred and two (60.36%) males, 101 (59.76%) current or former smokers, 115 (68.05%) with hypertension, 69 (40.83%) with diabetes mellitus, and 40 (23.67%) with coronary artery disease. Median age was 71.84years, and mean follow-up was 2.17years. 65 (38.46%) had a prior ipsilateral endovascular intervention, and 18 (10.65%) were redo bypasses. 21 (12.43%) were deemed clinically high-risk, 44 (26.04%) were high-risk conduits, and 118 (69.82%) had high-risk anatomic factors. Freedom from amputation at 1year was 87.05% in this cohort which was similar to the overall SVS OPG cohort (88.9%). Amputation-free survival at 1year was 77.78%, which was also similar to the overall SVS OPG cohort (76.5%). Primary patency at one and threeyears was 46.84% and 37.59%, assisted patency at one and threeyears was 61.87%and 44.81%, and secondary patency at one and threeyears was 72.13% and 61.16%. The majority of patients undergoing LEB in the endovascular era meet the SVS OPG criteria for high risk. Despite this, the 1-year limb salvage and amputation-free survival in this cohort were equivalent to the SVS OPG LEB cohort. This supports the continued use of LEB for limb salvage in high-risk patients and those who have failed endovascular approaches.

The Effect of Chronic and End-Stage Renal Disease on Long-Term Outcomes after Infrainguinal Bypass

Patients undergoing infrainguinal bypass for chronic limb threatening ischemia (CLTI) with renal dysfunction are at an increased risk for perioperative and long-term morbidity and mortality. Our goal was to examine perioperative and 3-year outcomes after lower extremity bypass for CLTI stratified by kidney function. A retrospective, single-center analysis of lower extremity bypass for CLTI was performed between 2008 and 2019. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60mL/min/1.73m2), chronic kidney disease (CKD) (eGFR 15-59mL/min/1.73m2), and end-stage renal disease (ESRD) (eGFR <15mL/min/1.73m2). Kaplan-Meier and multivariable analysis were performed. There were 221 infrainguinal bypasses performed for CLTI. Patients were classified by renal function as normal (59.7%), CKD (24.4%), and ESRD (15.8%). Average age was 66years and 65% were male. Overall, 77% had tissue loss with 9%, 45%, 24%, and 22% being Wound, Ischemia, and foot Infection stages 1-4, respectively. The majority (58%) of bypass targets was infrapopliteal and 58% used ipsilateral greater saphenous vein. The 90-day mortality and readmission rates were 2.7% and 49.8%, respectively. ESRD, compared to CKD and normal renal function, respectively, had the highest 90-day mortality (11.4% vs. 1.9% vs. 0.8%, P=0.002) and 90-day readmission (69% vs. 55% vs. 43%, P=0.017). On multivariable analysis, ESRD, but not CKD, was associated with higher 90-day mortality (odds ratio (OR) 16.9, 95% confidence interval (CI) 1.83-156.6, P=0.013) and 90-day readmission (OR 3.02, 95% CI 1.2-7.58, P=0.019). Kaplan-Meier 3-year analysis showed no difference between groups for primary patency or major amputation; however, ESRD, compared to CKD and normal renal function, respectively, had worse primary-assisted patency (60% vs. 76% vs. 84%, P=0.03) and survival (72% vs. 96% vs. 94%, P=0.001). On multivariable analysis, ESRD and CKD were not associated with 3-year primary patency loss/death, but ESRD was associated with higher primary-assisted patency loss (hazard ratio (HR) 2.61, 95% CI 1.23-5.53, P=0.012). ESRD and CKD were not associated with 3-year major amputation/death. ESRD was associated with higher 3-year mortality (HR 4.95, 95% CI 1.52-16.2, P=0.008) while CKD was not. ESRD, but not CKD, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary-assisted patency, there were no differences in loss of primary patency or major amputation.

The management of patients with popliteal artery aneurysms presenting with acute limb ischemia

ObjectiveEndovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI. MethodsThe Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year. ResultsUrgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality. ConclusionsEndovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.

Postoperative Clostridium difficile infection has a differential procedure-specific association with surgical outcomes in contemporary United States practice.

The Centers for Disease Control and Prevention has made the prevention of in-hospital Clostridium difficile infection a priority. However, whether there is a differential impact of Clostridium difficile on surgical patients remains undefined. Therefore, we quantified the procedure-specific association between postoperative Clostridium difficile and surgical outcomes to define opportunities for targeted quality improvement. We studied patients undergoing major cardiac, vascular, general, or oncologic procedures using the Vizient database from 2015 to 2019. Our primary exposure was postoperative Clostridium difficile infection. Our primary outcomes were postoperative length of stay, hospitalization cost, readmission, and in-hospital mortality. We used linear and logistic regression for risk adjustment. The incidence of Clostridium difficile infection was 1.6% (n= 6,506/397,750). Patients with Clostridium difficile were older, more comorbid, and more frequently underwent urgent surgery. The median postoperative length of stay was 7 days (interquartile range: 5-11 days), and it was 66% longer among those with Clostridium difficile (P < .001). Similarly, the median hospitalization cost was $31,000 (interquartile range: $20,000-$49,000), and it was 51% greater among patients with Clostridium difficile (P < .001). Postoperative Clostridium difficile was associated with more readmissions after coronary artery bypass grafting, small bowel resection, colectomy, gastrectomy, pancreatectomy, and infrainguinal bypass (adjusted odds ratio range: 1.4-1.7), but not after open aneurysm repair, suprainguinal bypass, or esophagectomy. Clostridium difficile was associated with increased mortality after coronary artery bypass grafting, small bowel resection, colectomy, and infrainguinal bypass (adjusted odds ratio range: 1.3-2.7), but not after open aneurysm repair, suprainguinal bypass, esophagectomy, gastrectomy, or pancreatectomy. Postoperative Clostridium difficile infection was differentially associated with increased length of stay, cost, readmissions, and mortality across specific procedures. This was most apparent after infrainguinal bypass, small bowel resection, colectomy, and coronary artery bypass grafting. Accordingly, a targeted Clostridium difficile reduction effort for these procedures may offer a more effective approach toward reducing infection rates.

Impact of ambulatory status change on survival in patients with chronic limb-threatening ischemia undergoing infrainguinal surgical or endovascular revascularization

ObjectiveThis study aimed to evaluate the influence of change in ambulatory status on the prognosis of patients with chronic limb-threatening ischemia (CLTI) undergoing infrainguinal bypass surgery or endovascular therapy (EVT). MethodsWe retrospectively analyzed data from two vascular centers for patients who underwent revascularization for CLTI between 2015 and 2020. The primary endpoint was overall survival (OS), and the secondary endpoints were changes in ambulatory status and postoperative complications. ResultsThroughout the study, 377 patients and 508 limbs were analyzed. In the preoperative nonambulation cohort, the average body mass index (BMI) was lower in the postoperative nonambulatory group than in the postoperative ambulatory group (P < .01). The percentage of cerebrovascular disease (CVD) was higher in the postoperative nonambulatory group than in the postoperative ambulatory group (P = .01). In the preoperative ambulation cohort, the average controlling nutritional status (CONUT) score was higher in the postoperative nonambulatory group than in the postoperative ambulatory group (P < .01). There was no difference in the bypass percentage and the EVT in the preoperative nonambulation (P = .32) and ambulation (P = .70) cohorts. According to the change in ambulatory status before and after revascularization, the 1-year OS rates were 86.8% in the ambulatory → ambulatory group, 81.1% in the nonambulatory → ambulatory group, 54.7% in the nonambulatory → nonambulatory group, and 23.9% in the ambulatory → nonambulatory group (P < .01). On multivariate analysis, increased age (P = .04), higher Wound, Ischemia, and foot Infection stage (P = .02), and increased CONUT score (P < .01) were independent risk factors for the decline in ambulatory status in patients with preoperative ambulation. In patients with preoperative nonambulation, increased BMI (P < .01) and absence of CVD (P = .04) were independent factors related to the improved ambulatory status. The percentages of postoperative complications were 31.0% and 17.0% in the preoperative nonambulation and the preoperative ambulation in the overall cohort (P < .01). Preoperative nonambulatory status (P < .01), CONUT score (P < .01), and bypass surgery (P < .01) were risk factors for postoperative complications. ConclusionsImproved ambulatory status is associated with better OS in patients with preoperative nonambulatory status after infrainguinal revascularization for CLTI. Although patients with preoperative nonambulatory status have a risk of postoperative complication, some may benefit from revascularization if they have no factors such as low BMI and CVD, improving their ambulatory status.

Routine Completion Angiography for Infrainguinal Bypasses Using Prosthetic Conduit: No Effect on Postoperative Patency

Recent studies have demonstrated increased postoperative patency with the use of routine completion angiography for bypass using venous conduit. Compared to vein conduits, however, prosthetic conduits are less plagued by technical issues such as unlysed valves or arteriovenous fistulae. The effect of routine completion angiography on bypass patency in prosthetic bypasses has yet to be compared to the more traditional selective use of completion imaging. A retrospective review of all infrainguinal bypass procedures using prosthetic conduit completed at a single hospital system from 2001 to 2018 was performed. Demographics, comorbidities, intraoperative reintervention rates, and 30-day rates of graft thrombosis were analyzed. Statistical analysis included t-tests, chi-square tests, and cox regression. Four hundred and ninety-eight bypasses that were performed in 426 patients met inclusion criteria. Fifty-six (11.2%) bypasses were classified into the routine completion angiogram group compared to 442 (88.8%) into the no completion angiogram group. Patients who underwent routine completion angiograms had a rate of intraoperative reintervention of 21.4%. When comparing bypasses that underwent routine completion angiography versus no completion angiography, there were no significant differences in rates of reintervention (3.5% vs. 4.5%, P=0.74) or graft occlusion (3.5% vs. 4.7%, P=0.69) at 30-days postoperatively. Almost one-quarter of lower extremity bypasses using prosthetic conduit that undergo routine completion angiography undergo postangiogram bypass revision; however, this is not associated with an increased graft patency at 30 days postoperatively.

Iliac artery calcification score stratifies mortality risk estimation in patients with chronic limb-threatening ischemia undergoing revascularization

ObjectivePatients with chronic limb-threatening ischemia (CLTI) are at high risk for adverse limb outcomes and mortality. Using the Vascular Quality Initiative (VQI) prediction model to estimate mortality after revascularization can assist with clinical decision-making. We aimed to improve the discrimination of the 2-year VQI risk calculator by incorporating a common iliac artery (CIA) calcification score based on computed tomography scans. MethodsThis was a retrospective analysis of patients who underwent infrainguinal revascularization for CLTI from January 2011 to June 2020 and had a computed tomography scan of the abdomen/pelvis 2 years before or up to 6 months after revascularization. CIA calcium morphology, circumference, and length were scored. Bilateral scores were summed for the total calcium burden (CB) score, which was trichotomized (mild, 0-15; moderate, 16-19; severe, 20-22). The VQI CLTI model was used to categorize patients as low, medium, or high risk for mortality. ResultsA total of 131 patients with a mean age of 69±12 years were included in the study, and 86 (66%) were men. CB scores were mild in 52 (40%), moderate in 26 (20%), and severe in 53 (40%) patients. Older patients (P = .0002) and those with coronary artery disease (P = .06) had higher CB scores. Patients with severe CB scores were more likely to undergo infrainguinal bypass compared with those with mild or moderate CB scores (P = .006). The 2-year VQI mortality risk was calculated to be low in 102 (78%), medium in 23 (18%), and high in 6 (4.6%) patients. In the “low-risk” VQI mortality subgroup, 46 (45%) patients had mild, 18 (18%) had moderate, and 38 (37%) had severe CB scores, and patients with severe CB scores had significantly higher risk of mortality compared with those with mild or moderate scores (hazard ratio, 2.5; 95% confidence interval, 1.2-5.1; P = .01). In this “low-risk” VQI mortality subgroup, CB score further stratified the risk of mortality (P = .04). ConclusionsHigher total CIA calcification was significantly associated with mortality in patients undergoing infrainguinal revascularization for CLTI, and preoperative assessment of CIA calcification may help with perioperative risk stratification and guide clinical decision making in this population.

Impact of Revascularization Technique on the Outcomes of Peripheral Graft Revision Procedures

The acute occlusion of a peripheral bypass graft leads to acute limb ischemia (ALI) and threatens the viability of the limb if left untreated. The aim of the present study was to analyze the results of surgical and hybrid revascularization techniques for patients with ALI due to peripheral graft occlusions. A retrospective analysis of 102 patients undergoing treatment for ALI due to peripheral graft occlusion between 2002 and 2021 was carried out at a tertiary vascular center. Procedures were classified as surgical when only surgical techniques were used and as hybrid when surgical procedures were combined with endovascular techniques such as balloon or stent angioplasty or thrombolysis. Endpoints were primary and secondary patency and amputation-free survival after 1 and 3years. Of all patients, 67 met the inclusion criteria, 41 were treated surgically and 26 by hybrid procedures. There were no significant differences in the 30-day patency rate, 30-day amputation rate, and 30-day mortality. The 1- and 3-year primary patency rates were 41.4% and 29.2% overall, respectively; 45% and 32.1% in the surgical group, respectively; and 33.2% and 26.6% in the hybrid group, respectively. The 1- and 3-year secondary patency rates were 54.1% and 35.8% overall, respectively; 52.5% and 34.2% in the surgical group, respectively; and 54.4% and 43.5% in the hybrid group, respectively. The 1- and 3-year amputation-free survival rates were 67.5% and 59.2%, overall, respectively; 67.3% and 67.3% in the surgical group, respectively; and 68.5% and 48.2% in the hybrid group, respectively. There were no significant differences between the surgical and the hybrid groups. The results of surgical and hybrid procedures after bypass thrombectomy for ALI to eliminate the cause of infrainguinal bypass occlusion are comparable with good midterm results in terms of amputation-free survival. New endovascular techniques and devices need to be established in comparison to the results of these proven surgical revascularization methods.

Differences In Long-Term Outcomes In End-Stage Kidney Disease Patients With Chronic Limb-Threatening Ischemia

End-Stage Kidney Disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. ESKD patients are underrepresented in vascular surgery research, despite comprising an important patient population. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI).

Preoperative Anemia Is Associated With Poorer Postoperative Outcomes In Patients Undergoing Infrainguinal Bypass Surgery

Preoperative Anemia Is Associated With Poorer Postoperative Outcomes In Patients Undergoing Infrainguinal Bypass Surgery

Preoperative Anemia is Associated with Poorer Postoperative Outcomes in Patients Undergoing Infrainguinal Bypass Surgery

Preoperative anemia is an important, modifiable risk factor among surgical patients. However, data are scarce on the impact of preoperative anemia on postoperative outcomes after infrainguinal bypass. In this multi-institutional analysis, data were retrospectively collected on all infrainguinal bypass procedures performed between 2010 and 2020. Patients were grouped by preoperative hemoglobin as per the National Cancer Institute anemia scale (mild, 10g/dL-lower limit of normal; moderate, 8.0-9.9g/dL; severe, 6.5-7.9g/dL). Multivariable comparisons were performed using logistic regression analysis. A total of 492 patients underwent bypass for peripheral artery disease over the 10-year study period. Median preoperative hemoglobin was 11.0g/dL (interquartile range 9.5-12.7) and median follow-up was 1.7years. Preoperative anemia was prevalent among bypass patients (mild 52.4% [n=258], moderate 26.4% [n=130], and severe 5.1% [n=25]). Women were more likely to have moderate (49.2% [women] vs. 50.8% [men]) or severe anemia (52.0% [women] vs. 48.0% [men]) compared with normal hemoglobin (17.7% [women] vs. 82.3% [men]) (P<0.001). Patients with preoperative anemia were more likely to present with tissue loss (22.8% [normal] vs. 47.7% [moderate] vs. 52.0% [severe], P=0.01). Bypass target and conduit types were similar between groups. Anemic patients had longer median hospital length of stay compared with nonanemic patients (4days [normal] vs. 5days [mild] vs. 6days [moderate] vs. 7days [severe], P<0.001). Postoperative mortality at 30 days was similar across anemia groups (2.5% [normal] vs. 4.6% [moderate] vs. 8.0% [severe], P=0.23). On multivariable analysis, however, postoperative mortality was independently associated with severe anemia (odds ratio 7.5 [1.2-48.8], P=0.04) and male gender (odds ratio 7.5 [1.2-26.4], P=0.03). Preoperative anemia is common among patients undergoing infrainguinal bypass surgery and is an independent risk factor for postoperative mortality. Future investigation is needed to determine whether correction of anemia improves postoperative outcomes in these high-risk patients.