Lower Extremity Arterial Bypass Research Articles

Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease

ObjectiveWhile existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis. ResultsA total of 44,675 patients undergoing open lower extremity revascularization were identified, of which 1,807 patients were on chronic steroids and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep SSI (OR 1.37, 95% CI 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43) and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), UTI (OR 1.54, 95% CI 11.13-2.09), DVT (OR 1.60, 95% CI 1.01-2.53), and 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37) and mortality (OR 1.33, 95% CI 1.01-1.76) compared to non-chronic steroid users. ConclusionThis study confirms that chronic corticosteroid use is associated with higher risk of surgical site infections (SSIs) in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.

Endoscopic Vein Harvest and its Effect on Lower Extremity Arterial Bypass Patency

Endoscopic Vein Harvest and its Effect on Lower Extremity Arterial Bypass Patency

How I do it: Endoscope-assisted in situ arterial reconstruction of the lower limb

Arterial reconstruction with the great saphenous vein is a frequently performed vascular surgery technique for revascularization of chronic limb threatening ischemia. Surgeon variations of the procedure are common and aim to balance patency, limb salvage, complications, hospital resources, and technical feasibility. We describe a minimally invasive revascularization option using endoscope assistance for in situ great saphenous vein–arterial bypass to treat infrainguinal occlusive disease. We highlight patient selection, operating room setup, instrument details, and procedure strategies that facilitate the use of this technique. The development and refinement of minimally invasive techniques for lower extremity arterial bypass are critical to reduce wound complications and improve limb salvage outcomes in patients.

The obesity paradox exists for perioperative complications and mortality following lower extremity arterial bypass surgery

ObjectiveThe obesity paradox refers to a phenomenon by which obese individuals experience lower risk of mortality and even protective associations from chronic disease sequelae when compared with the non-obese and underweight population. Prior literature has demonstrated an obesity paradox after cardiac and other surgical procedures. However, the relationship between body mass index (BMI) and perioperative complications for patients undergoing major open lower extremity arterial revascularization is unclear. MethodsWe queried the Vascular Quality Initiative for individuals receiving unilateral infrainguinal bypass between 2003 and 2020. We used multivariable logistic regression to assess the relationship of BMI categories (underweight [<18.5 kg/m2], non-obese [18.5-24.9 kg/m2], overweight [25-29.9 kg/m2], Class 1 obesity [30-34.9 kg/m2], Class 2 obesity [35-39.9 kg/m2], and Class 3 obesity [>40 kg/m2]) with 30-day mortality, surgical site infection, and adverse cardiovascular events. We adjusted the models for key patient demographics, comorbidities, and technical and perioperative characteristics. ResultsFrom 2003 to 2020, 60,588 arterial bypass procedures met inclusion criteria for analysis. Upon multivariable logistic regression with the non-obese category as the reference group, odds of 30-day mortality were significantly decreased among the overweight (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53-0.78), Class 1 obese (OR, 0.65; 95% CI, 0.52-0.81), Class 2 obese (OR, 0.66; 95% CI, 0.48-0.90), and Class 3 obese (OR, 0.61; 95% CI, 0.39-0.97) patient categories. Conversely, odds of 30-day mortality were increased in the underweight patient group (OR, 1.58; 95% CI, 1.16-2.13). Furthermore, a BMI-dependent positive association was present, with odds of surgical site infections with patients in Class 3 obesity having the highest odds (OR, 2.10; 95% CI, 1.60-2.76). Finally, among the adverse cardiovascular event outcomes assessed, only myocardial infarction (MI) demonstrated decreased odds among overweight (OR, 0.82; 95% CI, 0.71-0.96), Class 1 obese (OR, 0.78; 95% CI, 0.65-0.93), and Class 2 obese (OR, 0.66; 95% CI, 0.51-0.86) patient populations. Odds of MI among the underweight and Class 3 obesity groups were not significant. ConclusionsThe obesity paradox is evident in patients undergoing lower extremity bypass procedures, particularly with odds of 30-day mortality and MI. Our findings suggest that having higher BMI (overweight and Class 1-3 obesity) is not associated with increased mortality and should not be interpreted as a contraindication for lower extremity arterial bypass surgery. However, these patients should be under vigilant surveillance for surgical site infections. Finally, patients that are underweight have a significantly increased odds of 30-day mortality and may be more suitable candidates for endovascular therapy.

Outcomes of lower extremity arterial bypass using the Human Acellular Vessel in patients with chronic limb-threatening ischemia

ObjectivePatients with chronic limb-threatening ischemia (CLTI) and no great saphenous vein to use as a conduit for arterial bypass have a high risk for amputation despite advances in medical and endovascular therapies. This report presents findings from a U.S. Food and Drug Administration (FDA) supported study of the Human Acellular Vessel (HAV) (Humacyte Inc.) used as a conduit for arterial bypass in patients with CLTI and inadequate or absent autologous conduit. MethodsThe HAV is a 6-mm, 40-cm vessel created from human vascular smooth muscle cells seeded onto a polyglycolic acid scaffold pulsed in a bioreactor for 8 weeks as cells proliferate and the scaffold dissolves. The resultant vessel is decellularized, creating a nonimmunogenic conduit composed of collagen, elastin, and extracellular matrix. The FDA issued an Investigational New Drug for an intermediate-sized, single-center study of the HAV under the agency's Expanded Access Program in patients with advanced CLTI and inadequate or absent autologous conduit. Technical results and clinical outcomes were analyzed and reported. ResultsBetween March 2021 and July 2023, 29 patients (20 males; mean age, 71 ± 11 years) underwent limb salvage operation using the HAV as a bypass conduit. Most patients had advanced CLTI (Rutherford class 5/6 in 72%; wound, ischemia, and foot infection stage 3/4 in 83%), and 97% had previously failed revascularization(s) of the extremity. Two HAVs were sewn together to attain the needed bypass length in 24 patients (83%). Bypasses were to tibial arteries in 23 patients (79%) and to the popliteal artery in 6 (21%). Technical success was 100%, and the 30-day mortality rate was 7% (2 patients). With 100% follow-up (median, 9.3 months), the limb salvage rate was 86% (25/29 patients). There were 16 reinterventions to restore secondary patency, of which 15 (94%) were successful. Primary and secondary patency of the HAV at 9 months were 59% and 71%, respectively. ConclusionsThe HAV has demonstrated short- to intermediate-term safety and efficacy as an arterial bypass conduit in a complex cohort of patients with limb-threatening ischemia and no autologous options. This experience using the FDA’s Expanded Access Program provides real-world data to inform regulatory deliberations and future trials of the HAV, including the study of the vessel as a first-line bypass conduit in less severe cases of chronic limb ischemia.

Readmission After Lower Extremity Bypass Following Discharge to a Rehabilitation or Nursing Facility

IntroductionHospital readmission after lower extremity arterial bypass (LEB) is common. Patients are often discharged to a facility after LEB as a bridge to home. Our objective was to define the association between discharge to a facility and readmission after LEB. MethodsWe used the Vascular Quality Initiative to study patients who underwent LEB from 2017 to 2022. The primary exposure was discharge location. The primary outcome was 30-d hospital readmission. ResultsWe included 6076 patients across 147 centers. The overall 30-d readmission rate was 18%. Readmission occurred among 15% of patients discharged home, 22% of patients discharged to a rehabilitation facility, and 25% of patients discharged to a nursing home. After controlling for patient and procedural factors, there was no significant association between discharge location and 30-d readmission (rehabilitation versus home odds ratio: 1.06, 95% confidence interval: 0.87-1.29; nursing facility versus home odds ratio: 1.21, 95% confidence interval: 0.99-1.47). Female sex, end-stage renal disease, diabetes, heart failure, pulmonary disease, smoking, preoperative functional impairment, tibial bypass target, critical limb threatening or acute ischemia, and postoperative complications including surgical site infection, change in renal function and graft thrombosis were associated with an increased likelihood of readmission. ConclusionsPatients discharged home after LEB experienced a similar likelihood of readmission as those discharged to a facility. While discharge to a facility may aid in care transitions, it did not appear to lead to reduced 30-d readmissions. The recommended discharge location should be predicated on patient care needs and not as a perceived mechanism to reduce readmissions.

Paradoxical Associations Exist Between BMI Category and Perioperative Complications Following Lower Extremity Arterial Bypass

Paradoxical Associations Exist Between BMI Category and Perioperative Complications Following Lower Extremity Arterial Bypass

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

Importance of Limb Severity on Primary Graft Patency of Ipsilateral Single Saphenous Vein Grafts for Lower Extremity Artery Bypass in Chromic Limb-threatening Ischemia

Approximately 30% of infrainguinal vein bypasses fail within 2 years after placement. A previous study demonstrated limb severity influenced cellular responses of saphenous veins used for lower extremity arterial bypass. The aim of this study was to assess the impact of wound, ischemia, and foot infection (WIfI) on primary graft patency of ipsilateral saphenous vein grafts. This is a retrospective, observational cohort study of autogenous vein bypass for chromic limb-threatening ischemia. Between 2014 and 2019, 201 (of 253) limbs receiving ipsilateral single great saphenous vein grafts were enrolled as research subjects. The outcome of interest was loss of primary graft patency >1 month after surgery because of occlusion or intervention for graft stenosis. Perioperative graft failure due to technical error successfully repaired by revision surgery were included; however, perioperative unrepaired failed graft and patients dying within 30 days after surgery were excluded, leaving 191 vein grafts for analysis of 2-year primary graft patency. Factors associated with loss of graft patency were predicted by Cox regression modeling based on patients’ background and limb severity. Seventy-six grafts (40%) lost primary patency at 2 years after surgery. The highest stage of WIfI classification had significantly lower primary graft patency than a bundle of other lower stages (49% vs 66%; P = .04). When focusing on the three factors of WIfI, higher wound grade (2 and 3) significantly impaired graft patency compared with lower grade (49% vs 68%; P = .016) and existence of foot infection (grade 1-3) also impaired primary graft patency rate (49% vs 63%; P < .05). There was a trend to lower patency for ischemia grade 3 than grade 2 (54% vs 65%; P = .06). Female sex (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.0-2.6; P = .04), chronic heart failure (HR, 2.0; 95% CI, 1.2-3.2; P < .01), higher wound grade (HR, 1.9; 95% CI, 1.1-3.1; P = .01) were significant by multivariate analysis. Intriguingly, the impact of wound and foot infection grade on loss of primary patency was not significant for men (n = 129 limbs) (P = .35 for wound and P = .30 for foot infection); however, it was for women (n = 62 limbs) (P = .018 for wound and P = .059 for foot infection). Limb severity as classified by WIfI, especially wound grade, was associated with loss of primary graft patency. This impact was weighted in women, not men; hence, further basic investigation will be needed with focus on differing cellular responses of saphenous vein stratified by sex.

Duplicate Great Saphenous Vein Utilization for Long Segment Tibial Bypass Without Need for Spliced Re-Anastomosis.

There is significant benefit to utilizing autologous venous conduit in lower extremity arterial bypass surgery. Specifically, improved patency is well documented relative to prosthetic or non-autologous biological conduits. The smaller caliber the target artery, the more critical using an autologous conduit becomes in striving to achieve long term graft survival. Another benefit to venous conduit is resistance to infection. Presented herein are the technique and images of a duplicate great saphenous vein (GSV) system with a common trunk being utilized to create a single long autologous venous conduit. Intraoperative images as well as conceptual drawing are provided. The non-reversed segment of the bypass is treated with a valvulatome. This allows for creation of a non-spliced autologous conduit when the distal aspect of the primary GSV is too diminutive for bypass. Surveillance duplex imaging 3months after surgery revealed no evidence of stenosis in the bypass and a normalization of the ABI. The area corresponding to the repair of the common trunk was identified on duplex and noted to have a robust diameter. He is doing well with full resolution of rest pain and claudication symptoms. This technique of utilizing a duplicate greater saphenous vein system to maintain a single lower extremity autologous venous conduit for arterial bypass is beneficial to keep in the armamentarium of vascular surgeons.

Outcomes of Cadaveric Veins as Conduits for Lower Extremity Arterial Bypass

For patients with from critical limb ischemia, a cryopreserved saphenous vein (CSV) can be used if an autogenous vein is not available. The purpose of our study was to determine whether CSVs are acceptable conduits for lower extremity bypass.

Catastrophic Antiphospholipid Syndrome Following Lower Extremity Arterial Bypass Surgery

Catastrophic Antiphospholipid Syndrome Following Lower Extremity Arterial Bypass Surgery

Risk Factors for Bypass Graft Thrombosis at Initial Discharge after Lower Extremity Arterial Bypass

Unkart, Jonathan MD, MPH, MS; Janssen, Claire B. MD; Moacdieh, Munir Paul MD; Malas, Mahmoud MD, MS, FACS Author Information

Obesity Paradox Exists for Mortality, but Not Wound Complications after Lower Extremity Arterial Bypass Surgery

Unkart, Jonathan MD, MPH, MS; Yei, Kevin S. BA; Naazie, Isaac N. MD, MPH; Elsayed, Nadin S.S. MD; Clary, Bryan M. MD, FACS; Malas, Mahmoud MD, MS, FACS Author Information

One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery

Delirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care. To evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery. This prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020. Major elective surgery and hospitalization. Cumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method-Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics. Of the 566 patients who were eligible for the study, a total of 497 patients (mean [SD] age, 76.8 [5.1] years; 281 women [57%]; 461 White participants [93%]) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean [SD] cost, $146 358 [$140 469] vs $94 609 [$80 648]). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year. These findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.

Factors associated with long-term graft patency after lower extremity arterial bypasses.

PurposeThis study was conducted to determine factors associated with long-term graft patency after lower extremity arterial bypass (LEAB).MethodsDatabase of LEABs for patients with chronic arterial occlusive disease (CAOD) at a single institution was retrospectively reviewed. To determine the factors we compared demographic, clinical, and procedural variables between 2 patient groups; group I (graft patency < 2 years) and group II (graft patency ≥ 5 years after LEAB) using univariable and multivariable analyses.ResultsAmong 957 LEABs, 259 limbs (group I, 125 limbs and group II, 134 limbs) in 213 patients were included for the analysis. On a univariable analysis, younger age (69 years vs. 66 years, P = 0.024), hypertension (60.8% vs. 74.6%, P = 0.017), claudication (51.2% vs. 70.9%, P = 0.001), absence of prior intervention (50.4% vs. 73.9%, P < 0.001), common femoral artery based bypass (57.6% vs. 70.1%, P = 0.035), above-the knee bypass (36.8% vs. 64.2%, P < 0.001), postoperative graft salvage procedure (3.2% vs. 14.8%, P = 0.001), and statin use (75.2% vs. 88.8, P = 0.004) were associated with long-term patency. On a multivariate analysis hypertension (odds ratio [OR], 1.91; P = 0.038), claudication (OR, 2.08; P = 0.032), no prior intervention (OR, 2.48; P = 0.001), vein graft (OR, 4.36; P = 0.001), above-the knee bypass (OR, 4.68; P < 0.001), and graft salvage procedures (OR, 7.70; P < 0.001) were identified as independent factors.ConclusionThese factors can be considered in decision making before treatment of patients with CAOD.

Reducing Length of Stay is not Associated with Increased Readmission Rates Following Lower Extremity Arterial Bypass

Objective: &#x0D; Traditional fee-for-service reimbursement models for medical services have been increasingly replaced with the merit-based and efficiency-driven pay-for-performance initiatives. Financial incentives to decrease expenditures have added pressure on hospitals and providers to reduce length of stay (LOS). Concern has been raised that this strategy may unwittingly increase readmission rates. We sought to better understand potential trade-offs between these two outcome measures for hospitals performing lower extremity arterial bypass (LEAB). &#x0D; Methods: &#x0D; We performed a retrospective observational cohort study of 479,366 Medicare beneficiaries undergoing LEAB in 1,708 hospitals from 2005-2009. Using LOS quintiles and a multiple logistic regression model, we generated risk-adjusted readmission rates (RARR) accounting for age, gender, pre-existing comorbidities, non-elective admission status, post-operative complications, and discharge destination. We then compared RARRs across LOS quintiles. Finally, we evaluated the association between hospital LOS on readmissions performance after adjusting for hospital volume, location, teaching status, bed size, and non-home discharges. &#x0D; Results: &#x0D; The mean hospital 30-day RARR was 14.5% (SD 3.5%) and the median LOS 4 days (range 3-6 days). Hospitals with the shortest median LOS (2.3 days) had slightly lower readmission rates compared to those with the highest median LOS (9.2 days) (13.3% vs 15.8%, p &lt;0.001). The Spearman correlation coefficient was 0.15 (p &lt; 0.001), indicating a very weak correlation between LOS and RARR. &#x0D; Conclusion and Potential Implications: &#x0D; At the hospital-level, there appears to be little tradeoff between LOS and RARR, implying these outcomes measure different domains of hospital quality and can be used as indicators of care quality and the likelihood for post-discharge adverse events. As it is possible for hospitals to perform well on both measures, pay-for-performance initiatives may consider incentivizing reducing LOS and readmissions.

The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

ObjectivePatient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia. MethodsThe National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications. ResultsThe Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01). ConclusionsCKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.

Outcomes of Gracilis Muscle Flaps in the Management of Groin Complications after Arterial Bypass with Prosthetic Graft

This study details 2-year outcomes of a modified gracilis muscle flap (GMF) technique in providing tissue coverage for groin complications after arterial bypass surgery with synthetic graft. All patients who developed groin infections after lower extremity arterial bypass with synthetic graft who underwent a GMF technique were included from June 2014 to March 2017 from a prospectively collected, purpose-built institutional database. Modifications to the standard technique included identification of the muscle using ultrasound to ensure precise skip incisions, preservation of the segmental blood supply, widening of the tunnel through which the muscle is retroflexed, placement of a wound vacuum-assisted closure for healing, and lifelong antibiotics. Demographics, laboratory values, bypass procedure, length of stay (LOS), disposition, and 1-, 3-, 6-, 12-, and 24-month follow-up data were collected. Analysis was performed via descriptive statistics. Over the 3-year study period, 22 patients underwent GMF after complications resulted from arterial bypass surgery. Types of bypass included aortobifemoral (32%), axillobifemoral (14%), femoral-femoral (23%), femoral-popliteal or mixed distal (27%), and thigh graft for dialysis (4%). Forty-five percentage of patients presented with graft infection, 50% with wound dehiscence, and 5% with graft disruption and bleeding. Only 23% of patients were candidates for sartorius muscle flap at the time of their initial procedure. The average case length was 64+19min. Sixty-four percentage of patients were discharged home with home health care and the remainder to a skilled nursing facility. The average LOS was 6.1+3.4days. Fifty-four percentages of wounds were healed at 1month and 100% at 3months with adjunctive vacuum-assisted closure therapy and lifelong antibiotics. Sixty percentage of patients were still alive at 24months, with 33% of grafts still patent at that time. Median survival was 18.1months, and median graft patency was 17.9months. GMF is a safe and effective treatment for groin complications after arterial bypass surgery with synthetic graft. Owing to its versatility, area of coverage, ease of use, and durability, it potentially should be considered as a primary form of muscle coverage for groin complications.

Variation in Transfusion Practices and the Association With Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative

Variation in Transfusion Practices and the Association With Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative