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Objectives-Patients undergoing lower extremity bypass are at high risk for surgical site infections (SSI). We examine lower extremity bypasses by graft origin and body mass index (BMI) classification to analyze differences in postoperative mortality and SSI occurrence. Methods-The 2005-2007National Surgical Quality Improvement Program (NSQIP), a multiinstitutional risk-adjusted database, was queried to compare perioperative mortality (30-day), overall morbidity, and SSIs after lower extremity arterial bypass for peripheral arterial disease. Bypass was stratified by graft origin as aorto-iliac, femoral, or popliteal. Patient demographics, comorbidities, operative, and post-operative occurrences were analyzed.

Background Percutaneous transluminal angioplasty +/− stent (PTA/S) and surgical bypass are both accepted treatments for claudication due to superficial femoral artery (SFA) occlusive disease. However, long-term results comparing these modalities for primary intervention in patients who have had no prior intervention has not been reported. We report our results with three year follow-up. Methods We reviewed all lower extremity bypass procedures at Beth Israel Deaconess Medical Center from 2001–2009 and all PTA/S performed from 2005 through 2009 for claudication. We excluded all limb salvage procedures and included only those that were undergoing their first intervention for claudication due to SFA disease. We recorded patient demographics, comorbidities, perioperative medications, TASC classification, and runoff. Outcomes included complications, restenosis, symptom recurrence, reinterventions, major amputation, and mortality. Results We identified 113 bypass grafts and 105 PTA/S of femoral-popliteal lesions without prior interventions. Bypasses were above the knee in 62% (45% vein) and below the knee in 38% (100% vein). Mean age was 63 (bypass) vs. 69 (PTA/S) (P<.01). Mean length of stay (LOS) was 3.9 vs. 1.2 days (P<.01). Bypass grafts were used less for TASC A (17% vs. 40%, P<.01), and more for TASC C (36% vs. 11%, P<.01) and TASC D (13% vs. 3%, P<.01) lesions. There were no differences in perioperative (2% vs. 0%, NS) or 3 year mortality (9 vs. 8%, NS). Wound infection was higher with bypass (16% vs. 0%, P<.01). None involved grafts. Bypass showed improved freedom from restenosis (73% vs. 42% - 3 years, HR 0.4, 95% CI 0.23–0.71), symptom recurrence (70% and 36% at 3 years, HR 0.37, 95% CI 0.2–0.56), and freedom from symptoms at last follow-up (83% vs. 49%, (HR 0.18, 95% CI 0.08–0.40). There was no difference in freedom from reintervention (77% vs. 66% at 3 years, NS). Multivariable analysis of all patients showed that restenosis was predicted by PTA/S (HR 2.5, 95% CI 1.4–4.4) and TASC D (HR 3.7, 95% CI 3.5–9) lesions. Recurrence of symptoms was similarly predicted by PTA/S (HR 3.0, 95% CI 1.8–5) and TASC D lesions (HR 3.1, 95% CI 1.4–7). Statin use postoperatively was predictive of patency (HR 0.6 95% CI 0.35–0.97) and freedom from recurrent symptoms (HR 0.6 95% CI 0.36–0.93). Conclusions Surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased LOS and wound infection. Statins improved freedom from restenosis and symptom recurrence overall.

Background Prosthetic graft infection is a major complication of peripheral vascular surgery. We investigated our institution’s experience over ten years with bypass grafts involving the femoral artery to determine the incidence and risk factors for prosthetic graft infection. Methods A retrospective cohort single institution review of prosthetic bypass grafts involving the femoral artery from 2001–2010 evaluated patient demographics, body mass index, comorbidities, indications, location of bypass, type of prosthetic material, case urgency, previous ipsilateral bypass or percutaneous interventions; and evaluated the incidence of graft infections, amputations, and mortality. Results There were 496 prosthetic grafts identified with a graft infection rate of 3.8% (n=19) at a mean follow-up of 27 months. Multivariable analysis shows that redo bypass (HR 5.8, 95% CI 2.2–15.0), active infection at time of bypass (HR 5.2, 95% CI 1.9–14.2), female gender (HR 4.5, 95% CI 1.6–12.7), and diabetes mellitus (HR 4.6, 95% CI 1.5–14.3) were significant predictors of graft infection. Graft infection was predictive of major lower extremity amputation (HR 9.8, 95% CI 3.5–27.1) as was preoperative tissue loss (HR 4.7, 95% CI 1.8–11.9). Graft infection did not predict long term mortality, however chronic renal insufficiency (HR 2.3, 95% CI 1.6–3.4), tissue loss (HR 1.4, 95% CI 1.0–1.9), and active infection (HR 2.3, 95% CI 1.6–3.4) did. Infected grafts were removed 79% of the time. Staphylococcus epidermidis (37%) and Methicillin-sensitive Staphylococcus aureus (26%) were the most common pathogens isolated. Conclusions Redo-bypass, female gender, diabetes, and active infection at time of bypass are associated with a higher risk for prosthetic graft infection and major extremity amputation, but do not confer an increased risk of mortality. Autologous vein for lower extremity bypass and endovascular interventions should be considered when feasible in high-risk patients.