Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization

Abstract

Objective Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment. Methods Patients undergoing non-emergent infrainguinal bypass between 2011 and 2014 were identified in the NSQIP-Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared to those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass to prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes. Results A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs. 7.4%; OR: 1.4, 95% CI: 1.1–1.7) and claudication (5.2% vs. 2.5%; 2.1, 1.3–3.5). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: 1.4, 1.1–1.8; claudication: 2.1, 1.3–3.5), bleeding (CLTI: 1.4, 1.2–1.6; claudication: 1.7, 1.3–2.4), and unplanned reoperation (CLTI: 1.2, 1.0–1.4; claudication: 1.6, 1.1–2.1), whereas major amputation was increased in CLTI patients only (1.3, 1.0–1.8). Perioperative mortality was not significantly different in patients undergoing secondary compared to primary bypass (CLTI: 1.7% vs. 2.2%, P = .22; claudication: 0.4% vs. 0.6%, P = .76). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs. 4.9%; OR: 1.5, 95% CI: 1.0–2.2), but fewer wound infections (7.3% vs. 12%; 0.6, 0.4–0.8) compared to patients with prior endovascular intervention. Conclusions Prior revascularization, in both patients with CLTI and claudication, is associated with worse perioperative outcomes compared to primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of patient selection for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.

Proposed Classification of Incision Complications: Analysis of a Prospective Study on Elective Open Lower-Limb Revascularization

“…In the proposed classification focusing on IC only, a grading was created based on their clinical consequences. After clustering severe IC grades 2-6, it was demonstrated that patient-related factors such as previous vascular surgery [11], anemia [12], and procedure-related factors such as the extent of the surgery [13] indeed had an impact on IC grade. Although a floor effect, which generally indicates the coarseness of a classification system, was observed in the system, it could be expected that the majority of these patients would not suffer from IC.…”

Editor's Choice – Infrainguinal Bypass Following Failed Endovascular Intervention Compared With Primary Bypass: A Systematic Review and Meta-Analysis

“…Five studies did not have information on the type of endovascular intervention performed, as the patients were often referred from peripheral hospitals without accompanying documentation or represented data obtained from multiple institutions. 16,18,20,26,27 The reporting of major adverse limb events (MALE) has been recommended by the Society for Vascular Surgery (SVS) Objective Performance Goals (OPG) Working Group specifically for use in critical trials involving patients with CLI and has been endorsed by both the SVS and the Food and Drug Administration. 32,33 MALE, which includes major above ankle amputation, new bypass, jump graft/interposition graft, graft occlusion, or major re-intervention requiring thrombectomy or thrombolysis, was infrequently reported and inconsistently described in the studies.…”

“…Others have argued that failure of any intervention may result from systemic effects such as latent hypercoagulability, propensity for neointimal hyperplasia, or aggressive atherosclerosis. 18,26,34,35 However, not all the data support this as Nolan et al found that prior contralateral revascularisation was not a risk factor for worse outcomes following subsequent bypass, indicating that local factors (conduit, runoff, distal target) are probably more important. 26 The presence of marginal vein quality at the time of the initial revascularisation has also been implicated, as this may lead an interventionalist to favour an initial endovascular procedure but limits the options for subsequent autogenous bypass.…”

“…Unfortunately, four studies tended to mix these patient populations, which made selecting out these subgroups difficult. 18,21,22,27 No cost analyses were performed, and quality of life reporting was also absent. Further studies should consider evaluating quality of life and cost effectiveness as it impacts the value of intervention in peripheral arterial disease.…”

Increased mortality in octogenarians treated for lifestyle limiting claudication

“…Furthermore, these open surgical procedures could represent a segment of the patient pool that after previous endovascular failures, have now opted for open surgery to treat their LLC [24].…”