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Effect of adjunct femoral endarterectomy in lower extremity bypass on perioperative and 1-year outcomes.

ABSTRACT: Isolated common femoral endarterectomy was recently reported to have a 30-day mortality of 3.4%. The effect of adjunctive femoral endarterectomy at the time of lower extremity bypass is not well described, and therefore, the purpose of this study was to determine its associated perioperative and long-term risk.Vascular Study Group of New England registry data were used to identify patients undergoing initial lower extremity bypass from 2003 to 2015. After univariate analysis, multivariable logistic regression was used to identify the independent association of endarterectomy with adverse perioperative events. Kaplan-Meier and Cox hazard models were used for the 1-year analysis.After exclusions, 4496 patients were identified as undergoing infrainguinal bypass (33% with endarterectomy). There was no difference in the proportion with chronic limb-threatening ischemia (CLI; 68% vs 67%; P = .24) or tissue loss of those with CLI (65% vs 63%; P = .34) between the adjunctive endarterectomy group and bypass alone, respectively. Patients undergoing adjunctive endarterectomy were older (mean 68 years vs 67 years; P = .02), more likely white (95% vs 93%; P = .02), smokers (91% vs 87%; P = .001), and more often had prior coronary artery bypass grafting/percutaneous coronary intervention (34% vs 31%; P = .02). The endarterectomy cohort had similar 30-day mortality (CLI: 2.6% vs 2.9%; P = .60; claudication: 0.2% vs 0.4%; P = 1.0) despite a longer operative time (median, 268 minutes vs 210 minutes; P < .001) and increased blood loss (median, 250 mL vs 180 mL; P < .001). Patients with CLI undergoing adjunctive endarterectomy had more in-hospital myocardial infarctions (MIs; 6.2% vs 3.8%; P = .003) and transfusions (11% vs 6.8%; P < .001). At 1-year, this group had a suggestion of improved freedom from major amputation (91% vs 87%; P = .049) and amputation-free survival (80% vs 76%; P = .03) that did not reach significance after adjustment. For patients with claudication and adjunctive endarterectomy, rates of MI (2.4% vs 0.9%; P = .02), renal dysfunction (3.6% vs 1.4%; P = .01), surgical site infection (SSI; 5.0% vs 2.6%; P = .02), and transfusion (4.6% vs 1.8%; P = .002) were higher. After adjustment, all patients undergoing adjunctive endarterectomy were at increased risk of MI (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2), SSI (OR, 1.5; 95% CI, 1.1-2.0), and bleeding requiring transfusion (OR, 1.8; 95% CI, 1.4-2.3). There were no differences in 1-year survival for CLI or claudication groups and no difference in all 1-year end points for patients with claudication.Adjunctive femoral endarterectomy with bypass is safe, with no difference in perioperative or 1-year mortality compared with bypass. However, surgeons should be aware that adjunctive endarterectomy is associated with an increased risk of bleeding, SSI, and MI, likely from these patients' disease burden and presumed more extensive atherosclerosis.

SUBMITTER: Soden PA

PROVIDER: S-EPMC5328855 | biostudies-literature | 2017 Mar

REPOSITORIES: biostudies-literature

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Effect of adjunct femoral endarterectomy in lower extremity bypass on perioperative and 1-year outcomes.

Soden Peter A PA Zettervall Sara L SL Shean Katie E KE Deery Sarah E SE Kalish Jeffrey A JA Healey Christopher T CT Kansal Nikhil N Schermerhorn Marc L ML

Journal of vascular surgery 20160912 3

<h4>Background</h4>Isolated common femoral endarterectomy was recently reported to have a 30-day mortality of 3.4%. The effect of adjunctive femoral endarterectomy at the time of lower extremity bypass is not well described, and therefore, the purpose of this study was to determine its associated perioperative and long-term risk.<h4>Methods</h4>Vascular Study Group of New England registry data were used to identify patients undergoing initial lower extremity bypass from 2003 to 2015. After univa ...[more]

PMID: 27633166

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Project description:Our aim was to evaluate the effect of gender on early and late procedural and functional outcomes of lower extremity bypass (LEB).We reviewed the records of 2576 patients (828 women; 32%) who underwent LEB for claudication or critical limb ischemia (CLI) in the Vascular Study Group of New England from 2003 to 2010. Logistic regression and proportional hazards models were used to adjust for potential confounding differences between genders. Morbidity, mortality, graft patency, freedom from major amputation, ambulation, and living status were analyzed postoperatively and over 1 year.Women were older (70 vs 68 years; P < .001), had more hypertension (89% vs 85%; P = .006), less coronary artery disease (35% vs 39%; P = .03), smoking (73% vs 88%; P < .001), and preoperative statin use (60% vs 64%; P = .04). Women were more likely to have CLI (76% vs 71%; P = .003), and ambulate with assistance at presentation (19% vs 16%; P = .02). Morbidity was similar except women had higher rates of reoperation for thrombosis (4% vs 2%; P < .001) without differences in major amputation (2% vs 1%; P = .13) or in-hospital mortality (1.7% vs 1.7%; P = .96). Women and men with claudication had similar 1-year graft patency rates. Women with CLI had lower rates of primary (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.03-1.48; P = .02), assisted primary (HR, 1.42; 95% CI, 1.15-1.76; P = .001) and secondary patency (HR, 1.40; 95% CI, 1.10-1.77; P = .006) during the first year compared with men. Freedom from amputation was similar for men and women with CLI (HR, 1.17; 95% CI, 0.84-1.63; P = .36). There were no differences in late survival between women and men with claudication (HR, 0.89; 95% CI, 0.60-1.31; P = .36) or CLI (HR, 0.94; 95% CI, 0.81-1.09; P = .39). More female claudicants were not independently ambulatory at discharge (30% vs 19%; P = .002) and were discharged to a nursing home (15% vs 5%; P < .001) but these differences did not persist at 1 year. Women with CLI were more likely to be nonambulatory at discharge (13% vs 9%; P = .006) and at 1 year (13% vs 8%; P < .001). More women with CLI were discharged to a nursing home (44% vs 35%; P = .01) and resided there at 1 year (11% vs 7%; P = .02).Women have complication rates similar to men with inferior early and late functional outcomes after LEB. The reduced patency rates in women with CLI did not translate into differences in limb salvage. These findings might help define physician and patient expectations for women before revascularization.

Project description:ObjectiveControversy persists surrounding the perceived bleeding risk associated with perioperative clopidogrel use in patients undergoing lower extremity bypass (LEB). The purpose of this study was to examine the LEB bleeding risk and clinical sequelae associated with clopidogrel.MethodsAll LEBs in the Vascular Quality Initiative (VQI) from 2008 to 2014 were studied. The exposure was perioperative clopidogrel. Primary outcomes were blood transfusion, estimated blood loss ≥500 mL, and reoperation for bleeding. Secondary outcomes included mean operative time, major cardiac events, respiratory complications, infectious complications, and in-hospital mortality. Univariate and multivariable analyses were used to analyze patients on the basis of clopidogrel use and its association with outcomes. Nonparametric test for trend and Mantel-Haenszel methods were used to analyze association of clopidogrel use with blood transfusion and secondary outcomes.ResultsAmong the LEB cohort (N = 9179), 28% (n = 2544) were taking clopidogrel and 72% (n = 6635) were not. Patients taking clopidogrel were more likely to have coronary disease, prior coronary intervention, abnormal findings on stress test, and aspirin use (P < .001 for all). Patients taking clopidogrel were more likely to receive blood transfusion (38% vs 24%; P < .001) and to have estimated blood loss ≥500 mL (21% vs 12%; P < .001). Reoperation for bleeding rates were similar (0.9% vs 1.1%; P = .9). Clopidogrel use was also associated with increased mean operative times (244 minutes vs 232 minutes; P < .001) as well as with cardiac complications (8.8% vs 6.5%; P = .001), respiratory complications (2.5% vs 1.6%; P = .007), and in-hospital mortality (1.3% vs 0.8%; P = .03). Multivariable analysis demonstrated that clopidogrel was associated with increased risk of 1- or 2-unit blood transfusion (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.1; P < .001) and >2-unit blood transfusion (OR, 2.0; 95% CI, 1.7-2.5; P < .001). Major cardiac events (OR, 1.2; 95% CI, 1.0-1.5; P = .05) and respiratory complications (OR, 1.4; 95% CI, 1.0-2.0; P = .03) were also independently associated with clopidogrel use. Weighted Mantel-Haenszel ORs controlling for blood transfusion amount revealed no remaining effect of clopidogrel on major cardiac events (OR, 1.1; P = .4) or respiratory complications (OR, 1.0; P = .8).ConclusionsPerioperative clopidogrel use in LEB surgery is associated with increased blood loss and blood transfusion. Associated clinical sequelae include increased cardiac and pulmonary complications. Accordingly, surgeons should consider discontinuation of perioperative clopidogrel when it is clinically appropriate unless it is strongly indicated at the time of LEB.

Project description:ObjectiveOptimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention.MethodsA regional multicenter registry was queried between 2003 and 2013 for HD patients (N = 689) undergoing open surgical bypass (n = 295) or endovascular intervention (n = 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation.ResultsAmong the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb ischemia and 8% for claudication. Overall survival at 1, 2, and 5 years survival remained low at 60%, 43%, and 21%, respectively. Overall 1- and 2-year AFS was 40% and 17%. Mortality accounted for the primary mode of failure for both open bypass (78%) and endovascular interventions (80%) at two years. Survival, AFS, and freedom from major adverse limb event outcomes did not differ significantly between revascularization techniques. At 2 years, endovascular patency was higher than open bypass (76% vs 26%; 95% confidence interval [CI], 0.28-0.71; P = .02). Multivariate analysis identified age ≥80 years (hazard ratio [HR], 1.9; 95% CI, 1.4-2.5; P < .01), indication of rest pain or tissue loss (HR, 1.8; 95% CI, 1.3-2.6; P < .01), preoperative wheelchair/bedridden status (HR, 1.5; 95% CI, 1.1-2.1; P < .01), coronary artery disease (HR, 1.5; 95% CI, 1.2-1.9; P < .01), and chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8; P = .01) as independent predictors of death. The presence of three or more risk factors resulted in predicted 1-year mortality of 64%.ConclusionsOverall survival and AFS among HD patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings and justifies a prudent approach to patient selection. Focus for improved results should emphasize predictors of survival to better identify those most likely to benefit from revascularization.

Dataset Information

Effect of adjunct femoral endarterectomy in lower extremity bypass on perioperative and 1-year outcomes.

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Effect of adjunct femoral endarterectomy in lower extremity bypass on perioperative and 1-year outcomes.

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