Low Ejection Fraction Predicts Shortened Survival in Patients Undergoing Infrainguinal Arterial Reconstruction

The Impact of Ejection Fraction on Major Adverse Limb Events after Lower Extremity Revascularization

BACKGROUND

Peripheral arterial disease (PAD) is commonly associated with coronary artery disease, and echocardiography is frequently performed before lower extremity revascularization (LER). However, the incidence of various echocardiographic findings in patients with PAD and their impact on the outcomes of LER has not been well studied. Reduced ejection fraction (EF) ≤ 40% is associated with increased major adverse limb events (MALE) after LER.

METHODS

The electronic medical records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF. Patient, transthoracic echocardiogram, procedural characteristics, and outcomes were compared between the 2 groups.

RESULTS

A total of 1,114 patients (N = 131, 11.8% with reduced EF) underwent LER between 2013 and 2019. Patients with reduced EF were more likely to be male and have a history of coronary artery disease and heart failure. Furthermore, they were more likely to have diastolic dysfunction with moderate to severe mitral and tricuspid valve regurgitation. Patients with reduced EF were more likely to undergo LER for chronic limb-threatening ischemia, and to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. Lastly, the 2 groups had no difference in overall MALE or major amputation. However, on Kaplan-Meier curves, MALE-free survival was significantly lower for patients with reduced EF. Regression analysis demonstrated that indication and not EF was associated with MALE and MALE-free survival.

CONCLUSIONS

Reduced EF is associated with decreased MALE-free survival for patients with PAD undergoing LER.

The effect of congestive heart failure on perioperative outcomes in patients undergoing lower extremity revascularization

BACKGROUND

As the management of peripheral arterial disease evolves, determining the factors affecting the outcome of lower extremity interventions is important. The presence of peripheral arterial disease is associated with a twofold increase in the prevalence of congestive heart failure (CHF), with reports of increased perioperative complications. This study evaluated CHF as a predictor of acute postoperative complications in patients undergoing lower extremity bypass.

METHODS

The study group consisted of all patients entered in a prospective, multicenter database (American College of Surgeons National Surgical Quality Improvement Program) undergoing infrainguinal bypass (IIB) from 2005 to 2010. Patients with a new diagnosis of CHF ≤30 days before surgery were compared with those without such a diagnosis. Patency rates at 30 days, morbidity, and mortality were compared between groups using a multivariate logistic regression analysis controlling for covariates.

RESULTS

There were 18,645 IIB patients, of which 488 (2.6%) had history of CHF. CHF patients were older and had higher rates of comorbidities than those without CHF. In univariate analysis, IIB graft failure was not significantly different for patients with CHF (6.8%) vs those without (5.2%; P = .13). There was no difference in patency for femoral popliteal grafts (no CHF, 96.5%; CHF, 96.3%; P = .89) or for femoral-tibial grafts (no CHF, 91.9%; CHF, 89.3%; P = .20). However, CHF was significantly associated with postsurgery cardiac events (P = .007), pneumonia, prolonged intubation, reintubation, sepsis, return to the operating room, 30-day mortality, and length of stay >9 days (all P < .0001). After adjusting for covariates associated with CHF, compared with patients without CHF, those with CHF had an 82% higher odds of postoperative pneumonia (95% confidence interval [CI], 13%-94%; P = .014), an 87% increase in the odds of prolonged intubation (95% CI, 16%-201%; P = .011), a 73% increase in the odds of reintubation (95% CI, 12%-167%; P = .014), a 55% increase in the odds of sepsis or septic shock (95% CI, 11%-118%; P = .011), a 29% increase in the odds of returning to the operating room (95% CI, 4%-61%; P = .022), a 121% increase in the odds of 30-day mortality (95% CI, 56%-214%; P < .0001), and a 102% increase in the odds of postsurgery length of stay >9 days (95% CI, 64%-148%; P < .0001).

CONCLUSIONS

Recently diagnosed or exacerbated CHF does not affect acute IIB graft patency. However, CHF may increase the complication rates for perioperative pneumonia, prolonged intubation, reintubation, sepsis, return to the operating room, extended length of stay, and mortality. Therefore, before pursuing lower extremity interventions in patients with a history of CHF, one should incorporate an individualized approach to optimize the success of the revascularization while minimizing medical comorbidities.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A survival prediction model to facilitate clinical decision making

BACKGROUND

An intention-to-treat analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI) due to infrainguinal disease who survived for 2 years after intervention, initial randomization to a bypass surgery (BSX)-first vs balloon angioplasty (BAP)-first revascularization strategy was associated with improvements in subsequent overall survival (OS) and amputation-free survival (AFS) of about 7 and 6 months, respectively. This study explored the value of baseline factors to estimate the likelihood of survival to 2 years for the trial cohort (Cox model) and for individual BASIL trial patients (Weibull model) as an aid to clinical decision making.

METHODS

Of 452 patients presenting to 27 United Kingdom hospitals, 228 were randomly assigned to a BSX-first and 224 to a BAP-first revascularization strategy. Patients were monitored for at least 3 years. Baseline factors affecting the survival of the entire cohort were examined with a multivariate Cox model. The chances of survival at 1 and 2 years for patients with given baseline characteristics were estimated with a Weibull parametric model.

RESULTS

At the end of follow-up, 172 patients (38%) were alive without major limb amputation of the trial leg, and 202 (45%) were alive. Baseline factors that were significant in the Cox model were BASIL randomization stratification group, below knee Bollinger angiogram score, body mass index, age, diabetes, creatinine level, and smoking status. Using these factors to define five equally sized groups, we identified patients with 2-year survival rates of 50% to 90%. The factors that contributed to the Weibull predictive model were age, presence of tissue loss, serum creatinine, number of ankle pressure measurements detectable, maximum ankle pressure measured, a history of myocardial infarction or angina, a history of stroke or transient ischemia attack, below knee Bollinger angiogram score, body mass index, and smoking status.

CONCLUSIONS

Patients in the BASIL trial were at high risk of amputation and death regardless of revascularization strategy. However, baseline factors can be used to stratify those risks. Furthermore, within a parametric Weibull model, certain of these factors can be used to help predict outcomes for individuals. It may thus be possible to define the clinical and anatomic (angiographic) characteristics of SLI patients who are likely-and not likely-to live for >2 years after intervention. Used appropriately in the context of the BASIL trial outcomes, this may aid clinical decision making regarding a BSX- or BAP-first revascularization strategy in SLI patients like those randomized in BASIL.