Outcomes In Vascular Surgery Patients Research Articles

Automated Electronic Frailty Index is Associated with Non-home Discharge in Patients Undergoing Open Revascularization for Peripheral Vascular Disease.

Frailty is associated with adverse surgical outcomes including post-operative complications, needs for post-acute care, and mortality. While multiple frailty screening tools exist, most are time and resource intensive. Here we examine the association of an automated electronic frailty index (eFI), derived from routine data in the Electronic Health Record (EHR), with outcomes in vascular surgery patients undergoing open, lower extremity revascularization. A retrospective analysis at a single academic medical center from 2015 to 2019 was completed. Information extracted from the EHR included demographics, eFI, comorbidity, and procedure type. Frailty status was defined as fit (eFI≤0.10), pre-frail (0.10<eFI≤0.21), and frail (eFI>0.21). Outcomes included length of stay (LOS), 30-day readmission, and non-home discharge. We included 295 patients (mean age 65.9years; 31% female), with the majority classified as pre-frail (57%) or frail (32%). Frail patients exhibited a higher degree of comorbidity and were more likely to be classified as American Society of Anesthesiologist class IV (frail: 46%, pre-frail: 27%, and fit: 18%, P = 0.0012). There were no statistically significant differences in procedure type, LOS, or 30-day readmissions based on eFI. Frail patients were more likely to expire in the hospital or be discharged to an acute care facility (31%) compared to pre-frail (14%) and fit patients (15%, P = 0.002). Adjusting for comorbidity, risk of non-home discharge was higher comparing frail to pre-frail patients (OR 3.01, 95% CI 1.40-6.48). Frail patients, based on eFI, undergoing elective, open, lower extremity revascularization were twice as likely to not be discharged home.

SP5.2.5 A 4-year single-centre cohort study assessing outcomes in vascular surgery patients undergoing calf fasciotomies

Abstract Aims Acute compartment syndrome (ACS) is a surgical emergency. Delayed diagnosis and fasciotomy can result in irreversible muscle necrosis causing permanent disability and major amputation. This study compared patient outcomes following calf fasciotomies to prevent ACS (prophylactic) versus treat ACS (therapeutic) and early (within 6 hours of ACS diagnosis) versus delayed fasciotomies (beyond 6 hours) at a single vascular centre. Methods All patients undergoing calf fasciotomies between 1st January 2017 and 31st December 2020 were identified from a prospectively collected departmental database. Caldecott-approved data collection was conducted. The primary outcomes were wound infection, foot drop, muscle debridement, split-skin graft (SSG) requirement, vacuum dressing, 30-day amputation and death rates. Statistical analysis was performed using Fisher’s exact test. Results 73 patients (51 men, 22 women; median age 67, IQR 56-75 years) underwent calf fasciotomies (44 therapeutic and 29 prophylactic) mainly following acute thromboembolic ischaemia. Higher complication rates occurred among delayed (15) versus early (29) fasciotomy patients: wound infection (13.3% vs 3.4%), foot drop (20.0% vs 3.4%), muscle debridement (40.0% vs 24.1%), loss of anterior compartment (13.3%, 3.4%) need for SSG (29.5% vs 17.2%), vacuum dressing (46.7% vs 20.7%) and 30-day amputation rate (20.0% vs 13.8%) but lower 30-day death rate 13.3% vs 17.2%). None of these results were statistically significant. 34.1% of delayed fasciotomies were due to awaiting emergency theatre availability. Conclusion ACS patients undergoing calf fasciotomies are at high risk of complications including amputation and death. Ongoing education on mortality risk and early communication with emergency theatres are critical in their management.

Frailty and Vascular Surgery: Age Never Lies

“Alas! In the clothes of the greatest potentate, what is there but a man?”(Robert Louis Stevenson, The Suicide Club)1Stevenson R.L. The Suicide Club. London Magazine, London1878Google Scholar By 2050, more than 35% of all European inhabitants will be 60 years of age or older.2Etzioni D.A. Liu J.H. Maggard M.A. Ko C.Y. The aging population and its impact on the surgery workforce.Ann Surg. 2003; 238: 170-177Crossref PubMed Scopus (551) Google Scholar Hence, frailty, defined as multidimensional vulnerability due to age associated decline in physiological reserve, is an impending issue for all surgical disciplines.3Robinson T.N. Wu D.S. Pointer L. Dunn C.L. Cleveland Jr., J.C. Moss M. Simple frailty score predicts postoperative complications across surgical specialties.Am J Surg. 2013; 206: 544-550Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar It appears to be related to adverse outcomes in the short and long term after vascular surgical procedures.4Shinall Jr., M.C. Arya S. Youk A. Varley P. Shah R. Massarweh N.N. et al.Association of preoperative patient frailty and operative stress with postoperative mortality.JAMA Surg. 2019; 13e194620Google Scholar,5Houghton J.S.M. Nickinson A.T.O. Morton A.J. Nduwayo S. Pepper C.J. Rayt H.S. et al.Frailty factors and outcomes in vascular surgery patients: a systematic review and meta-analysis.Ann Surg. 2019; (Epub ahead of print 22 October 2019)https://doi.org/10.1097/SLA.0000000000003642Crossref PubMed Scopus (28) Google Scholar In their present paper, Ambler et al. underline the relevance of frailty for patient outcomes after vascular surgery, namely the treatment of abdominal aortic aneurysms, acute and chronic limb ischaemia, and carotid disease.6Ambler G.K. Kotta P.A. Zielinski L. Kalyanasundaram A. Brooks D.E. Ali A. et al.The effect of frailty on long-term outcomes in vascular surgical patients.Eur J Vasc Endovasc Surg. 2020; 60: 264-272Abstract Full Text Full Text PDF Scopus (9) Google Scholar In their methodologically sound study, the authors evaluated the Addenbrookes Vascular Frailty Score (AVFS) as a promising tool to assess the effect of pre-operative existing frailty on the five year mortality and re-admission rate.7Ambler G.K. Brooks D.E. Al Zuhir N. Ali A. Gohel M.S. Hayes P.D. et al.Effect of frailty on short- and mid-term outcomes in vascular surgical patients.Br J Surg. 2015; 102: 638-645Crossref PubMed Scopus (70) Google Scholar Furthermore, they created an addendum to the AVFS by combining the six established factors: the longer (L)AVFS, which should focus, in particular, on long term outcome. The handy score, based on variables such as haemoglobin <120 g/L, lack of independent mobility, polypharmacy, and emergency admission, can easily be applied in daily practice. According to the findings of Ambler et al.,7Ambler G.K. Brooks D.E. Al Zuhir N. Ali A. Gohel M.S. Hayes P.D. et al.Effect of frailty on short- and mid-term outcomes in vascular surgical patients.Br J Surg. 2015; 102: 638-645Crossref PubMed Scopus (70) Google Scholar patient age, lack of mobility, polypharmacy, and emergency admission were significantly related to mortality over a five year follow up period. The AVFS and the LAVFS were able to stratify patients according to their long term survival and re-admission free survival rates. Regarding the ability to divide patients into different survival groups, the LAVFS seems to be favourable. Finally, both scoring systems could be evaluated as useful and necessary additions to the current treatment guidelines for decision making in elderly patients. Even if some relevant limitations, such as the missing presentation of mortality details and the joint assessment of four different vascular surgical disorders, have to be considered, this study emphasises the need to assess our old and frail patients appropriately. The LAVFS could improve the treatment of older vascular surgical patients by enabling a more accurate patient assessment. Finally, this could help to avoid harmful and possibly unnecessary surgery. The Effect of Frailty on Long Term Outcomes in Vascular Surgical PatientsEuropean Journal of Vascular and Endovascular SurgeryVol. 60Issue 2PreviewFrailty is a multidimensional vulnerability due to age associated decline. The impact of frailty on long term outcomes was assessed in a cohort of vascular surgical patients. Full-Text PDF Open Archive

The Addenbrookes Vascular Frailty Score Predicts Adverse Outcomes in Vascular Surgery Patients

The Addenbrookes Vascular Frailty Score Predicts Adverse Outcomes in Vascular Surgery Patients

Frailty Factors and Outcomes in Vascular Surgery Patients: A Systematic Review and Meta-analysis.

To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes. Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken. Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO, and Scopus. Quality of studies was assessed using Newcastle-Ottawa scores (NOS) and quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RRs), and associations with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs). Data were pooled using random-effects models. Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥ 7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age [MD 4.05 years; 95% confidence interval (CI) 3.35, 4.75], female sex (RR 1.32; 95% CI 1.14, 1.54), and lower body mass index (MD -1.81; 95% CI -2.94, -0.68). Frailty was associated with 30-day mortality [adjusted OR (AOR) 2.77; 95% CI 2.01-3.81), postoperative complications (AOR 2.16; 95% CI 1.55, 3.02), and long-term mortality (HR 1.85; 95% CI 1.31, 2.62). Sarcopenia was not associated with any outcomes. Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.

The Effect of Frailty on Outcome After Vascular Surgery

Frailty is a state of increased vulnerability and is a stronger predictor for post-operative outcome than age alone. The aim of this study was to determine whether frailty is associated with adverse 30 day outcome in vascular surgery patients. This was a prospective cohort study. All electively operated vascular surgery patients between March 2010 and October 2017 (n=1201), aged≥60 years were evaluated prospectively. Exclusion criteria were arteriovenous access surgery, percutaneous interventions and minor amputations, resulting in 825 patients for further analysis whereas 195 had incomplete data on Groningen Frailty Indicator (GFI) and were excluded. Frailty was measured using the GFI, a screening tool covering 16 items in the domains of functioning. Patients with a total score of ≥4 were classified as frail. The primary outcome parameter was 30 day morbidity (based on the Comprehensive Complication Index). Secondary outcome measures were 30 day mortality, hospital readmission, and type of care facility after discharge. Outcomes were adjusted for sex, body mass index, smoking status, hypertension, Charlson Comorbidity Index, and type of intervention. There was an unequal sex distribution (77.6% male). The mean age was 72.1 years. One hundred and eighty-four patients (22.3%) were considered frail. The mean Comprehensive Complication Index was 8.5. Frail patients had a significantly higher Comprehensive Complication Index (3.7 point increase, p=.005). Patients with impaired cognition and reduced psychosocial condition, two domains of the GFI, had a significantly higher Comprehensive Complication Index. Also, the 30 day mortality rate was higher in frail patients (2.7 point increase; p=.05), and they were discharged to a care facility more often (7.7 point increase; p<.001). There was no significant difference in readmission rates between frail and non-frail patients. Frailty is associated with a higher risk of post-operative complications and discharge to a nursing home after vascular surgery. Some frailty domains (mobility, nutrition, cognition and psychosocial condition) appear to have a more pronounced impact.

Sensor-Based Upper-Extremity Frailty Assessment for the Vascular Surgery Risk Stratification

BackgroundAvailable methods for determining outcomes in vascular surgery patients are often subjective or not applicable in nonambulatory patients. The purpose of the present study was to assess the association between vascular surgery outcomes and a previously validated upper-extremity function (UEF) method, which incorporates wearable motion sensors for the physical frailty assessment. Materials and methodsPatients (≥50 y old) undergoing vascular surgery were recruited. Participants performed the 20-s UEF test, which involved rapid elbow flexion. This technology quantifies physical frailty features including slowness, weakness, exhaustion, and flexibility, which allows grouping individuals into nonfrail, prefrail, and frail categories. Surgical outcomes included length of hospital stay, discharged disposition, and 30-d mortality, complications, readmission, and reintervention(s). Associations between outcomes and frailty were assessed using nominal logistic regression models, adjusted for age, gender, body mass index, and wound classification. ResultsThirty-seven participants were recruited: eight nonfrail (age = 62.0 ± 10.6); 22 prefrail (age = 65.6 ± 11.6); and seven frail (age = 68.0 ± 8.0). Significant associations were observed between frailty and length of hospital stay (three times longer among frail participants, P = 0.03), mortality after surgery (two incidents among frail participants, P < 0.01), and adverse discharge disposition (all nonfrail patients were discharged home, whereas only 43% of frail patients discharged home, P = 0.01). ConclusionsThis is the first study to validate the utility of UEF among patients undergoing any vascular surgery. Findings suggest that UEF may provide an objective and simple approach for assessing frailty to predict adverse events after vascular surgery, especially for nonambulatory patients.

Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence.

Frailty is presumably associated with an elevated risk of postoperative mortality and adverse outcome in vascular surgery patients. The aim of our review was to identify possible methods for risk assessment and prehabilitation in order to improve recovery and postoperative outcome. The literature search was performed via PubMed, Embase, OvidSP, and the Cochrane Library. We collected papers published in peer-reviewed journals between 2001 and 2018. The selection criterion was the relationship between vascular surgery, frailty and postoperative outcome or mortality. A total number of 52 publications were included. Frailty increases the risk of non-home discharge independently of presence or absence of postoperative complications and it is related to a higher 30-day mortality and major morbidity. The modified Frailty Index showed significant association with elevated risk for post-interventional stroke, myocardial infarction, prolonged in-hospital stays and higher readmission rates. When adjusted for comorbidity and surgery type, frailty seems to impact medium-term survival (within 2 years). Preoperative physical exercising, avoidance of hypalbuminemia, psychological and cognitive training, maintenance of muscle strength, adequate perioperative nutrition, and management of smoking behaviours are leading to a reduced length of stay and a decreased incidence of readmission rate, thus improving the effectiveness of early rehabilitation. Pre-frailty is a dynamically changing state of the patient, capable of deteriorating or improving over time. With goal-directed preoperative interventions, the decline can be prevented.

Evaluating the Role of Preoperative Medicine Consults on Clinical Outcomes in Vascular Surgery Patients

The Internal Medicine Perioperative Consult Team (IMPCT) was introduced at our institution in 2015 with the goal of improving preoperative optimization to reduce postoperative complications. The objective of this study was to evaluate the effect of IMPCT on clinical outcomes in patients undergoing vascular surgery. A retrospective review of all vascular patients who received preoperative IMPCT consults between January 2015 and December 2017 at a tertiary care teaching hospital was undertaken. In addition, a control group (2:1) from the same period who did not receive IMPCT consults were matched to the IMPCT cohort based on age, sex and surgical intervention. Patient demographics, comorbidities, and postoperative complications, including troponin levels, were collected. The primary outcomes were delays in surgery, postoperative complications, and length of stay. Two hundred patients were identified: 71 IMPCT and 129 control patients. Average age, sex and surgical procedure were no different between the two groups. Delay in surgery was not significantly different between IMPCT (22%) and control groups (26%; P = .09). Average days of delay was also similar, 4.89 days versus 4.94 days (P = .97). Postoperative complication rate in the IMPCT group was higher than the control group but did not reach significance, 59.1% versus 19.3% (P = .09). Cardiac complications were the most common in both groups, 31.0% and 30.2%, (P = .13), respectively. The IMPCT group had higher elevated postoperative troponin levels compared with the control group, 20% versus 16% (P < .05). Length of stay trended toward higher for IMPCT compared with control patients, 16.2 days versus 9.5 days (P = .08). The introduction of a new perioperative medicine consult service at our institution did not improve vascular surgery patient outcomes but may delay surgery and prolong hospital stay. Prospective studies are needed to determine IMPCT's role in this patient population.

Type D Personality and Health-Related Quality of Life in Vascular Surgery Patients

BackgroundThis study evaluated the association of type D personality and health-related quality of life (HRQoL) and assessed the stability of type D personality in vascular surgery patients during the year after surgery.MethodIn a prospective cohort study between 2008 and 2014, 294 patients were assessed with validated questionnaires preoperatively and at 1, 6, and 12 months after surgery. Associations between type D personality, depression, and HRQoL were analyzed by generalized estimating equation models. Type D personality was analyzed in its standard dichotomous form as well as continuous (z) scores of its two components, negative affectivity (NA) and social inhibition (SI), and their interaction term.ResultsPrevalence of type D personality varied between 18% and 25%. However, only 9% of the complete responders were classified as type D personality at all four assessments, whereas one third changed between type D classifications. Continuous scores showed greater stability over time. Dichotomized type D personality measured over time was significantly associated with impaired HRQoL, but this was not the case if measured once at baseline, like in general use. The continuous NA score and depression were also significantly associated with impaired HRQoL over time.ConclusionType D personality was not a stable trait over time. Preoperative assessment of type D personality did not predict improvement in HRQoL after vascular surgery. However, the study revealed associations between the NA component of type D personality, depression, and lower HRQoL. This indicates that measures of overall negative affect should be taken into account when assessing HRQoL patient-reported outcomes in vascular surgery patients.

Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery

ObjectiveHyperglycemia is a common occurrence in patients undergoing cardiovascular surgery. It has been identified in several surgical cohorts that improved perioperative glycemic control reduced postoperative morbidity and mortality. A significant portion of the population with peripheral arterial disease suffers from the sequelae of diabetes or metabolic syndrome. A paucity of data exists regarding the relationship between perioperative glycemic control and postoperative outcomes in vascular surgery patients. The objective of this study was to better understand this relationship and to determine which negative perioperative outcomes could be abated with improved glycemic control. MethodsThis is a retrospective review of a vascular patient database at a large academic center from 2009 to 2013. Eligible procedures included carotid endarterectomy and stenting, endovascular and open aortic aneurysm repair, and all open bypass revascularization procedures. Data collected included standard demographics, outcome parameters, and glucose levels in the perioperative period. Perioperative hyperglycemia was defined as at least one glucose value >180 mg/dL within 72 hours of surgery. The primary outcome was 30-day mortality, with secondary outcomes of complications, need to return to the operating room, and readmission. ResultsOf the total 1051 patients reviewed, 366 (34.8%) were found to have perioperative hyperglycemia. Hyperglycemic patients had a higher 30-day mortality (5.7% vs 0.7%; P < .01) and increased rates of acute renal failure (4.9% vs 0.9%; P < .01), postoperative stroke (3.0% vs 0.7%; P < .01), and surgical site infections (5.7% vs 2.6%; P = .01). In addition, these patients were also more likely to undergo readmission (12.3% vs 7.9%; P = .02) and reoperation (6.3% vs 1.8%; P < .01). Furthermore, multivariable logistic regression demonstrated that perioperative hyperglycemia had a strong association with increased 30-day mortality and multiple negative postoperative outcomes, including myocardial infarction, stroke, renal failure, and wound complications. ConclusionsThis study demonstrates a strong association between perioperative glucose control and 30-day mortality in addition to multiple other postoperative outcomes after vascular surgery.

Hypoalbuminemia Predicts Perioperative Morbidity and Mortality after Infrainguinal Lower Extremity Bypass for Critical Limb Ischemia

Poor nutritional status has been associated with a higher risk of morbidity and mortality in general surgery patients; however, outcomes in vascular surgery patients are unclear. Our goal was to determine the effect of poor nutritional status on perioperative morbidity and mortality after lower extremity bypass (LEB). The 2005-2012 National Surgical Quality Improvement Program was analyzed to determine associated complications, mortality, length of stay (LOS), and readmissions for patients with hypoalbuminemia (serum albumin <3.5g/dL and <2.8g/dL) undergoing infrainguinal lower extremity bypass for critical limb ischemia. Multivariable analyses were performed to assess associated risk factors while adjusting for possible confounders. There were 5,110 LEB identified with an albumin level recorded. There were 2,327 (45.5%) patients with a low preoperative albumin. Patients with a low albumin were more likely to have diabetes, chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, renal failure, dialysis dependence, hypertension, history of transient ischemic attack or stroke, steroid use, impaired functional status, dyspnea at rest, anemia, prior operations within 30days, preoperative wounds or infections, and a tibial target (P<0.05). Multivariable analyses showed that low albumin was independently associated with increased mortality (odds ratio [OR]: 1.8, 95% confidence interval [95% CI]: 1.3-2.6, P=0.001), return to the operating room (OR: 1.4, 95% CI: 1.2-1.6, P<0.001), and increased LOS (MR: 1.2, 95% CI: 1.1-1.2, P<0.001). When compared with patients with normal albumin, patients with more severe hypoalbuminemia, less than 2.8g/dL, showed further increased risk of mortality (OR: 2.5, 95% CI: 1.6-3.8), return to the operating room (OR: 1.6, 95% CI: 1.3-2.0), and prolonged LOS (MR: 1.2, 95% CI: 1.2-1.3). Poor preoperative hypoalbuminemia is associated with morbidity and mortality after infrainguinal lower extremity bypass for critical limb ischemia. Evaluation and optimization of nutritional status should be performed preoperatively in this high risk population.

The effect of hydroxyethyl starches and crystalloid fluids on mortality and need for dialysis in vascular surgery patients

Previous research has indicated that fluid choice is an important component of the resuscitation of the critically-ill patient. Synthetic hydroxyethyl starches (HES) may remain within the intravascular space compared to crystalloid solutions, yet they have also been associated with acute kidney injury. Data comparing HES and crystalloid solutions in anesthesia is incomplete. The goal of this study was to evaluate the effect of utilizing HES on adverse patient outcomes in vascular surgery patients at a Canadian academic hospital.

Commentary on: “White Matter Damage of the Brain is Associated With Poor Outcomes in Vascular Surgery Patients with Claudication: A Pilot Study”

Changes in cerebral white matter can be investigated using newer MRI-diffusion technologies. In the current issue of the European Journal of Vascular and Endovascular Surgery, a pilot study reports on the association between peripheral arterial disease (PAD) and white matter changes in the brain using MRI-diffusion imaging and calculation of fractional anisotropy. The study reports a reduction in the fractional anisotropy scale in patients with PAD, especially those suffering fatal or severe cardiovascular events during follow up. This is a new finding, which is worthy of further evaluation. In particular, such complex measurements need to be validated regarding inter-individual and inter-observer variability: is the anisotropy value the same in the morning as in the evening? Water diffusion displays directionality because of the presence of complex microstructural barriers in tissue. The extent of directionality of water diffusion can be expressed as fractional anisotropy, but what does this actually mean, and how is it calculated? It has been speculated to reflect fiber density, axonal diameter, myelination in white matter and metabolism. The current pilot study showing this new association is small, and its results must, therefore, be validated in larger prospective studies (as was stated by the authors). However, a study like this actually raises more questions than it answers: How does fractional anisotropy develop differently in patients with PAD compared to the changes observed in an ageing human? Are the white matter changes in aorto-iliac atherosclerosis different from

The Impact of Perioperative Red Blood Cell Transfusions on Postoperative Outcomes in Vascular Surgery Patients

Red blood cell (RBC) transfusions are common in vascular surgery and aim to reduce tissue ischemia. However, the evidence that transfusions are beneficial is contradictory. This study evaluates the impact of perioperative transfusion (transfusion within 3 days of surgery) on 30-day postoperative outcomes in elective vascular surgery patients. This observational cohort included 1,041 vascular surgery patients between 2002 and 2011 in a tertiary referral center for whom hemoglobin levels were retrospectively available. Patients who received transfusions after 3 days postoperatively were excluded. A propensity score was developed for the likelihood of receiving perioperative transfusion. The study end points were 30-day cardiovascular (CV) events (myocardial infarction, heart failure, arrhythmias, stroke, asymptomatic troponin-T release, and CV death) and all-cause mortality. Multivariable logistic regression analyses, adjusting for relevant confounders and transfusion propensity, were used to determine the associations between perioperative transfusion and the study end points. The final study sample comprised 992 patients; 265 (27%) patients received perioperative transfusions. During the 30-day follow-up, a total of 190 (19%) patients suffered from a 30-day postoperative CV event, of which 116 (44%) occurred in patients who received perioperative RBC transfusions compared with 74 (10%) patients without transfusions (P < 0.01). The end point all-cause mortality was reached in 36 (4%) patients-26 (10%) patients with perioperative RBC transfusion compared with 10 (1%) patients without transfusion (P < 0.01). Perioperative transfusion was associated with an independently increased risk of 30-day CV events (odds ratio 5.0; 95% confidence interval 3.1-8.2) and all-cause mortality (odds ratio 4.4; 95% confidence interval 1.6-12.1). Perioperative transfusion is associated with a strongly increased risk of both 30-day CV events and mortality in elective vascular surgery patients.

White Matter Damage of the Brain is Associated with Poor Outcome in Vascular Surgery Patients with Claudication: A Pilot Study

Peripheral arterial disease (PAD) is a systemic atherosclerotic syndrome with high post-operative morbidity and mortality. Fractional anisotropy (FA), an index measured by magnetic resonance diffusion tensor imaging (DTI), has been shown to be exceedingly sensitive to microstructural damage in brain white matter tracts. It is hypothesized that pre-operative white matter damage is more extensive in PAD patients scheduled for vascular surgery who experience an adverse long-term outcome. Preoperative FA values were obtained in 24 consecutive PAD patients (age >40 years) scheduled for elective infrainguinal revascularization surgery and in 15 healthy age matched participants. All patients had their clinical history taken and underwent physical examination and laboratory tests. After surgery, patients were followed for a median of 52 months (range 40-63) and major adverse cardiovascular and cerebrovascular events (MACCE) were recorded. There were no statistically significant differences in baseline demographic or clinical variables between the MACCE group and the non-MACCE group. During follow up, eight PAD patients suffered a MACCE and they had lower FA values than patients without MACCE or healthy controls (mean ± SD 0.370 ± 0.017 vs. 0.392 ± 0.023 vs. 0.412 ± 0.018, p = .036 and p = .00007, respectively). Voxelwise analysis of the FA data revealed diffuse spatial distribution of white matter damage in PAD patients. There was no statistically significant association between the FA values and other clinical variables. Microstructural white matter damage was associated with poor outcome in PAD patients with claudication requiring surgical revascularization, and its extent may have clinical value in risk stratification.

Usefulness of Pre-Operative Copeptin Concentrations to Predict Post-Operative Outcome After Major Vascular Surgery

The aim of this study was to investigate whether preoperative determination of plasma copeptin levels in addition to plasma N-terminal pro–B-type natriuretic peptide (NT–pro-BNP) could help improve risk stratification in patients who undergo major vascular surgery. One hundred ninety-eight consecutive patients who underwent major vascular surgery (58.6% infrainguinal aortic reconstruction, 23.7% abdominal aortic aneurysm surgery, 17.7% carotid endarterectomy) were included in this study. Patients were monitored for in-hospital and long-term (2-years) major adverse cardiac events, consisting of cardiac death, nonfatal myocardial infarction, and emergent coronary revascularization. Overall, 40 patients (20.2%) reached the primary end point, and most of these events occurred during the index hospital stay (n 18 [45%]). In univariate Cox regression analysis, increasing concentrations of copeptin were significant determinants of outcome as a continuous variable (hazard ratio [HR] 1.012, p 0.005) and as a dichotomized variable according to the recommended cutoff of 14.0 pmol/L (HR 4.116, p 14 pmol/L were significant independent predictors of outcome (HR 2.842, p 0.002) in addition to type of surgery, history of myocardial infarction, elevated levels of cardiac troponin T, and NT–pro-BNP levels. In conclusion, the results of this study suggest that preoperative determination of this new biomarker could substantially improve prediction of perioperative and postoperative outcomes in vascular surgery patients. © 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108:1188 –1195)

Influence of Aortic Valve Calcium on Outcome in Patients Undergoing Peripheral Vascular Surgery

Vascular surgery patients are at increased risk of adverse cardiovascular events because of silent coronary artery disease and an increased propensity for left ventricular dysfunction. The Revised Cardiac Risk Index is commonly used for preoperative risk stratification. Aortic valve calcium is associated with cardiovascular mortality in the general population. The present study evaluated the prognostic implications of aortic valve calcium on 30-day postoperative and long-term outcomes in vascular surgery patients. Echocardiographic aortic valve evaluation was completed in 1,172 vascular surgery patients. Aortic valve sclerosis was defined by the presence of thickening and/or calcium of ≥1 cusps of a tricuspid aortic valve not inducing stenosis (i.e., with a maximal velocity at continuous Doppler of <2.5 m/s). Stenosis was defined as a maximum velocity of >2.5 m/s. Troponin-T measurements and electrocardiograms were performed routinely after surgery. The study end points were the composite of postoperative cardiovascular events and long-term mortality. Aortic valve sclerosis was present in 416 patients (36%), and aortic valve stenosis was present in 30 patients (3%). After multivariate regression analyses adjusted for age, gender, Revised Cardiac Risk Index, hypertension, hypercholesterolemia, and medication use, aortic valve sclerosis was not associated with either the postoperative or long-term outcomes. In contrast, aortic valve stenosis was associated with a greater postoperative and long-term event rate (odds ratio 3.9, 95% confidence interval 1.7 to 8.7; and hazard ratio 2.1, 95% confidence interval 1.2 to 3.7, respectively). In conclusion, the present study has shown that aortic valve calcium is common in vascular surgery patients. Its presence is associated with negative postoperative and long-term outcomes.

Usefulness of Pre-Operative Copeptin Concentrations to Predict Post-Operative Outcome After Major Vascular Surgery

The aim of this study was to investigate whether preoperative determination of plasma copeptin levels in addition to plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) could help improve risk stratification in patients who undergo major vascular surgery. One hundred ninety-eight consecutive patients who underwent major vascular surgery (58.6% infrainguinal aortic reconstruction, 23.7% abdominal aortic aneurysm surgery, 17.7% carotid endarterectomy) were included in this study. Patients were monitored for in-hospital and long-term (2-years) major adverse cardiac events, consisting of cardiac death, nonfatal myocardial infarction, and emergent coronary revascularization. Overall, 40 patients (20.2%) reached the primary end point, and most of these events occurred during the index hospital stay (n = 18 [45%]). In univariate Cox regression analysis, increasing concentrations of copeptin were significant determinants of outcome as a continuous variable (hazard ratio [HR] 1.012, p = 0.005) and as a dichotomized variable according to the recommended cutoff of 14.0 pmol/L (HR 4.116, p <0.001). Subgroup analyses revealed that especially patients at low estimated risk according to plasma NT-pro-BNP levels were at significantly higher risk for worse outcomes with higher copeptin levels (HR 5.983, p = 0.002). In multivariate Cox regression analysis, copeptin concentrations >14 pmol/L were significant independent predictors of outcome (HR 2.842, p = 0.002) in addition to type of surgery, history of myocardial infarction, elevated levels of cardiac troponin T, and NT-pro-BNP levels. In conclusion, the results of this study suggest that preoperative determination of this new biomarker could substantially improve prediction of perioperative and postoperative outcomes in vascular surgery patients.

Relation between Preoperative and Intraoperative New Wall Motion Abnormalities in Vascular Surgery Patients

Coronary revascularization of the suspected culprit coronary lesion assessed by preoperative stress testing is not associated with improved outcome in vascular surgery patients. Fifty-four major vascular surgery patients underwent preoperative dobutamine echocardiography and intraoperative transesophageal echocardiography. The locations of left ventricular rest wall motion abnormalities and new wall motion abnormalities (NWMAs) were scored using a seven-wall model. During 30-day follow-up, postoperative cardiac troponin release, myocardial infarction, and cardiac death were noted. Rest wall motion abnormalities were noted by dobutamine echocardiography in 17 patients (31%), and transesophageal echocardiography was noted in 16 (30%). NWMAs were induced during dobutamine echocardiography in 17 patients (31%), whereas NWMAs were observed by transesophageal echocardiography in 23 (43%), kappa value = 0.65. Although preoperative and intraoperative rest wall motion abnormalities showed an excellent agreement for the location (kappa value = 0.92), the agreement for preoperative and intraoperative NWMAs in different locations was poor (kappa value = 0.26-0.44). The composite cardiac endpoint occurred in 14 patients (26%). There was a poor correlation between the locations of preoperatively assessed stress-induced NWMAs by dobutamine echocardiography and those observed intraoperatively using transesophageal echocardiography. However, the composite endpoint of outcome was met more frequently in relation with intraoperative NWMAs.