Lower Extremity Bypass Surgery Research Articles

Impact of Wound Closure Technique on Surgical Site Infection after Lower Extremity Bypass Surgery

Impact of Wound Closure Technique on Surgical Site Infection after Lower Extremity Bypass Surgery

Racial Disparity in Perioperative Aspirin Utilization Impacts Survival of Black Patients Undergoing Lower Extremity Bypass Surgery

Racial Disparity in Perioperative Aspirin Utilization Impacts Survival of Black Patients Undergoing Lower Extremity Bypass Surgery

Lower Extremity Bypass for Occlusive Disease: A Brief History

ObjectivesThis is a narrative review that aims to highlight key advancements which led to the current state of lower extremity bypass surgery. It focuses on key contributors during the last century who have driven the standardization of surgical treatment of peripheral arterial occlusive disease. MethodsA narrative review was conducted utilizing available resources in the scientific and historical literature to track landmark achievements in the development of modern lower extremity bypass surgery for occlusive disease, focusing primarily on the last century of advancement. ResultsSeveral critical conceptual, technological, and technical landmarks were identified as critical components of modern lower extremity bypass surgery. This includes fundamental development in the techniques of vascular anastomosis led by Carrel and others, a developing understanding of vascular occlusive disease as a localized and segmental process with broad implementation of the techniques of arteriography, and the development of safe thromboendarterectomy aided by the development and utilization of heparin for anti-coagulation. These factors led to the first femoral to popliteal artery bypass by Jean Kunlin in 1948. From here, advances in vascular prosthetic material pioneered by Voorhees and others, alternative vascular conduits, increasing acceptance of tibial revascularization, and dispelling the myth of diabetic “small vessel” disease broadened revascularization options for patients with complex patterns of occlusive disease and those who have limited conduit availability. ConclusionsModern lower extremity bypass surgery for occlusive disease arose steadily over the course of a century driven by complex problem-solving in the pathophysiological understanding of atherosclerosis, technical developments in vascular anastomosis and arteriography, and evolution in conduit materials and pharmacologic therapy. Future advancements in bypass surgery are targeted on solving the complex problems of anastomotic intimal hyperplasia, expanding technology for alternative vascular conduits, ongoing optimization of risk factors and scrutiny of outcomes to make patient-centered, evidence-based decisions regarding revascularization strategy.

Outcomes and predictors of amputation-free survival in patients undergoing below-knee popliteal-distal bypass

ObjectiveThe infrageniculate popliteal artery is a potential source for inflow in lower extremity bypass surgery in patients with isolated tibial artery disease. The objective of our study was to assess the short- and long-term outcomes of popliteal-distal bypasses using data from the Vascular Quality Initiative (VQI). MethodsThe VQI registry was queried between 2003 and 2021 for patients undergoing surgical revascularizations with the below-knee popliteal artery serving as inflow. Demographics, comorbidities, intraoperative characteristics, and postoperative complications were analyzed. Kaplan-Meier models were used to estimate amputation-free survival, survival, and freedom from amputation. Cox regression analysis was conducted to determine factors associated with major amputation or death. ResultsA total of 1884 procedures were analyzed. The mean age of the included patients was 67.7 years. The most frequently observed preoperative comorbidities included insulin-dependent diabetes (52.3%), coronary disease (32.4%), and end-stage renal disease (14.4%). Of all the patients, 670 (35.6%) had a history of ipsilateral endovascular intervention. The procedures were performed for a variety of indications, including tissue loss (84.3%), rest pain (10.9%), and claudication (4.8%). Intraoperatively, the outflow targets were the dorsalis pedis (31.4%), the posterior tibial (24.4%), and the anterior tibial arteries (15.6%). Vein conduit was used in 92.1% of cases. The rate of perioperative myocardial infarction (MI) was 2.4%, and the 30-day mortality was 1.9%. The median length of follow up was 371 days. Amputation-free survival was found to be 85.6% (95% confidence interval [CI], 84.0%-87.2%) at 6 months and 78.6% (95% CI, 76.6%-80.4%) at 12 months. Survival was found to be 93.4% (95% CI, 92.2%-94.5%) at 6 months and 88.6% (95% CI, 87.1%-90.0%) at 12 months. Freedom from amputation was found to be 92.0% (95% CI, 90.7%-93.3%) at 6 months and 89.0% (95% CI, 87.3%-90.4%) at 12 months. Cox regression analysis demonstrated that age greater than 65 years, congestive heart failure, coronary artery disease, and end-stage renal disease were associated with a higher risk of major amputation or death (P < .05). ConclusionsBelow-knee popliteal-distal bypass is a safe and effective approach to treat severe tibial vessel occlusive disease in this challenging patient cohort. Patients exhibited low perioperative complication rates and good amputation-free survival at 1 year.

Long-Term Outcome of Lower Extremity Bypass Surgery in Diabetic and Non-Diabetic Patients with Critical Limb-Threatening Ischaemia in Germany.

To present the short- and long-term outcomes of lower extremity bypass (LEB) surgery in patients with critical limb-threatening ischaemia (CLTI), comparing diabetic (DM) and non-diabetic (non-DM) patients. Retrospective analysis of anonymised data from a nationwide health insurance company (AOK). Data from 22,633 patients (DM: n = 7266; non-DM: n = 15,367; men: n = 14,523; women: n = 8110; mean patient age: 72.5 years), who underwent LEB from 2010 to 2015, were analysed. The cut-off date for follow-up was December 31, 2018 (mean follow-up period: 55 months). Perioperative mortality was 10.0% for DM and 8.2% for non-DM (p < 0.001). Patients with crural/pedal bypasses (n = 8558) had a significantly higher perioperative mortality (10.3%) than those with above-the-knee (n = 7246; 5.8%; p < 0.001) and below-the-knee bypasses (n = 6829; 8.9%; p = 0.003). The 9-year survival rates in DM patients were significantly worse, at 21.5%, compared to non-DM, at 31.1% (p < 0.001). This applied to both PAD stage III (DM: 34.4%; non-DM: 45.7%; p < 0.001) and PAD stage IV (DM: 18.5%; non-DM: 25.0%; p < 0.001). Patients with crural/pedal bypasses had a significantly inferior survival rate (25.5%) compared to those with below-the-knee (27.7%; p < 0.001) and above-the-knee bypasses (31.7%; p < 0.001). Perioperative and long-term outcomes regarding survival and major amputation rate for CLTI patients undergoing LEB are consistently worse for DM patients compared to non-DM patients.

Long-term outcome and cancer incidence after lower extremity bypass surgery in patients with critical limb threatening ischemia.

The influence of cancer development on long-term outcome after lower extremity bypass surgery in patients with critical limb threatening ischemia was investigated. Patient survival and cancer incidence were recorded for 21,082 patients with peripheral artery disease (PAD) stage III (n = 5631; 26.7%) and stage IV (n = 15,451; 73.3%) registered with the AOK health insurance company in Germany who underwent infrainguinal bypass surgery. All patients were preoperative and in their history cancer-free. After a median follow-up of 44months, 25.6% of all patients developed cancer (Kaplan-Meier estimated), with no significant differences between patients with PAD stage III and IV (cancer incidence stage III 25.7%, stage IV 25.5%; p = 0.421). In the Cox regression analysis, male gender (HR 1.885; 95% CI 1.714-2.073, p < 0.001) and age over 70years (HR 1.399; 95% CI 1.285-1.522, p < 0.001) were significant risk factors for the development of cancer. Survival was significantly lower in stage IV (23.4%) compared to stage III (44.5%) (HR 1.720; 95% CI 1.645-1.799, p < 0.001). Cancer was a significant risk factor for overall survival in PAD stage III patients (HR: 1.326; 95% CI 1.195-1.471, p < 0.001) but not in PAD stage IV (HR 0.976; 95% CI 0.919-1.037, p = 0.434). Patients with PAD stage III have significantly better survival after infrainguinal bypass surgery compared to patients with stage IV. While cancer incidence was essential for survival in stage III, it was of no importance in stage IV.

Perioperative complications following open or endovascular revascularization for chronic limb-threatening ischemia in the BEST-CLI Trial

ObjectiveAnticipated perioperative morbidity is an important factor for choosing a revascularization method for chronic limb-threatening ischemia (CLTI). Our goal was to assess systemic perioperative complications of patients treated with surgical and endovascular revascularization in the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial. MethodsBEST-CLI was a prospective randomized trial comparing open (OPEN) and endovascular (ENDO) revascularization strategies for patients with CLTI. Two parallel cohorts were studied: Cohort 1 included patients with adequate single-segment great saphenous vein (SSGSV), whereas Cohort 2 included those without SSGSV. Data were queried for major adverse cardiovascular events (MACE–composite myocardial infarction, stroke, death), non-serious (non-SAEs) and serious adverse events (SAEs) (criteria–death/life-threatening/requiring hospitalization or prolongation of hospitalization/significant disability/incapacitation/affecting subject safety in trial) 30 days after the procedure. Per protocol analysis was used (intervention received without crossover), and risk-adjusted analysis was performed. ResultsThere were 1367 patients (662 OPEN, 705 ENDO) in Cohort 1 and 379 patients (188 OPEN, 191 ENDO) in Cohort 2. Thirty-day mortality in Cohort 1 was 1.5% (OPEN 1.8%; ENDO 1.3%) and in Cohort 2 was 1.3% (2.7% OPEN; 0% ENDO). MACE in Cohort 1 was 4.7% for OPEN vs 3.13% for ENDO (P = .14), and in Cohort 2, was 4.28% for OPEN and 1.05% for ENDO (P = .15). On risk-adjusted analysis, there was no difference in 30-day MACE for OPEN vs ENDO for Cohort 1 (hazard ratio [HR] 1.5; 95% confidence interval [CI], 0.85-2.64; P = .16) or Cohort 2 (HR, 2.17; 95% CI, 0.48-9.88; P = .31). The incidence of acute renal failure was similar across interventions; in Cohort 1 it was 3.6% for OPEN vs 2.1% for ENDO (HR, 1.6; 95% CI, 0.85-3.12; P = .14), and in Cohort 2, it was 4.2% OPEN vs 1.6% ENDO (HR, 2.86; 95% CI, 0.75-10.8; P = .12). The occurrence of venous thromboembolism was low overall and was similar between groups in Cohort 1 (OPEN 0.9%; ENDO 0.4%) and Cohort 2 (OPEN 0.5%; ENDO 0%). Rates of any non-SAEs in Cohort 1 were 23.4% in OPEN and 17.9% in ENDO (P = .013); in Cohort 2, they were 21.8% for OPEN and 19.9% for ENDO (P = .7). Rates for any SAEs in Cohort 1 were 35.3% for OPEN and 31.6% for ENDO (P = .15); in Cohort 2, they were 25.5% for OPEN and 23.6% for ENDO (P = .72). The most common types of non-SAEs and SAEs were infection, procedural complications, and cardiovascular events. ConclusionsIn BEST-CLI, patients with CLTI who were deemed suitable candidates for open lower extremity bypass surgery had similar peri-procedural complications following either OPEN or ENDO revascularization: In such patients, concern about risk of peri-procedure complications should not be a deterrent in deciding revascularization strategy. Rather, other factors, including effectiveness in restoring perfusion and patient preference, are more relevant.

Sex-based differences in outcomes after lower extremity bypass for chronic limb-threatening ischemia

Background and aimsLower extremity bypass surgery is an effective treatment option for patients with chronic limb-threatening ischemia (CLTI). Recent studies have suggested that sex-based differences may impact patient outcomes following lower extremity revascularization, however, results have been inconsistent. MethodsIn this multicenter analysis, we retrospectively identified all infrainguinal bypass procedures performed for CLTI from 2002 to 2021. Patients were separated into two groups based on sex. Primary outcomes were major limb amputation and reintervention for graft patency. ResultsOf 843 bypasses performed over the study period, 347 (41.2%) patients were female. Racial/ethnic distribution and medical comorbidities were similar across sex groups. Surgical indications and operative details were also similar between groups, including conduit type (49.9% autogenous), bypass target (65.4% infrageniculate), and concurrent endarterectomy (38.9%). Female and male patients had similar hospital length of stay (6 days [4-9] vs 6 days [4-9]), hospital readmission (25.6% vs 25.0%), and postoperative complications (p=NS each). Female patients had higher major amputation rates (10.1% vs 6.3%, p=0.04) after one year, whereas reintervention rates were similar between groups (26.2% vs 24.6%, p=NS). After accounting for patient factors, female sex (odds ratio [OR] 1.02 [1.00–1.04]), infrageniculate target (OR 1.02 [1.00–1.04]), and bypass for tissue loss (OR 1.02 [1.00–1.04]) were associated with major amputation after bypass (p<0.05 each). ConclusionsFemale sex is associated with a small but significant increase major amputation after lower extremity bypass surgery for CLTI, despite similar clinical presentation, medical comorbidities, and operative details. These data support the increasingly recognized sex disparities in peripheral arterial disease.

Reducing Surgical Site Infections with Silver-impregnated Dressings in Lower Extremity Bypass Patients

Surgical site infection (SSI) after lower extremity (LE) bypass surgery is associated with longer length of stay, higher hospital cost, increased morbidity, and even graft loss. Silver-impregnated dressings have been used by other surgical subspecialties to decrease SSI with reported success. The National Surgical Quality Improvement Program (NSQIP) published a national expected rate of 7.9% for SSI after LE bypass surgery. In 2018, our institutional SSI rate was 12.8%. To reduce this rate, we transitioned to silver-impregnated dressings for all LE bypass procedures and studied the subsequent impact on SSIs. We used NSQIP data to retrospectively study two consecutive cohorts of vascular surgery patients at a single institution who underwent LE bypasses. Patients in 2019 underwent the standard of care surgery with standard sterile gauze postoperative dressings. Patients in 2020 underwent standard of care surgery and were treated with silver-impregnated dressings. NSQIP criteria were used to determine if patients developed SSIs within 30 days of surgery. The Fischer exact and χ2 tests were used to compare groups before and after the intervention. A total of 282 patients underwent LE bypass in 2019 and 2020. The standard of care cohort had 168 patients with sterile gauze dressings, whereas the cohort after intervention had 114 patients with silver-impregnated dressings. The groups were similar in terms of demographics and comorbidities (Table). When considering all classifications of SSI, there were significantly fewer infections in the silver dressing group compared with the sterile gauze group (9.6 % vs 20.8%; P = .014). There was a non-statistically significant reduction in readmissions and unplanned return to the operating room in the silver dressing group. This study demonstrated a significantly lower rate of SSIs in patients undergoing LE bypass with use of a silver-impregnated dressing when compared with a sterile gauze dressing. Although our study does not demonstrate a causal relationship, this relatively inexpensive and low-risk intervention's association with a significant decrease in an otherwise very serious postoperative complication argues for a change in clinical practice or prospective confirmatory studies to optimize patient outcomes after LE bypass.TableDemographic and comorbidity differences between groups of patients who underwent lower extremity (LE) bypass surgery using sterile gauze dressing (2019) and silver-impregnated dressing (2020), and NSQIP-collected outcomes regarding postoperative surgical site infection (SSI), wound dehiscence, unplanned return to operating room, and readmission within 30 daysSterile gauze (n = 168)Silver dressing (n = 114)P-valueMale gender109 (64.8)79 (69.3).5Age, years67.1 (10.8)66.0 (11.2).4Race.7 Asian1 (0.6)2 (1.8) Black or African American25 (14.9)13 (11.4) Unknown11 (6.5)7 (6.1) White131 (78.0)92 (80.7)Emergent surgery10 (5.9)4 (3.5).4Active smoker78 (46.4)52 (45.6).9Diabetes.4 Yes, insulin-dependent47 (28.0)39 (34.2) Yes, non-insulin-dependent32 (19.1)23 (20.2) No89 (53.0)52 (45.6)Hypertension133 (79.2)93 (81.6).6Chronic obstructive pulmonary disease26 (15.5)15 (13.2).6Dialysis10 (5.9)10 (8.8).4Superficial SSI35 (20.8)11 (9.7).014Deep SSI5 (3.0)2 (1.8).7Organ space SSI2 (1.2)6 (5.3).07Wound dehiscence6 (3.6)5 (4.4).8Unplanned return to operating room43 (25.6)32 (28.1).7Readmission39 (23.2)30 (26.3).2Data are presented as mean (standard deviation) or number (%). Open table in a new tab

Perioperative Systemic Complications and Adverse Events in the BEST-CLI Trial

Perioperative morbidity is a major deciding factor for choosing the revascularization method for chronic limb-threatening ischemia. Our goal was to assess systemic perioperative complications in the BEST-CLI trial. The BEST-CLI trial was a prospective randomized trial comparing open (OPEN) and endovascular (ENDO) revascularization strategies. There were two Cohorts: Cohort 1 included patients with adequate single segment great saphenous vein, Cohort 2 included those without single segment great saphenous vein. Data were queried for major adverse cardiovascular events (MACE; a composite of myocardial infarction, stroke, death), nonserious (non-SAE) and SAE 30 days after randomization. Per protocol analysis was used (intervention received without crossover). There were 1367 (662 OPEN, 705 ENDO) patients in Cohort 1 and 379 (188 OPEN, 191 ENDO) in Cohort 2. Thirty-day mortality was low in Cohort 1 being 1.5% (OPEN 1.8%; ENDO 1.3%) and Cohort 2 being 1.3% (2.7% OPEN; 0% ENDO). MACE in Cohort 1 were 4.98% for OPEN vs 3.3% for ENDO (P = .12) and Cohort 2 were 4.3% for OPEN and 1.6% for ENDO (P = .16). On multivariable analysis, there was no difference in 30-day MACE for OPEN vs ENDO for Cohort 1 (HR, 1.49; 95% CI, .85-2.62; P = .17) or Cohort 2 (HR, 2.25; 95% CI, .49-10.4; P = .3). Acute renal failure was similar by intervention with Cohort 1 being 3.6% for OPEN vs 2.1% for ENDO (HR, 1.6; 95% CI, .85-3.12; P = .14) and Cohort 2 being 4.2% vs 1.6% (HR, 2.86; 95% CI, .75-10.8; P = .12). Venous thromboembolism rates were also low with Cohort 1 at 0.7% (OPEN 0.9%; ENDO 0.4%) and Cohort 2 at 0.3% (OPEN 0.5%; ENDO 0%). Patients with non-SAE in Cohort 1 were 23.4% for OPEN and 17.9% for ENDO (P = .06) and in Cohort 2 were 21.8% for OPEN and 19.9% for ENDO (P = .71). Patients with SAE were Cohort 1 were 35.3% for OPEN and 31.6% for ENDO; P = .57 and Cohort 2 were for 25.5% OPEN and 23.6% for ENDO (P = .72) (Table). Most common etiologies for non-SAE and SAE were infectious, procedural complications, and related to underlying peripheral vascular disease. Patients with chronic limb-threatening ischemia who were deemed suitable for open lower extremity bypass surgery have similar periprocedural complications following either OPEN or ENDO revascularization. The choice of revascularization strategy should be based primarily on effectiveness in restoring adequate and durable limb perfusion.TableCardiovascular complications and adverse events by interventionOutcomeCohort 1 OPENCohort 1 ENDOP valueCohort 2 OPENCohort 2 ENDOP valuen = 662n = 705n = 188n = 191MACE4.98%3.3%.124.3%1.6%.16Non-SAE23.4%17.9%.0621.8%19.9%.71SAE35.3%31.6%.5725.5%23.6%.72ENDO, Endovascular; MACE, Major adverse cardiovascular event; OPEN, open repair; SAE, serious adverse event. Open table in a new tab

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits: Presented at the Seventy-fourth Annual Meeting of the Society for Vascular Surgery, San Diego, CA, August 18-21, 2021.

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits: Presented at the Seventy-fourth Annual Meeting of the Society for Vascular Surgery, San Diego, CA, August 18-21, 2021.

Limb salvage in octogenarians with critical limb ischemia after lower extremity bypass surgery

ObjectivesPeripheral artery disease is a worldwide epidemic that affects millions of patients, especially the elderly. It has a prevalence of 20% in individuals >80 years old. Although peripheral artery disease affects >20% of octogenarians, information about limb salvage rates in this patient population is limited. Therefore, this study aims to understand the impact of bypass surgery on limb salvage in patients aged >80 years with critical limb ischemia. MethodsWe conducted a retrospective analysis by querying the electronic medical records at a single institution from 2016 through 2022 to identify the population of interest and analyzed their outcomes after lower extremity bypass. The primary outcomes were limb salvage and primary patency, with hospital length of stay and 1-year mortality as secondary outcomes. ResultsWe identified 137 patients who met the inclusion criteria. The lower extremity bypass population was divided into two cohorts: <80 years old (n = 111) with a mean age of 66 or ≥80 years old (n = 26) with a mean age of 84 years. The gender distribution was similar (P = .163). No significant difference was found in the two cohorts when it came to coronary artery disease, chronic kidney disease, or diabetes mellitus. However, when current and former smokers were grouped together, they were significantly more common in the younger cohort when compared with nonsmokers (P = .028). The primary end point of limb salvage was not significantly different between the two cohorts. Hospital length of stay was not significantly different between the two cohorts with 4.13 days vs 4.17 days in the younger vs octogenarian cohorts, respectively (P = .95). The 30-day all-cause readmissions were also not found to be significantly different between the two groups. The primary patency at 1 year was 75% and 77% (P = .16) for the <80-year-old and ≥80-year-old cohorts, respectively. Mortality was low in both cohorts, with two and three for the younger and octogenarian populations, respectively; thus, no analysis was performed. ConclusionsOur study shows that octogenarians who undergo the same preoperative risk assessment as younger populations have similar outcomes when it comes to primary patency, hospital length of stay, and limb salvage when comorbidities were considered. Further studies need to be done to determine the statistical impact on mortality in this population with a larger cohort.

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits

BackgroundPatients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) have a high risk of adverse limb and cardiovascular events. The results from the VOYAGER PAD (efficacy and safety of rivaroxaban in reducing the risk of major thrombotic vascular events in subjects with symptomatic peripheral artery disease undergoing peripheral revascularization procedures of the lower extremities) trial have demonstrated that rivaroxaban significantly reduced this risk with an overall favorable net benefit for patients undergoing surgical revascularization. However, the efficacy and safety for those treated by surgical bypass, including stratification by bypass conduit (venous or prosthetic), has not yet been described. MethodsIn the VOYAGER PAD trial, patients who had undergone surgical and endovascular infrainguinal LER to treat PAD were randomized to rivaroxaban 2.5 mg twice daily or placebo on top of background antiplatelet therapy (aspirin 100 mg to be used in all and clopidogrel in some at the treating physician’s discretion) and followed up for a median of 28 months. The primary end point was a composite of acute limb ischemia, major amputation of vascular etiology, myocardial infarction, ischemic stroke, and cardiovascular death. The principal safety outcome was major bleeding using the TIMI (thrombolysis in myocardial infarction) scale. The index procedure details, including conduit type (venous vs prosthetic), were collected at baseline. ResultsAmong 6564 randomized patients, 2185 (33%) had undergone surgical LER. Of these 2185 patients, surgical bypass had been performed for 1448 (66%), using a prosthetic conduit for 773 patients (53%) and venous conduit for 646 patients (45%). Adjusting for the baseline differences and anatomic factors, the risk of unplanned limb revascularization in the placebo arm was 2.5-fold higher for those receiving a prosthetic conduit vs a venous conduit (adjusted hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.65-3.90; P < .001), and the risk of acute limb ischemia was three times greater (adjusted HR, 3.07; 95% CI, 1.84-5.11; P < .001). The use of rivaroxaban reduced the primary outcome for the patients treated with bypass surgery (HR, 0.78; 95% CI, 0.62-0.98), with consistent benefits for those receiving venous (HR, 0.66; 95% CI, 0.49-0.96) and prosthetic (HR, 0.87; 95% CI, 0.66-1.15) conduits (Pinteraction = .254). In the overall trial, major bleeding using the TIMI scale was increased with rivaroxaban. However, the numbers for those treated with bypass surgery were low (five with rivaroxaban vs nine with placebo; HR, 0.55; 95% CI, 0.18-1.65) and not powered to show statistical significance. ConclusionsSurgical bypass with a prosthetic conduit was associated with significantly higher rates of major adverse limb events relative to venous conduits even after adjustment for patient and anatomic characteristics. Adding rivaroxaban 2.5 mg twice daily to aspirin or dual antiplatelet therapy significantly reduced this risk, with an increase in the bleeding risk, but had a favorable benefit risk for patients treated with bypass surgery, regardless of conduit type. Rivaroxaban should be considered after lower extremity bypass for symptomatic PAD to reduce ischemic complications of the heart, limb, and brain.

Regional Anesthesia for Vascular Surgery and Pain Management

Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.

Limb Salvage in Octogenarians With Critical Limb Ischemia After Lower Extremity Bypass Surgery

Limb Salvage in Octogenarians With Critical Limb Ischemia After Lower Extremity Bypass Surgery

The Effect of Height on Adverse Short-Term Outcomes Following Lower-Extremity Bypass Surgery in Subjects with Diabetes Mellitus

Abstract Background: The objective of this investigation was to evaluate adverse short-term outcomes following open lower extremity bypass surgery in subjects with diabetes mellitus with a specific comparison performed based on subject height. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to select those subjects with CPT codes 35533, 35540, 35556, 35558, 35565, 35566, 35570 and 35571 and with the diagnosis of diabetes mellitus. This resulted in 83 subjects ≤60 inches, 1084 subjects &gt;60 inches and &lt;72 inches, and 211 subjects ≥72 inches. Results: No differences were observed between groups with respect to the development of a superficial surgical site infection (9.6% vs. vs. 6.4% vs. 5.7%; p=0.458), deep incisional infection (1.2% vs. 1.4% vs. 2.8%; p=0.289), sepsis (2.4% vs. 2.0% vs. 2.8%; p=0.751), unplanned reoperation (19.3% vs. 15.6% vs. 21.8%; p=0.071), nor unplanned hospital readmission (19.3% vs. 14.8% vs. 17.1%; p=0.573). A significant difference was observed between groups with respect to the development of a wound disruption (4.8% vs. 1.3% vs. 4.7%; p=0.001). A multivariate regression analysis was performed of the wound disruption outcome with the age, gender, race, ethnicity, height, weight, current smoker and open wound/wound infection variables. Race (p=0.025) and weight (p=0.003) were found to be independently associated with wound disruption, but height was not (p=0.701). Conclusions: The results of this investigation demonstrate no significant difference in short-term adverse outcomes following the performance of lower extremity bypass surgery based on patient height.

Clinical outcomes in patients with infrapopliteal arterial occlusive disease treated by lower extremity bypass surgery: a comparison of atherosclerosis and thromboangiitis obliterans.

Surgical bypasses are commonly utilized for the treatment of infrapopliteal arterial occlusive disease resulting from atherosclerosis (ASO) and thromboangiitis obliterans (TAO), especially when endovascular procedures fail. The aim of this study is to compare the in-hospital and follow-up outcomes of ASO and TAO patients treated with infrapopliteal bypass surgery. A total of 32 infrapopliteal bypasses were analyzed in 18 TAO patients and 14 ASO patients. Preoperative and postoperative arterial Doppler ultrasonography was performed in all patients. The ankle-brachial index (ABI) was calculated preoperatively and postoperatively in all cases. All patients were followed-up for at least one year and clinical outcomes were recorded. Within 1-7 days postoperatively, 4 grafts in TAO patients occluded; nevertheless, 1 graft occlusion occurred in ASO patients. Patency rates at in-hospital were 77.8% and 92.9% in TAO and ASO patients, respectively. In 27 patients with successful infrapopliteal bypass, ABIs and crural peak arterial flow velocities significantly increased at 1-7 days postoperatively. During the period of follow-up, 6 graft occlusions occurred in TAO patients, and one ASO patient died of myocardial infarction. Patency rates at follow-up were 44.5% and 85.7% in TAO and ASO patients. For TAO patients with graft failure, ABIs at follow-up did not statistically differ from those postoperatively; however, they were significantly higher than those preoperatively. Infrapopliteal bypass surgery is a feasible and effective procedure for ASO and TAO patients. Patency rates are lower in TAO than those in ASO during the in-hospital and follow-up period. However, TAO patients had the ischemic symptom relief and the improvement in ABI despite graft occlusion one year postoperatively.

Higher Risk of Early and Late Failure to Rescue From a Major Cardiovascular Event in Patients With Prior Coronary Revascularization Undergoing Lower Extremity Bypass Surgery for Chronic Limb-Threatening Ischemia

Atherosclerosis is the underlying cause of chronic limb-threatening ischemia (CLTI) and coronary artery disease (CAD). Patients undergoing management of CLTI are known to have a history of CAD or prior coronary revascularization. This study aims to investigate the occurrence of major cardiovascular events (MACE) in CLTI and failure to rescue after MACE.

An Enhanced Recovery After Surgery Protocol Decreases the Use of Narcotics in Infrainguinal Bypass Patients.

"Enhanced recovery after surgery" (ERAS) protocols use a multisystem approach to target homeostatic physiology via opioid-minimizing analgesia. The aim of this study is to determine if an ERAS protocol for lower extremity bypass surgery improves pain control and decreases narcotics. From July 2020 through June 2021, all patients that underwent infrainguinal lower extremity bypass procedures were subject to the ERAS protocol and compared to a "pre-ERAS" group between June 2016 through May 2020. Preoperatively, ERAS patients were given celecoxib, gabapentin, and acetaminophen while postoperatively they were given standing acetaminophen, gabapentin, ketorolac, and tramadol with as needed use of oxycodone. Pain scores were recorded using a numerical rating pain scale. Demographics, length of stay, 30-day complications, and disposition metrics were recorded. There were 50 patients in the ERAS group, compared to 114 before its implementation. The mean age was 70.5 (ERAS group) versus 68.7 (pre-ERAS group) and a majority were male (P > .05). Enhanced recovery after surgery patients were less likely to have chronic kidney disease (P = .01). Enhanced recovery after surgery patients had improved length of stay (3.6 ± 2.3days vs 4.8 ± 3.2days, ERAS vs pre-ERAS, P = .01). There was no significant difference between groups for the remaining demographics (P > .05). One patient (2%) in the ERAS group used patient-controlled analgesia, compared to 30 patients (26%) in the pre-ERAS group (P < .001). Cumulative pain control in the first 12hours was significantly better in the ERAS group (P = .05). Pain control at discharge was similar between the 2 groups (3 pain score vs 3 pain score, pre-ERAS vs ERAS, P > .05). Our study utilized a multisystem approach to optimize the physiologic stress response to vascular surgery while reducing high potency narcotic use. We show that an ERAS protocol provides noninferior pain control with less potent pain medication and improves the length of stay for patients undergoing infrainguinal bypass surgery.

Implementation of Transitional Care Planning is Associated with Reduced Readmission Rates in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Arterial Disease

Patients undergoing lower extremity bypasses (LEB) are at a high risk of developing post-discharge complications requiring readmission. Health systems have developed several strategies to mitigate this risk. One such measure is developing comprehensive Transitional Care Program (TCP), which includes phone calls to patients after being discharged from the hospital. Our study aimed to assess short-term readmission, mortality, and amputation rates of patients who participated in TCP by completing at least one post-discharge follow-up phone call after undergoing LEB for revascularization of peripheral arterial disease (PAD). A retrospective review was completed for patients who underwent LEB surgery between January 2010 and January 2020 to treat PAD at Penn State Hershey Medical Center. Immediate discharge follow-up was done via telephone calls using a standardized script. Patients were then divided into two groups, those who did not have a successful follow-up call (Group I) and those who had at least one successful follow-up call within seven days after discharge (Group II). Univariate analysis was used to compare preoperative demographics, intraoperative variables, and postoperative outcomes. The probability of readmission and risk factors contributing to it were computed using multiple stepwise forward regression analyses. Epidemiological analysis was done to evaluate the risk of readmission in the group receiving post-discharge follow-up calls. A total of 457 patients underwent LEB from 2010 to 2020 and qualified for inclusion in the study. Among these patients, 126 (27.6%) did not have a successful post-discharge follow-up call (Group I), whereas, 331 (72.4%) patients did complete a successful call (Group II). The mean age of patients was 66.7years. There were no significant differences in preoperative baseline patient characteristics or intraoperative factors. Patients who completed a successful call had lower readmission rates within thirty days of the operation (8.8 vs. 17.5%, P=0.008), and this was sustained in multivariate analysis (adjusted odds ratio AOR: 0.18, [confidence interval CI: 0.05-0.66], P=0.009). However, no differences were observed for thirty-day mortality (Group-I: 3.2% versus Group-II: 1.2%, P=0.152) or amputation (Group-I: 9.6% versus Group II 5.9%, P=0.162). Among those who had a successful call, patients with a history of smoking (AOR: 4.05 [CI: 1.21, 17.12] P=0.025), diabetes mellitus (AOR: 3.42 [CI: 1.35, 8.7] P=0.01) and myocardial infarction (AOR: 7.15 [CI: 1.76, 20.1] P=0.006) had a much higher chances of readmission. Risk analysis using epidemiological methods showed that by receiving a call, the risk of readmission could be dropped to half (RR: 0.50 [CI: 0.30, 0.84]), with an attributable risk reduction of -8.7% (CI: -15.9%, -1.4%). This single-institution retrospective study demonstrates the importance of immediate discharge follow-up phone calls in patients who undergo open lower extremity revascularization to reduce thirty-day readmissions. Our analysis showed patients who received immediate follow-up phone calls were less likely to be readmitted to the hospital. The development of reliable and efficient systems to enhance immediate discharge follow-up in vascular surgery patients is pivotal to improving quality of care, preventing readmissions, and reducing healthcare costs.