TY - JOUR
T1 - Major adverse limb events and major adverse cardiac events after contemporary lower extremity bypass and infrainguinal endovascular intervention in patients with claudication
AU - Fashandi, Anna Z.
AU - Mehaffey, J. Hunter
AU - Hawkins, Robert B.
AU - Kron, Irving L.
AU - Upchurch, Gilbert R.
AU - Robinson, William P.
N1 - Funding Information:
The National Heart, Lung, and Blood Institute of the National Institutes of Health under Award No. T32 HL007849 supported research reported in this publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Publisher Copyright:
© 2018
PY - 2018/12
Y1 - 2018/12
N2 - Objective: Major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) at 30 days provide standardized metrics for comparison and have been adopted by the Society for Vascular Surgery's objective performance goals for critical limb ischemia. However, MALEs and MACEs have not been widely adopted within the claudication population, and the comparative outcomes after lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) remain unclear. The purpose of this study was to compare MALEs and MACEs after LEB and IEI in a contemporary national cohort and to determine predictors of MALEs and MACEs after revascularization for claudication. Methods: A national data set of LEB and IEI performed for claudication was obtained using National Surgical Quality Improvement Program vascular targeted Participant Use Data Files from 2011 to 2014. Patients were stratified by LEB vs IEI and compared by appropriate univariate analysis. The primary outcomes were MALE (defined as untreated loss of patency, reintervention on the index arterial segment, or amputation of the index limb) and MACE (defined as stroke, myocardial infarction, or death). Multivariable logistic regression was used to identify predictors of MALEs and MACEs. Results: A total of 3925 infrainguinal revascularization procedures (2155 LEB and 1770 IEI) were performed for claudication. There was no difference in 30-day MALEs between LEB and IEI (4.0% vs 3.2%; P =.17). On multivariable logistic regression, predictors of 30-day MALEs included tibial revascularization (odds ratio [OR], 2.2; P <.0001) and prior LEB on the same arterial segment (OR, 1.8; P =.004). LEB had significantly higher 30-day MACEs (2.0% vs 1.0%; P =.01) but similar mortality (0.5% vs 0.4%; P =.6). Predictors of MACEs included LEB vs IEI (OR, 2.1; P =.01), chronic obstructive pulmonary disease (OR, 2.2; P =.01), dialysis dependence (OR, 4.4; P =.003), and diabetes (OR, 1.9; P =.02). Conclusions: In this large national cohort, LEB and IEI for claudication are associated with similar 30-day MALEs. Tibial revascularization and revascularization after prior failed bypass predict MALEs in claudicants and should therefore be undertaken with caution. LEB was associated with more 30-day MACEs but comparable 30-day mortality compared with IEI. Patients with end-stage renal disease, chronic obstructive pulmonary disease, and diabetes are at high risk for MACEs. The risk of 30-day MACEs after LEB should be weighed against the longer term outcomes of LEB vs IEI and conservative management, particularly in these higher risk patients. This analysis helps define contemporary 30-day outcomes after infrainguinal revascularization performed for claudication and serves as a baseline with which the short-term outcomes of future treatments can be compared.
AB - Objective: Major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) at 30 days provide standardized metrics for comparison and have been adopted by the Society for Vascular Surgery's objective performance goals for critical limb ischemia. However, MALEs and MACEs have not been widely adopted within the claudication population, and the comparative outcomes after lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) remain unclear. The purpose of this study was to compare MALEs and MACEs after LEB and IEI in a contemporary national cohort and to determine predictors of MALEs and MACEs after revascularization for claudication. Methods: A national data set of LEB and IEI performed for claudication was obtained using National Surgical Quality Improvement Program vascular targeted Participant Use Data Files from 2011 to 2014. Patients were stratified by LEB vs IEI and compared by appropriate univariate analysis. The primary outcomes were MALE (defined as untreated loss of patency, reintervention on the index arterial segment, or amputation of the index limb) and MACE (defined as stroke, myocardial infarction, or death). Multivariable logistic regression was used to identify predictors of MALEs and MACEs. Results: A total of 3925 infrainguinal revascularization procedures (2155 LEB and 1770 IEI) were performed for claudication. There was no difference in 30-day MALEs between LEB and IEI (4.0% vs 3.2%; P =.17). On multivariable logistic regression, predictors of 30-day MALEs included tibial revascularization (odds ratio [OR], 2.2; P <.0001) and prior LEB on the same arterial segment (OR, 1.8; P =.004). LEB had significantly higher 30-day MACEs (2.0% vs 1.0%; P =.01) but similar mortality (0.5% vs 0.4%; P =.6). Predictors of MACEs included LEB vs IEI (OR, 2.1; P =.01), chronic obstructive pulmonary disease (OR, 2.2; P =.01), dialysis dependence (OR, 4.4; P =.003), and diabetes (OR, 1.9; P =.02). Conclusions: In this large national cohort, LEB and IEI for claudication are associated with similar 30-day MALEs. Tibial revascularization and revascularization after prior failed bypass predict MALEs in claudicants and should therefore be undertaken with caution. LEB was associated with more 30-day MACEs but comparable 30-day mortality compared with IEI. Patients with end-stage renal disease, chronic obstructive pulmonary disease, and diabetes are at high risk for MACEs. The risk of 30-day MACEs after LEB should be weighed against the longer term outcomes of LEB vs IEI and conservative management, particularly in these higher risk patients. This analysis helps define contemporary 30-day outcomes after infrainguinal revascularization performed for claudication and serves as a baseline with which the short-term outcomes of future treatments can be compared.
KW - Claudication
KW - Endovascular
KW - Peripheral bypass surgery
KW - Peripheral vascular disease
KW - Revascularization
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U2 - 10.1016/j.jvs.2018.06.193
DO - 10.1016/j.jvs.2018.06.193
M3 - Article
C2 - 30470369
AN - SCOPUS:85056641144
SN - 0741-5214
VL - 68
SP - 1817
EP - 1823
JO - Journal of vascular surgery
JF - Journal of vascular surgery
IS - 6
ER -