Lower Extremity Revascularization Procedures Research Articles

Outcomes of Femoral Popliteal Bypass in Octogenarians.

Femoral-popliteal bypass (FPB) surgery is a common lower extremity revascularization procedure. As the population continues to age, this procedure is being performed increasingly on older patients. This study investigated whether outcomes differ in this population. Patients over and less than 80 years old who underwent FPB between 2009-2013 were queried using an existing hospital registry. Demographics, comorbidities, intraoperative complications, perioperative outcomes, and two-year patencies were compared. Twenty-four patients in the octogenarian cohort (OC) and 72 patients in the non-octogenarian cohort (NOC) were identified. There was a lower prevalence of smoking (p=0.018) and higher prevalence of hypertension (p=0.021) among octogenarians. Other medical characteristics were similar (p<0.05). There were no differences in use of vein versus PTFE (p=0.002) as a conduit, or above (OC 20.0% vs. NOC 36.7%), versus below knee (OC 80.0% vs. NOC 63.3%) distal anastomosis (p>0.05) between the groups. There was a difference (p<0.01) in indication for procedure (OC/NOC): claudication (0%/44%), limb salvage (71%/31%), and rest pain (29%/25%). There were no differences in 30-day readmissions (17% vs. 21%; p=0.59) or incidence of postoperative (25% vs. 19%; p=0.56) or intraoperative complications (8.3% vs. 4.2%; p=0.52). Length of stay (LOS) was longer and statistically significant in octogenarians (12 days vs. 7 days; p=0.032) and remained significant after multivariate linear regression (p=0.015). Patencies in OC were lower and dropped faster after six months; however, there were no statistically significant differences in patencies at any time interval (p>0.05). The position of the distal anastomosis relative to the knee, conduit type, and indication were not independently predictive of patency outcomes (p>0.05). The safety and efficacy of FPB in octogenarians is similar to the general population despite LOS in octogenarians being 5.98 days longer. While the difference in indication suggests that vascular surgeons are more conservative in treating octogenarians, our analysis did not reveal significant differences between populations and suggests that lower extremity bypass can be performed safely with comparable results in this cohort. A larger cohort is needed to validate these results.

Hemoglobin A1c levels are related to patency and adverse limb events in diabetics after revascularization

ObjectivePoor glycemic control in the perioperative period has been reported to be associated with early and late major adverse limb events (MALEs). However, these studies were mostly from large databases or lacked long-term outcomes. We examined the long-term effects of high hemoglobin A1c (HbA1c) level on patency, MALE, limb salvage (LS) and survival after lower extremity revascularization procedures in patients with diabetes. MethodsPatients with diabetes who underwent revascularization for Rutherford class 3 to 6 ischemia between May 2002 and December 2018 were identified. Patients with an HbA1c of ≤7% were compared with those with an HbA1c of >7% for patency, MALE, survival, LS, and amputation-free survival. ResultsOf 706 patients, 699 had HbA1c data (775 limbs), with 311 (357 limbs) in the HbA1c ≤7% and 388 (418 limbs) in the HbA1c >7% groups. Patients with an HbA1c of >7% were younger (69.9 ± 10.2 years vs 71.7 ± 9.5 years; P = .011), had higher lipid levels, insulin use (70% vs 49%; P < .01), American Society of Anesthesiologists classification of 4, and had a lower prevalence of chronic kidney disease (32% v s41%; P = .023). Patients with an HbA1c of >7% were more likely to present with chronic limb-threatening ischemia (CLTI) (79% vs 72%; P = .019) and undergo infrapopliteal interventions (49% vs 42%; P = .005), with no difference in anatomical complexity (TransAtlantic Inter Society Consensus class C/D, 75% vs 77%; P = .72) or type of revascularization (24% vs 18% open, 66% vs 70% endovascular, 10% vs 12% hybrid; P = .236). Patency and freedom from MALE were significantly lower in patients with an HbA1c of >7% for infrainguinal revascularizations, whereas amputation-free survival and overall survival were similar. In patients with chronic limb-threatening ischemia, LS rates at 5 years were significantly lower in patients undergoing open revascularization (HbA1c > 7%: 64% ± 6% vs HbA1c < 7%:86% ± 5%; P = .020), whereas it was similar after endovascular interventions (HbA1c > 7%:79% ± 4% vs HbA1c < 7%:77% ± 3%; P = .631). Seventy patients with an HbA1c of >7% lost limbs vs 38 patients with an HbA1c of ≤7% (P = .007). In multivariate analysis, HbA1c was associated significantly with primary patency. HbA1c, insulin use, level of intervention, and angiotensin-converting enzyme inhibitor use were associated with MALE. ConclusionsA perioperative HbA1c of >7% is associated with poorer patency rates and increased MALE, especially at the infrainguinal level revascularization in patients with diabetes, with no significant impact on survival. LS is impacted after open, but not after endovascular revascularization.

Abstract 1150: Effect Of Diabetes On Clinical Outcomes In Patients With Peripheral Arterial Disease Undergoing Lower Extremity Revascularization: A Systematic Review And Meta-analysis

Background: Peripheral arterial disease (PAD) is highly prevalent and has a well-known association with diabetes. It is still unknown if diabetes worsens clinical outcomes after lower extremity revascularization (LER). Research question: What is the impact of diabetes on clinical outcomes in patients with PAD undergoing LER. Goals: In this meta-analysis, we assessed the effect of diabetes on mortality, major limb amputation, and major adverse cardiovascular events (MACE) in patients with PAD following endovascular or open LER during the perioperative period and within 30 days of follow-up. Methods: We performed a systematic search of PubMed, Embase, and Cochrane databases to December 2023, including studies that compared the clinical outcomes of patients with diabetes and without diabetes following LER procedure. Review Manager 5.4 was used for statistical analysis. I 2 statistics were used to examine heterogeneity. A random-effects model was applied to all analyses. Results: Of the 3,810 articles screened, five observational studies with 55,444 patients were included. A total of 51.13 % had diabetes. There was no significant association between diabetes and mortality (RR 0.96; 95 % confidence interval (CI) 0.74 - 1.26; I 2 = 69%; P = 0.79; Figure 1A). However, diabetes was associated with a significantly increased risk of major limb amputation by 50% (RR 1.50; 95 % CI 1.03 - 2.21; I 2 = 94%; P = 0.04; Figure 1B), and an 18% significantly higher risk of experiencing MACE (RR 1.18; 95 % CI 1.08 - 1.29; I 2 = 0%; P = 0.0005; Figure 1C). Conclusion: Our findings suggest that diabetes is associated with an increased risk of major amputation and MACE but not with mortality in patients following LER.

Differences between Lower Extremity Arterial Occlusion vs. Stenosis and Predictors of Successful Endovascular Interventions.

Background and Objectives: In patients with peripheral artery disease, there is insufficient understanding of characteristics that predict successful revascularization of the lower extremity (LE) chronic total occlusions (CTOs) and baseline differences in demographic, clinical, and angiographic characteristics in patients with LE CTO vs. non-CTO. We aim to explore these differences and predictors of successful revascularization among CTO patients. Materials and Methods: Two vascular centers enrolled LE-CTO patients who underwent endovascular revascularization. Data on demographics, clinical, angiographic, and interventional characteristics were collected. LE non-CTO arterial stenosis patients were compared. A total of 256 patients with LE revascularization procedures were studied; among them, 120 had CTOs and 136 had LE stenosis but no CTOs. Results: Aspirin use (Odds ratio, OR: 3.43; CI 1.32-8.88; p = 0.011) was a positive predictor whereas a history of malignancy (OR: 0.27; CI 0.09-0.80; p = 0.018) was a negative predictor of successful crossing in the CTO group. The CTO group had a higher history of myocardial infarction (29.2 vs. 18.3%, p = 0.05), end-stage renal disease (19.2 vs. 9.6%, p = 0.03), and chronic limb-threatening ischemia as the reason for revascularization (64.2 vs. 22.8%, p < 0.001). They were more likely to have advanced TransAtlantic Inter-Society Consensus (TASC) stages, multi-vessel revascularization procedures, longer lesions, and urgent treatment. Conclusions: The use of aspirin is a positive predictor whereas a history of malignancy is a negative predictor for successful crossing in CTO lesions. Additionally, LE-CTO patients have a higher incidence of comorbidities, which is expected given their higher disease burden. Successful endovascular re-vascularization can be associated with baseline clinical variables.

Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention

PurposeTo examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4–6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI). Materials and MethodsTwo contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass). ResultsAfter PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58–6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06–23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71–33.50; P = .008). ConclusionsESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4–6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.

Luminal Gain After Atherectomy Measured by Intravascular Ultrasound (IVUS) and Impact on Short-term Results

Atherectomy has been proposed to debulk lesions prior to intervention. Data on the degree of luminal gain after this procedure are not available. We evaluated immediate luminal gain, measured by intravascular ultrasound (IVUS) following various types of percutaneous atherectomy. Short-term patency and residual stenosis was measured by duplex ultrasound (DUS). We prospectively collected data on 79 consecutive lower extremity revascularization procedures where atherectomy was performed. Severity of arterial stenosis was measured using angiography and IVUS. IVUS was used to identify severe (>70%) stenosis and the percent stenosis pre and immediately post atherectomy. The difference represented percent luminal gain by atherectomy alone. Comparisons were analyzed using various atherectomy techniques including excimer laser, excisional rotational, and orbital atherectomy. Peak systolic velocities from pretreatment DUS were compared with post treatment DUS at 1 month follow up to evaluate effectiveness of atherectomy type in relation to degree of stenosis. We performed lower extremity angiography with atherectomy on 79 legs in 75 patients with an average age of 75.4 years (range, 40-91 years). Procedures included excimer laser (n = 35), excisional rotational (n = 33), and orbital atherectomy (n = 11). Sixty-eight above-knee (ATK) atherectomy and 28 below-knee (BTK) atherectomy procedures were performed. Patients presented with Rutherford Class 3 (62%; n = 49), Class 4 (16%; n = 13), Class 5 (19%; n = 15), and Class 6 (1.3%; n = 1). Atherectomy was performed in 68 vessels ATK and 28 vessels BTK with 16% of patients having multivessel intervention. In-stent stenosis was the indication for atherectomy in 22 vessels (28%). Average luminal gain was 23.6% for ATK atherectomy (range, 10%-39%) and 24.2% for BTK vessels (range, 11%-34%; P > .05). There was no difference in luminal gain based on atherectomy type, laser (25%), excisional rotational (23%) and orbital atherectomy (23%; P > .05. There was also no difference in luminal gain based on gender, male 26% and female 24% (P > .05). Using DUS pre and post angiogram with intervention, we noted an average decrease in PSV of 90 cm/s, 122.4 cm/s, 106.9 cm/s, and 31.4 cm/s for the common femoral artery, superficial femoral artery, above-knee popliteal artery, and below-knee popliteal artery, respectively. Atherectomy results in an average luminal gain of 24% regardless of location of atherectomy (ATK vs BTK), type of atherectomy device, or gender. This is associated with high rates of patency in both BTK and ATK vessels at short-term follow-up.

Neutrophil-to-lymphocyte Ratio Is A Superior Prognostic Marker To Frailty In Patients Undergoing Open Lower Extremity Revascularization

Neutrophil-to-Lymphocyte ratio (NLR) is an easily obtained, low-cost marker of inflammation that has been shown to correlate with higher mortality and longer hospital stays in patients undergoing open lower extremity revascularization procedures. However, NLR has never been compared to other established risk calculators. We compared the prognostic value of NLR to the modified frailty index (mFI), a validated frailty metric.

Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity.

Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.

Obesity and Postoperative Outcomes Following Open Lower Extremity Revascularization Procedures

Prior research on the relationship between obesity and postoperative outcomes in patients undergoing lower extremity vascular surgeries has shown conflicting results. There is some data to suggest that obesity (body mass index of >30 kg/m2) correlates with postoperative wound infection (POI) and hospital length of stay (LOS), but not mortality or major adverse limb event (MALE). We sought to identify the maximal body mass index cut-off point for stratifying patients by mortality risk and to investigate the relationship between obesity and mortality, MALE, hospital LOS, and postoperative wound infection in patients undergoing open lower extremity revascularization procedures.

Major Adverse Limb Events Among Patients with Premature Peripheral Artery Disease Compared with Those at the Common Age Undergoing Revascularization in the Vascular Quality Initiative

Premature peripheral artery disease (PAD), defined as≤50years of age, is associated with poor outcomes following lower extremity revascularization (LER). However, the specific characteristics and outcomes of this group of patients compared to those at the common age undergoing revascularization have not been examined. The aim of this study is to compare patients with early versus late onset premature PAD undergoing LER focusing on major adverse limb events (MALEs). All LER procedures (open and endovascular) in the Vascular Quality Initiative (VQI) were reviewed. A histogram of patient age at the time of initial LER (no prior LER) was used to define the common age, which included all patients within one standard deviation of the mean. Characteristics and outcomes of patients with premature PAD were compared to patients treated at the common age of presentation undergoing LER. A histogram of all patients undergoing LER was used to define 60 to 80years as the common age. Patients with premature PAD were more likely to be female, African American, and Hispanic compared to patients at the common age. Patients with premature PAD were also more likely to have insulin-dependent diabetes, be current smokers, on dialysis, and be treated for claudication. Patients with premature PAD were less likely to have Transatlantic Intersociety Consensus (TASC II) C or D disease and were less likely to be on antiplatelets and statins. These differences were more pronounced in patients with chronic limb-threatening ischemia (CLTI). Cox proportional hazards regression demonstrated that premature PAD was independently associated with major adverse limb events (MALEs) at 1-year for patients with claudication (HR:1.7, 95% CI:1.4-2.0) and CLTI (HR:1.3, 95% CI:1.2-1.5) compared to patients 60 to 80years of age. Patients with premature PAD have significant differences in characteristics compared to patients treated at the common age. Vascular providers should emphasize medical therapy prior to LER given the lower rates of medical optimization and worse 1-year MALEs in patients with premature PAD.

Neutrophil-To-Lymphocyte Ratio as a Predictive Tool for Post-Operative Outcomes in Patients Undergoing Open Lower Extremity Revascularization Procedures

Elevated neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, has been shown to correlate with worse outcomes in patients undergoing vascular surgery. Limited data exists on the association of NLR and outcomes in patients undergoing lower extremity vascular surgery. We sought to investigate whether preoperative NLR correlates with outcomes in patients undergoing open lower extremity revascularization procedures. We conducted a retrospective analysis of a prospectively maintained database of patients who underwent open lower extremity revascularization procedures from January 2011 to January 2017 (N=535). Preoperative NLR was calculated within 6months of surgery. Primary outcomes were major adverse limb event (MALE) or death. The maximally-ranked statistic method was used to determine the NLR cut-off point. Kaplan-Meier analyses of death and MALE and NLR were used to compare the groups by NLR cut-off point. We conducted a multivariate analysis of the association between NLR and mortality using Cox proportional hazard models, including confounding variables such as age, smoking status, and diabetes. P-values <0.05 were considered statistically significant. Two hundred and fifty four patients undergoing surgery from January 2011 to January 2013 were analyzed. The median NLR was 3.6 interquartile range [IQR 2.5-6.7]. The analysis showed a negative correlation between elevated NLR and mortality (P<0.001), but not MALE (P=0.8). Controlling for multiple comorbidities including gender, age, smoking, body mass index (BMI), diabetes, hyperlipidemia, hypertension, and infection, the NLR cut-off point was a significant independent predictor of mortality (P<0.0001), but not MALE (P=0.551). Elevated NLR was also correlated with statistically and clinically significant longer hospital stays (6.5 [IQR 3.0-12.8] days vs. 4.0 [IQR 2.0-8.0] days, P=0.027). This study suggests that NLR is an independent predictor of mortality and hospital length of stay in patients undergoing open lower extremity revascularizations. Going forward, we plan to expand this study to include more patients and to compare NLR to other risk assessment tools.

Age and Neutrophil-to-Lymphocyte Ratio as Predictive Tools for Postoperative Outcomes in Patients Undergoing Open Lower Extremity Revascularization Procedures

Prior research has shown that elevated neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, correlates with worse outcomes in patients undergoing vascular surgery. In the case of lower extremity revascularization procedures, both age and NLR have been shown to be independently correlated with worse outcomes. We sought to investigate whether preoperative NLR correlates with outcomes after controlling for age in patients undergoing open lower extremity revascularization procedures.

Obesity and Postoperative Outcomes in Patients Undergoing Open Lower Extremity Revascularization Procedures

Prior research has shown conflicting results when looking at the relationship between obesity and postoperative outcomes in patients undergoing lower extremity vascular surgeries. There are some data to suggest that obesity, defined as a body mass index (BMI) >30 kg/m2, correlates with postoperative wound infection and hospital length of stay (LOS), but not mortality or major adverse limb event (MALE). We sought to identify the maximal BMI cutoff point for stratifying patients by mortality risk and to investigate the relationship between obesity and mortality, MALE, LOS, and postoperative wound infection in patients undergoing open lower extremity revascularization procedures.

Objective Coagulation Profiling Provides Novel Insight into Potential Risk Factors for Peripheral Artery Disease in Women

The prevalence and burden of peripheral artery disease (PAD) is equal, if not higher, in women as compared with men, and it is known that clinical outcomes in women after revascularization procedures are worse. However, women are notably under-represented in existing PAD studies, contributing to a significant gap in clinical knowledge regarding the risk factors and nature history of female-specific disease. Traditional comorbidities associated with cardiovascular disease and PAD are more prevalent in men than women, suggesting that alternative etiologies may be contributing to atherosclerosis in female patients. Thromboelastography with platelet mapping (TEG-PM) measures the viscoelastic properties of a blood clot as a dynamic process and may provide an integral key to the next stage of patient-centered hypercoaguability assessment. This prospective observational study aimed to characterize the clinical and TEG-PM profiles of female and male patients prior to lower extremity revascularization procedures. All patients undergoing named vessel revascularization during December 2020 to December 2021 at a large tertiary institution were prospectively included. TEG-PM assays were performed on patients prior to surgery. These data, along with clinical metrics, were compared between men and women. Univariate analysis was performed using the Student t test for continuous variables and the Fisher exact test for binary variables. One hundred twenty-one patients were enrolled, of which 40 (39.6%) were female. Female patients had significantly lower rates of hypertension (62.5% vs 88.9%; P < .01) and diabetes (25.0% vs 54.3%; P < .01) as compared with men. There were no significant differences in age at time of enrollment, body mass index, smoking status, or hyperlipidemia between groups (Table I). TEG-PM data demonstrated significantly higher levels of platelet aggregation in female patients compared with male patients (62.8 ± 36.6 vs 43.6 ± 34.9; P = .03) and significantly lower levels of platelet inhibition in female patients (37.2 ± 36.6 vs 56.4 ± 34.9; P = .03) (Fig 1). There was no significant difference in the use of monoantiplatet therapy (62.5% vs 61.7%; P = 1.00), dual antiplatelet therapy (22.5% vs 38.2%; P = 1.00), or anticoagulation (30.0% vs 46.9%; P = .08) between groups (Table I). In this preoperative cohort, we found traditional PAD risk factors, such as hypertension and diabetes, to be significantly higher in men compared with women. Viscoelastic data, however, showed significantly greater platelet reactivity in women compared with men. This important insight demonstrates that the prevailing paradigm of risk stratification and disease modification may not fit the female population with PAD, and provides an important basis for further research into gender-specific coagulation profiles.TableClinical and thromboelastography with platelet mapping metrics between female and male patients with peripheral arterial diseaseFemaleMean (SD) or No.(%)MaleMean (SD) or No.(%)PTotal patients4081Clinical factors Age, y69.1 (±11.7)67.4 (±10.2).50 BMI, kg/m226.8 (±8.9)27.5 (±4.9).65 Ever smoker19 (46.3)36 (44.4).85 HTN25 (62.5)72 (88.9)<.01 HLD27 (67.5)44 (54.3).18 DM10 (25.0)44 (54.3)<.01TEG values R time6.5 (±2.6)6.5 (±3.0).94 K time2.0 (±1.5)1.8 (±1.2).50 α-angle66.9 (±10.0)69.3 (±12.2).33 MA57.6 (±8.1)60.8 (±8.5).46Platelet mapping values % Platelet aggregation62.8 (±36.6)43.6 (±34.9).03 % Platelet inhibition37.2 (±36.6)56.4 (±34.9).03Anthrombotic therapy MAPT25 (62.5)50 (61.7)1.00 DAPT9 (22.5)31 (38.2)1.00 Full-dose AC12 (30.0)38 (46.9).08AC, Anticoagulation; BMI, body mass index; DAPT, dual antiplatelet therapy; DM, diabetes mellitus; HLD, hyperlipidemia; HTN, hypertension; MAPT, mono antiplatelet therapy; SD, standard deviation; TEG, thromboelastography.Boldface P indicates statistical significance. Open table in a new tab

Lower Extremity Revascularization Among Patients With Premature Peripheral Artery Disease Compared To Patients At The Common Age Of Presentation In The Vascular Quality Initiative

<h3>INTRODUCTION AND OBJECTIVES</h3> Premature peripheral artery disease (PAD) (age ≤50) is associated with poor outcomes following lower extremity revascularization (LER). However, the specific characteristics and outcomes compared to patients at the common age of presentation have not been examined. The aim of this study is to compare patients with premature PAD to patients with the common age of presentation undergoing LER. <h3>METHODS</h3> All LER procedures (open and endovascular) in the VQI were reviewed. A histogram of patient age at intervention for de novo disease (no prior LER) was used to define the common age of presentation. Characteristics and outcomes of patients with premature PAD were compared to patients treated at the common age of presentation.Figure 1 <h3>RESULTS</h3> The common age of presentation was defined as 60-80 years based on the histogram. (Figure) Patients with premature PAD were more likely to be female, African American, and Hispanic compared to patients at the common age of presentation. (Table) Patients with premature PAD also had higher rates of insulin-dependent diabetes, smoking, and dialysis, but less severe disease based on TASC classification. These differences in characteristics were more pronounced in patients with CLTI. Logistic regression demonstrated that premature PAD was independently associated with major adverse limb events (MALEs) at one-year for claudication (OR:1.68[1.38-2.04]) and CLTI (OR:1.31[1.13-1.51]) compared to patients 60-80-year-old. <h3>CONCLUSIONS</h3> Patients with premature PAD have significant differences in characteristics compared to patients treated at the common age of presentation. Despite having less severe disease burden, patients with premature PAD have worse one-year MALEs.

Evaluating Neutrophil-to-lymphocyte Ratio As A Predictive Tool For Post-operative Outcomes In Patients Undergoing Open Lower Extremity Revascularization Procedures

<h3>INTRODUCTION AND OBJECTIVES</h3> Elevated neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, has been shown to correlate with worse outcomes in patients undergoing vascular surgery. Limited data exists on the association of NLR with outcomes in patients undergoing lower extremity vascular surgery. We sought to investigate whether preoperative NLR correlates with outcomes in patients undergoing open lower extremity revascularization procedures. <h3>METHODS</h3> We conducted a retrospective analysis of a prospectively maintained database of patients who underwent open lower extremity revascularization procedures from January 2011 to January 2013 (N=179). Preoperative NLR was calculated within six months of surgery. Primary outcomes were major adverse limb event (MALE) or death. The maximally-ranked statistic method was used to determine the NLR cut-off point. Kaplan-Meier analyses of death and MALE and NLR were used to compare the groups by NLR cut-off point. We conducted a multivariate analysis of the association between NLR and mortality using Cox proportional hazard models, including confounding variables such as age, smoking status, and diabetes. <i>P-</i>values <i><</i>0.05 were considered statistically significant. <h3>RESULTS</h3> Ninety-two patients undergoing surgery from January 2011 to January 2013 were analyzed. The median NLR was 3.1 with IQR [2.3-5.6]. The analysis showed a negative correlation between NLR and mortality (P=0.001) and MALE (P =0.049) (Fig 1A and 1B). Controlling for multiple comorbidities including gender, age, smoking, BMI, diabetes, hyperlipidemia, and hypertension, the NLR cut-off point was a significant independent predictor of mortality (P=0.002), but not MALE (P=0.262). <h3>CONCLUSIONS</h3> This study suggests that NLR is an independent predictor of mortality in patients undergoing open lower extremity revascularizations. Going forward, we plan to expand this study to look at a more recent set of patients.Figure 1Figure 1

Association between Race and Perioperative Outcomes after Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis in NSQIP.

Previous studies have documented that Black patients have worse outcomes after lower extremity revascularization procedures compared with White patients. However, the association of race on carotid endarterectomy (CEA) outcomes is not well described. The aim of this study was to compare perioperative outcomes of CEA for Black vs White patients with asymptomatic carotid artery stenosis. All patients who underwent CEA for asymptomatic carotid stenosis in the ACS-NSQIP targeted vascular database (2011-2019) were included. Perioperative (30-day) outcomes were compared for Black vs White patients using multivariable logistic regression adjusting for age/sex, comorbidities, and disease characteristics. Of 16,764 asymptomatic CEA patients, 95.2% (N = 15,960) were White and 4.8% (N = 804) were Black. Black patients were slightly younger (mean age 71.4 ± 0.1 vs 69.9 ± 0.3 years, P < 0.001) and more frequently had high-grade carotid artery stenosis compared to White patients (79.5% vs 74.0%, p = 0.001). Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients (p ≤ 0.01). Crude perioperative stroke (2.4% vs 1.3%, p = 0.007) and stroke/death (2.6% vs 1.4%, p = 0.003) were higher for Black patients, but myocardial infarction (1.7% vs 1.5%, p = 0.67) and death (0.4% vs 0.2%, p = 0.12) were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke (odds ratio 1.66, 95% CI 1.01 to 2.73) and stroke/death (odds ratio 1.75, 95% CI 1.10 to 2.81) remained significantly higher for Black patients compared with White patients. Black patients undergoing CEA for asymptomatic carotid artery stenosis had more severe stenosis, more comorbidities, and worse perioperative outcomes compared to White patients. Overall, our data suggest substantial differences in the treatment and outcomes of asymptomatic carotid artery stenosis based on race.

Prescribing of Statins After Lower Extremity Revascularization Procedures in the US

The use of statins in patients with symptomatic peripheral artery disease remains suboptimal despite strong clinical practice guideline recommendations; however, it is unknown whether rates are associated with substantial improvements after lower extremity revascularization. To report longitudinal trends of statin use in patients with peripheral artery disease undergoing lower extremity revascularization and to identify the clinical and procedural characteristics associated with prescriptions for new statin therapy at discharge. This was a retrospective cross-sectional study using data from the Vascular Quality Initiative registry of patients who underwent lower extremity peripheral artery disease revascularization from January 1, 2014, through December 31, 2019. The Vascular Quality Initiative is a multicenter registry database including academic and community-based hospitals throughout the US. Patients aged 18 years or older undergoing lower extremity revascularization with available statin data (preprocedure and postprocedure) were included. Those not receiving statin therapy for medical reasons were excluded from final analyses. Patients undergoing lower extremity revascularization for whom statin therapy is indicated. Multivariate logistic regression was used to determine the clinical and procedural characteristics associated with new statin prescription for patients not already taking a statin preprocedure. The overall rates of statin prescription as well as rates of new statin prescription at discharge were determined. In addition, the clinical, demographic, and procedural characteristics associated with new statin prescription were analyzed. There were 172 025 procedures corresponding to 125 791 patients (mean [SD] age, 67.7 [11.0] years; 107 800 men [62.7%]; and 135 405 White [78.7%]) included in the analysis. Overall rates of statin prescription at discharge improved from 17 299 of 23 093 (75%) in 2014 to 29 804 of 34 231 (87%) in 2019. However, only 12 790 of 42 020 patients (30%) not already taking a statin at the time of revascularization during the study period were newly discharged with a statin medication. New statin prescription rates were substantially lower after endovascular intervention (7745 of 29 581 [26%]) than after lower extremity bypass (5045 of 12 439 [41%]). Body mass index of 30 or greater (odds ratio [OR], 1.13; 95% CI, 1.04-1.24; P < .001), diabetes (diet-controlled vs no diabetes, OR, 1.22; 95% CI, 1.05-1.41; P = .01), smoking (current vs never, OR, 1.32; 95% CI, 1.21-1.45; P < .001), hypertension (OR, 1.19; 95% CI, 1.09-1.29; P < .001), and coronary heart disease (OR, 1.26; 95% CI, 1.17-1.35; P < .001) were associated with an increased likelihood of new statin prescription after endovascular intervention, whereas female sex, older age, antiplatelet use, and prior peripheral revascularization were associated with a decreased likelihood. In this cross-sectional study, although statin use was associated with a substantial improvement after lower extremity revascularization, more than two-thirds of patients not already taking a statin preprocedure remained not taking a statin at discharge. Further investigations to understand the clinical implications of these findings and develop clinician- and system-based interventions are needed.

Lower Extremity Vascular Intervention Is Associated With Increased Mortality Following Kidney Transplantation

Approximately 25% of patients with end-stage renal disease (ESRD) have concomitant peripheral artery disease (PAD). Although kidney transplantation increases overall survival and quality of life in patients with ESRD, these patients remain at high risk for post-transplant sequelae related to PAD, including lower extremity revascularization procedures and amputations. The objective of this study was to determine the incidence of, and risk factors for, lower extremity vascular intervention (LEVI) following kidney transplantation using the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) dataset.

Immediate postoperative hyperglycemia after peripheral arterial bypass is associated with short-term and long-term poor outcomes

ObjectiveAlthough the impact of poorly controlled diabetes on surgical outcomes of patients undergoing lower extremity revascularization is well-known, it is not clear if immediate postoperative hyperglycemia (IPH) itself can be used as a surrogate for poor outcomes after peripheral arterial bypass. We sought to examine the effect of IPH in this patient population with its impact on short-term and long-term outcomes. MethodsRetrospective review was completed for 505 patients who underwent either suprainguinal bypass surgery or infrainguinal bypass surgery between July 2002 and April 2018 for the treatment of peripheral arterial disease. All patients were undergoing first-time open bypass grafting. Patients were stratified into those who were normoglycemic or hyperglycemic (glucose ≥ 140 mg/dL) within 24 hours after surgery. A comparative analysis was performed on comorbidities and outcomes. ResultsOf 505 patients who underwent bypass grafting, 255 patients (50.5%) were hyperglycemic. The mean age of patients was 63.5 ± 14.1 years. The median follow-up was 5.2 years (range, 0.0-15.2 years). The distribution of procedures was as follows: femoral to popliteal bypasses (29%), femoral to femoral bypasses (17%), femoral to tibial bypasses (12%), aortobifemoral bypasses (10%), iliofemoral bypasses (9%), and axillofemoral bypasses (7%). At 30 days, hyperglycemic patients had an increased incidence of limb loss (8.3% vs 4.0%) and myocardial infarction (4.8% vs 0.8%) and incurred higher costs of hospital stay ($27,701 vs $22,990) (all P < .05). At 10 years, these patients had a higher incidence of needing major amputations (15.4% vs 9.4%; P = .025). Hyperglycemia after infrainguinal bypass was associated with nearly twice the risk of limb loss at 5 years (hazard ratio, 1.91; P = .034). Among the cohort of patients who required major amputations, the time duration between index revascularization and amputation was significantly shorter as compared with normoglycemic patients (P = .003). ConclusionsIn this single-institution study with long-term follow-up, IPH was associated with increased rates of 30-day amputation and myocardial infarction, as well as an increased cost of hospital stay. In the long term, postoperative hyperglycemia was associated with greater major limb loss. Among the cohort of patients who required major amputations, the time period between revascularization and amputation was shorter for those patients who had IPH. IPH is an independent marker for poor outcomes after lower extremity revascularization procedures.