National trends of hybrid lower extremity revascularization in the ACS-NSQIP database

Abstract

Objectives Despite reports of increasing use of hybrid surgery for lower extremity revascularization in Europe, little is known about the performance of hybrid procedures in the U.S. This study aims to investigate contemporary national trends in frequency and operator distribution of hybrid lower extremity revascularization and compare the perioperative outcomes of independent vascular surgeons and other surgical specialists. We hypothesized that hybrid procedures are increasingly performed, and independent vascular surgeons have superior outcomes compared to other surgical specialists. Methods The 2005–2015 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was used to identify patients undergoing open or hybrid lower extremity revascularization based on Current Procedural Terminology codes. Only patients treated for peripheral artery disease, based on International Classification of Diseases codes-9, were included. A trend of yearly hybrid lower extremity revascularization compared to open lower extremity revascularization was obtained. The most commonly performed hybrid procedure was identified as well as the specialties of the primary operators. Operators were categorized as “independent vascular surgeons” and “other surgeons” if the primary operator was a non-vascular surgeon or a vascular surgeon assisted by a second specialist as part of a team. Patients undergoing this hybrid lower extremity revascularization by independent vascular surgeons were selected and matched (2:1) to the patients who underwent the same procedure by other surgical specialists. Matching was based on age, gender, functional status, American Society of Anesthesiologists classification, transfer status, emergent surgery, and indication. The characteristics and perioperative outcomes of those two groups were compared. Results The overall rate of hybrid procedures increased from 4% in 2005 to 14% in 2015 ( p < 0.0001). During this period, vascular surgeons independently performed 92.9% of all hybrid surgeries, with no significant change in the yearly trend ( p = 0.15). Femoral endarterectomy with retrograde aortoiliac intervention was identified as the most common procedure, accounting for 35.7% and 33.3% of hybrid lower extremity revascularization performed by independent vascular surgeons and other surgeons, respectively. After propensity matching, there were 212 patients treated by independent vascular surgeons and 106 patients treated by other surgeons, with no significant difference in demographics or comorbidities. There was no difference between independent vascular surgeons and other surgeons in mortality (1.4% and 2.8%, respectively, p = 0.30), overall morbidity (19.3% and 18.9% respectively, p = 0.91), and other complications. Conclusion Hybrid lower extremity revascularization for peripheral artery disease has been increasingly used and is performed primarily by independent vascular surgeons. Simple hybrid procedures may be performed safely by vascular surgeons as well as other trained surgical specialists.

Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization

“…Based on Current Procedural Terminology (CPT) codes as previously described, 3 a search of the NSQIP database identified 9430 cases of hybrid LER performed from January 1, 2005, to December 31, 2017. A hybrid case had at least one CPT code for an open procedure and at least one for an endovascular procedure (Appendix 1; available in the online version of the article).…”

“…Each of these 2 groups were then subcategorized based on the anatomical location of endovascular intervention, as previously described. 3 These subcategories included aortoiliac, femoropopliteal, tibial, or multilevel if more than one level was treated.…”

“…The prevalence of peripheral artery disease (PAD) in the United States is rising, and its incidence is expected to continue to increase 1 as the population ages. 2 A hybrid approach to lower extremity revascularization (LER) is growing in popularity, 3 as it is a less invasive revascularization strategy with reduced perioperative morbidity and mortality compared to an open approach. 4–6 Hybrid procedures also allow for the treatment of complex PAD under local anesthesia and/or peripheral nerve block with monitored anesthesia care (MAC).…”