Complication registration in patients after peripheral arterial bypass surgery

Unplanned Return to the Operating Room after Elective Oncologic Thoracic Surgery: A Further Quality Indicator in Surgical Oncology

Background: An unplanned return to the operating room (UROR) is defined as a readmission to the operating room because of a complication or an untoward outcome related to the initial surgery. The aim of the present report is to evaluate the role of URORs after elective oncologic thoracic surgery. Methods: In the study, 4012 consecutive patients were enrolled; among them, 71 patients (1.76%) had an unplanned return to the operating room. Age, sex, Charlson comorbidity index, induction treatments, type of the first operation, indication to readmission to the operating room and type of second operation, length of stay, complication after reoperation and outcomes were collected. Results: The mean age was 63.3 (SD: 13.0); there were 53 male patients (74.6%); the type of the first procedure was: lower lobectomy (11.3%), middle lobectomy (1.4%), upper lobectomy (22.5%), metastasectomy (5.6%), extrapleural pneumonectomy (4.2%), pneumonectomy (40.9%), pleural biopsy (5.6%) and other procedures (8.5%). Patients presenting complications after UROR had undergone a significantly longer first procedure (p < 0.02), had a longer length of stay (p < 0.001) and had higher post-operative mortality (p < 0.001). Conclusions: The patients experiencing UROR after elective oncologic thoracic surgery have significantly higher morbidity and mortality rates when compared to standard thoracic surgery. Bronchopleural fistula remains the most lethal complication in patients undergoing UROR.

The Incidence and Causes of Unplanned Reoperations as a Quality Indicator in Pediatric Surgery

Background: Unplanned return to the operating room (uROR) within the 30-day postoperative period can be used as a quality indicator in pediatric surgery. The aim of this study was to investigate and evaluate uROR as a quality indicator. Methods: The case records of pediatric patients who underwent reoperation within the 30-day period after primary surgery, from 1 January 2018 to 31 December 2020 were retrospectively reviewed. The primary outcome of the study was the rate of uROR as a quality indicator in pediatric surgery. Secondary outcomes were indications for primary and secondary surgery, types and management of complications, factors that led to uROR, length of hospital stay, duration of surgery and anesthesia, and starting time of surgery. Results: A total of 3982 surgical procedures, under general anesthesia, were performed during the three-year study period (2018, n = 1432; 2019, n = 1435; 2020, n = 1115). Elective and emergency surgeries were performed in 3032 (76.1%) and 950 (23.9%) patients, respectively. During the study period 19 (0.5%) pediatric patients, with the median age of 11 years (IQR 3, 16), underwent uROR within the 30-day postoperative period. The uROR incidence was 6 (0.4%), 6 (0.4%), and 7 (0.6%) for years 2018, 2019, and 2020, respectively (p = 0.697). The incidence of uROR was significantly higher in males (n = 14; 73.7%) than in females (n = 5; 26.3%) (p = 0.002). The share of unplanned reoperations in studied period was 4.5 times higher in primarily emergency surgeries compared to primarily elective surgeries (p < 0.001). The difference in incidence was 0.9% (95% CI, 0.4–1.4). Out of children that underwent uROR within the 30-day period after elective procedures, 50% had American Society of Anesthesiologists (ASA) score three or higher (p = 0.016). The most common procedure which led to uROR was appendectomy (n = 5, 26.3%) while the errors in surgical technique were the most common cause for uROR (n = 11, 57.9%). Conclusion: Unplanned reoperations within the 30-day period after the initial surgical procedure can be a good quality indicator in pediatric surgery. Risk factors associated with uROR are emergency surgery, male gender, and ASA score ≥3 in elective pediatric surgery.

Outcome of Endovascular Repair of Popliteal Artery Aneurysms using the Supera Stent

PURPOSE

To evaluate the efficacy of endovascular repair of popliteal artery aneurysms (PAAs) with a wire-interwoven nitinol stent.

MATERIALS AND METHODS

This is a prospective, descriptive, and analytical study. From January 2016 to December 2018, 28 consecutive patients (29 lower limbs) were treated for a PAA with the deployment of the Supera stent (Abbott Vascular, Illinois). Twenty-three (79.3%) PAAs were asymptomatic; 6 (20.7%) presented with symptoms. The mean diameter and length of the aneurysm were 26.8 mm (20-40 mm) and 47.1 mm (23-145 mm) respectively. The primary endpoint was the prevention of embolic symptoms. The secondary endpoints were aneurysm exclusion, aneurysm diameter decrease, freedom from reintervention, and preservation of preoperative runoff vessels.

RESULTS

Technical success was 100%, with a median of 2.4 run-off vessels at completion angiography, without any loss of run-off vessels. A double Supera stent was deployed in 10 cases. At completion angiography, a median of 2.4 runoff vessels were present, without any loss of runoff vessels. The mean follow-up time was 24.3 (12-35) months. Primary endpoints were reached in 100% of the cases and vessels run off was preserved in all cases. In 2 PAAs, complete sac thrombosis was witnessed at 6-month follow-up, while at 12-month follow-up, it was seen in 10 of 29 (34.4%) limbs. In all the other cases the diameter of the aneurysm remained stable, with a freedom from sac enlargement of 100%. No fractures or stent thromboses were detected.

CONCLUSIONS

For endovascular repair of PAAs, the use of a thick interwoven-wire stent, that could work like a multilayer flow modulator showed encouraging mid-term results with no cases of stent fracture, occlusion or aneurysm increase.

Modeling acute blood flow responses to a major arterial occlusion

OBJECTIVE

The development of earlier and less invasive treatments for peripheral arterial disease requires a more complete understanding of vascular responses following a major arterial occlusion. A mechanistic model of the vasculature of the rat hindlimb is developed to predict acute (immediate) changes in vessel diameters and smooth muscle tone following femoral arterial occlusion.

METHODS

Vascular responses of collateral arteries and distal arterioles to changes in pressure, shear stress, and metabolism are assessed before and after occlusion. The effects of exercise are also simulated and compared with venous flow measurements from WKY rats.

RESULTS

The model identifies collateral arteries as the primary contributors to flow compensation following occlusion. Increasing the number of capillaries has minimal effect on blood flow while increasing the number of collateral arteries significantly increases flow, since the primary site of resistance shifts upstream to the collateral arteries following occlusion. Despite significant collateral dilation, calf flow remains below pre-occlusion levels and the deficit becomes more severe with increased activity.

CONCLUSIONS

Although unable to compensate fully for an occlusion, the model demonstrates the importance of the shear response in collateral arteries and the metabolic response in the distal microcirculation in acute adaptations to a major arterial occlusion.

Not All Patients with Critical Limb Ischaemia Require Revascularisation

OBJECTIVES

International guidelines recommend revascularisation as the preferred treatment for patients with critical limb ischaemia (CLI). Most contemporary research focuses on the outcome of invasive procedures for CLI, but little is known about the outcome of conservative management. Amputation free survival (AFS) and overall survival (OS) was investigated in patients with CLI who did or did not receive revascularisation, and characteristics associated with clinical outcomes were explored.

METHODS

This was a retrospective cohort study of consecutive patients with chronic CLI between 2010 and 2014 in a Dutch university hospital. CLI was defined as the presence of ischaemic rest pain or tissue loss in conjunction with an absolute systolic ankle pressure < 50 mmHg or a toe pressure < 30 mmHg. Patients were divided into invasive (revascularisation within 6 weeks), deferred invasive (revascularisation after 6 weeks), or permanently conservative treatment groups. Univariable and multivariable survival analyses were used to identify factors associated with AFS and OS.

RESULTS

The majority (66.7%; N = 96) of the identified 144 patients with CLI (mean age 71.2 years; median follow-up 99 weeks) underwent revascularisation within 6 weeks of diagnosis. Deferred invasive treatment was provided in 18.1% (N = 26) patients and 22 patients (15.3%) were treated permanently conservatively. AFS and OS did not differ significantly between the three groups (Breslow-Wilcoxon p = .16 for AFS and p = .09 for OS). Age, chronic obstructive pulmonary disease (COPD), and heart disease were significant independent predictors of AFS. Age, COPD, and hypertension were significant independent predictors of OS. Treatment was not a significant predictor of either AFS or OS.

CONCLUSIONS

Not all patients with CLI require revascularisation to achieve an AFS that is similar to patients undergoing revascularisation, although the efficacy of conservative versus invasive treatment in CLI patients is still unclear. Further prospective studies should determine subgroups of patients in whom revascularisation may be omitted.

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.

Haemodynamic optimisation in lower limb arterial surgery: room for improvement?

BACKGROUND

Goal-directed therapy has been proposed to improve outcome in high-risk surgery patients. The aim of this study was to investigate whether individualised goal-directed therapy targeting stroke volume and oxygen delivery could reduce the number of patients with post-operative complications and shorten hospital length of stay after open elective lower limb arterial surgery.

METHODS

Forty patients scheduled for open elective lower limb arterial surgery were prospectively randomised. The LiDCO™plus system was used for haemodynamic monitoring. In the intervention group, stroke volume index was optimised by administering 250 ml aliquots of colloid intraoperatively and during the first 6 h post-operatively. Following surgery, fluid optimisation was supplemented with dobutamine, if necessary, targeting an oxygen delivery index level ≥ 600 ml/min(/) m(2) in the intervention group. Central haemodynamic data were blinded in control patients. Patients were followed up after 30 days.

RESULTS

In the intervention group, stroke volume index, and cardiac index were higher throughout the treatment period (45 ± 10 vs. 41 ± 10 ml/m(2), P < 0.001, and 3.19 ± 0.73 vs. 2.77 ± 0.76 l/min(/) m(2), P < 0.001, respectively) as well as post-operative oxygen delivery index (527 ± 120 vs. 431 ± 130 ml/min(/) m(2), P < 0.001). In the same group, 5/20 patients had one or more complications vs. 11/20 in the control group (P = 0.05). After adjusting for pre-operative and intraoperative differences, the odds ratio for ≥ 1 complications was 0.18 (0.04-0.85) in the intervention group (P = 0.03). The median length of hospital stay did not differ between groups.

CONCLUSION

Perioperative individualised goal-directed therapy may reduce post-operative complications in open elective lower limb arterial surgery.

A prospective randomized study comparing fibrin sealant to manual compression for the treatment of anastomotic suture-hole bleeding in expanded polytetrafluoroethylene grafts

OBJECTIVE

The ideal hemostatic agent for treatment of suture-line bleeding at vascular anastomoses has not yet been established. This study evaluated whether the use of a fibrin sealant containing 500 IU/mL thrombin and synthetic aprotinin (FS; marketed in the United States under the name TISSEEL) is beneficial for treatment of challenging suture-line bleeding at vascular anastomoses of expanded polytetrafluoroethylene (ePTFE) grafts, including those further complicated by concomitant antiplatelet therapies.

METHODS

Over a 1-year period ending in 2010, ePTFE graft prostheses, including arterio-arterial bypasses and arteriovenous shunts, were placed in 140 patients who experienced suture-line bleeding that required treatment after completion of anastomotic suturing. Across 24 US study sites, 70 patients were randomized and treated with FS and 70 with manual compression (control). The primary end point was the proportion of patients who achieved hemostasis at the study suture line at 4 minutes after start of application of FS or positioning of surgical gauze pads onto the study suture line.

RESULTS

There was a statistically significant difference in the comparison of hemostasis rates at the study suture line at 4 minutes between FS (62.9%) and control (31.4%) patients (P < .0001), which was the primary end point. Similarly, hemostasis rates in the subgroup of patients on antiplatelet therapies were 64.7% (FS group) and 28.2% (control group). When analyzed by bleeding severity, the hemostatic advantage of FS over control at 4 minutes was similar (27.8% absolute improvement for moderate bleeding vs 32.8% for severe bleeding). Logistic regression analysis (accounting for gender, age, intervention type, bleeding severity, blood pressure, heparin coating of ePTFE graft, and antiplatelet therapies) found a statistically significant treatment effect in the odds ratio (OR) of meeting the primary end point between treatment groups (OR, 6.73; P < .0001), as well as statistically significant effects for intervention type (OR, 0.25; P = .0055) and bleeding severity (OR, 2.59; P = .0209). The safety profile of FS was excellent as indicated by the lack of any related serious adverse events.

CONCLUSIONS

The findings from this phase 3 study confirmed that FS is safe and its efficacy is superior to manual compression for hemostasis in patients with peripheral vascular ePTFE grafts. The data also suggest that FS promotes hemostasis independently of the patient's own coagulation system, as shown in a representative population of patients with vascular disease under single- or dual-antiplatelet therapies.

Treatment for peripheral arterial obstructive disease: An appraisal of the economic outcome of complications

OBJECTIVE

This study determined the average estimated total costs after treatment for peripheral arterial occlusive disease (PAOD) and evaluated the effect of postoperative complications and their consequences for the total costs.

METHODS

Cost data on all admissions involving treatment for PAOD from January 2007 until July 2007 were collected. A prospective analysis was made using the patient-related risk factor and comorbidity (Society for Vascular Surgery/International Society of Cardiovascular Surgeons) classification, primary and secondary treatment, and prospectively registered complications. At admission, patients without complications were placed in group A, and those with complications were in group B. Prospectively registered complications were divided into patient management (I), surgical technique (II), patient's disease (III), and outside surgical department (IV). The consequences of these were divided into minor complication, no long-term consequence (1A), additional medication or transfusion (1B), surgical reoperation (2A), prolonged hospital stay (2B), irreversible physical damage (3), and death (4). The main outcome measures were total costs of patients and costs per patient (PP), with or without the presence of complications, cost of complications and costs per complication (PC), and the costs of their consequences calculated in euros (euro).

RESULTS

Ninety patients (mean age, 71.4 years; 59% men) were included. Group B patients had a significantly higher American Society of Anesthesiologists (4) and Fontaine (3) classification and more secondary procedures. Total costs were euro 1,716,852: group A, euro 512,811 (PP euro 12,820); and group B, euro 1,204,042 (PP euro 24,081). The costs of the 115 complications were euro 568,500 (PC euro 4943). Split by the cause of the complication, costs were I, euro 95,924 (PC euro 2998); II, euro 163,137 (PC euro 8157); III, euro 289,578 (PC euro 5171); and IV, euro 19,861 (PC euro 2837). The increase of costs in group B was mainly caused by additional medication or transfusion (1B) euro 348,293 (61.3%), a surgical reoperation (2A) euro 118,054 (20.8%), or prolonged hospital stay (2B) euro 60,451 (10.6%). Patients who died caused 23% of the total costs.

CONCLUSION

Complications cause an increase of the average estimated total costs in the treatment for peripheral arterial occlusive disease and are responsible for 33% of these total costs. The most expensive complications were errors in surgical technique and patient's disease, resulting in surgical reoperation or additional medication, or both, or transfusion, the two most expensive consequences.

The incidence of unplanned returns to the operating room after peripheral arterial bypass surgery and its value as indicator of quality of care

BACKGROUND

In recent years, a growing need has arisen to define possible indicators of quality of care.

METHODS

To examine whether unplanned return to the operating room within 30 days after the initial procedure could serve as an indicator to assess quality of care in peripheral arterial bypass surgery, all bypass procedures performed between January 1996 and January 2004 were evaluated. Data were obtained from a prospectively kept hospital registration system.

RESULTS

A total of 607 consecutive procedures were performed in 468 patients. The overall unexpected return to the operating room rate was 11.2%. Patients requiring peripheral arterial bypass surgery for critical ischemia with gangrene were significantly more at risk for an unplanned reoperation (20.2%) than patients with disabling claudication (2.1%) (P < .0001). Patients requiring femorocrural bypass surgery (24.2%) were also more at risk than patients with a suprageniculate bypass procedure (5.2%) (P < .0001).

CONCLUSIONS

Unplanned return to the operating room within 30 days after the initial operation can be a useful indicator of quality of care after peripheral arterial bypass surgery. However, a prospective, well-defined registration system to collect all data is essential. Furthermore, the severity of peripheral arterial disease and the type of procedure performed should be taken into account.

Infrainguinal occlusive disease: endovascular intervention is the first line therapy

The preferred treatment of infrainguinal occlusive disease at many centers has undergone a paradigm shift from open bypass to endovascular intervention as the first-line therapeutic modality. Our own experience supports a percutaneous first approach. Though skeptics initially cited lower primary patency rates for angioplasty when compared with bypass, more recent studies have shown favorable secondary patencies nearly challenging that of bypass. The need for repeat endovascular intervention to achieve a higher secondary patency is not a major deterring factor because most procedures are associated with a short hospital stay and a relatively low rate of complication. The risk is low and this complex group of patients can tolerate minimally invasive reinterventions well. The longevity of this patient population is generally short, and consequently less durable outcomes may be acceptable. Patients do require close follow-up with early treatment of restenosis. However, there appears to be a decreased cost of intervention when compared with surgery. Furthermore, the functional outcomes and quality of life appear more optimal with angioplasty. The concern that angioplasty may preclude future surgical intervention by damaging the distal bypass target has not borne true. It is unusual for a percutaneous therapy to eliminate the possibility of a bypass should the endovascular approach not be successful. Finally, advances in techniques and devices may herald improved outcomes because percutaneous therapy in the periphery is still in the early stages of its maturation. Thus, endovascular intervention has become an established, as well as a developed method for treating peripheral arterial occlusive disease and should be considered the first-line therapeutic modality for patients with.lower extremity vascular disease.

Shifting paradigms in the treatment of lower extremity vascular disease: a report of 1000 percutaneous interventions

OBJECTIVES

Catheter-based revascularization has emerged as an alternative to surgical bypass for lower extremity vascular disease and is a frequently used tool in the armamentarium of the vascular surgeon. In this study we report contemporary outcomes of 1000 percutaneous infra-inguinal interventions performed by a single vascular surgery division.

METHODS

We evaluated a prospectively maintained database of 1000 consecutive percutaneous infra-inguinal interventions between 2001 and 2006 performed for claudication (46.3%) or limb-threatening ischemia (52.7%; rest pain in 27.7% and tissue loss in 72.3%). Treatments included angioplasty with or without stenting, laser angioplasty, and atherectomy of the femoral, popliteal, and tibial vessels.

RESULTS

Mean age was 71.4 years and 57.3% were male; comorbidities included hypertension (84%), coronary artery disease (51%), diabetes (58%), tobacco use (52%), and chronic renal insufficiency (39%). Overall 30-day mortality was 0.5%. Two-year primary and secondary patencies and rate of amputation were 62.4%, 79.3%, and 0.5%, respectively, for patients with claudication. Two-year primary and secondary patencies and limb salvage rates were 37.4%, 55.4%, and 79.3% for patients with limb-threatening ischemia. By multivariable Cox PH modeling, limb-threat as procedural indication (P < 0.0001), diabetes (P = 0.003), hypercholesterolemia (P = 0.001), coronary artery disease (P = 0.047), and Transatlantic Inter-Society Consensus D lesion complexity (P = 0.050) were independent predictors of recurrent disease. For patients that developed recurrent disease, 7.5% required no further intervention, 60.3% underwent successful percutaneous reintervention, 11.7% underwent bypass and 20.5% underwent amputation. Patency rates were identical for the initial procedure and subsequent reinterventions (P = 0.97).

CONCLUSION

Percutaneous therapy for peripheral vascular disease is associated with minimal mortality and can achieve 2-year secondary patency rates of nearly 80% in patients with claudication. Although patency is diminished in patients with limb-threat, limb-salvage rates remain reasonable at close to 80% at 2 years. Percutaneous infra-inguinal revascularization carries a low risk of morbidity and mortality, and should be considered first-line therapy in patients with chronic lower extremity ischemia.

Nosocomial Infections after Peripheral Arterial Bypass Surgery

BACKGROUND

Hospital-acquired infections account for a substantial increase in morbidity and mortality. This prospective, single-center observational study was conducted to assess the incidence and analyze the risk factors of nosocomial infection after peripheral arterial bypass surgery.

METHODS

The incidence of nosocomial infections was registered in all patients undergoing peripheral arterial bypass surgery from January 1996 until December 2004, and risk factors for the development of a nosocomial infection were analyzed.

RESULTS

A total of 67 infections were diagnosed in association with 607 procedures, yielding an infection ratio of 10.0%. Surgical site infection was the most common (55.2%), followed by urinary tract infection (16.4%), pneumonia (14.9%) and bacteremia (10.4%). Staphylococcus aureus was the most commonly found isolate in surgical site infections (48.6%) and in bacteremia (42.9%). Age, the use of corticosteroids (p = 0.02), and critical ischemia with tissue loss (p = 0.009) could be identified as risk factors for the development of a nosocomial infection. Blood transfusion was a postoperative risk factor for nosocomial infection (p < .0001). Nosocomial infection was associated with a prolonged hospital stay (p < .0001).

CONCLUSIONS

This study provides a detailed description of the incidence and risk factors regarding nosocomial infection. More detailed studies are necessary to develop strategies to diminish the occurrence of nosocomial infection.

Can the incidence of unplanned reoperations be used as an indicator of quality of care in surgery?

The incidence of unplanned reoperations could potentially be used as an indicator of quality of care. This study provided insight into the incidence of unplanned reoperations in a surgical department and added to the discussion of the value of unplanned reoperations as an indicator of quality of care. Between January 1996 and December 2003, all unplanned reoperations were entered prospectively into a complication registration system. The number of unplanned reoperations was 447 (1.7%). Unplanned reoperations occurred frequently after vascular (6.5%) and colon surgery (5.7%) and were caused predominantly by errors in surgical technique (70%) and patients' comorbidities (21%). Mortality for patients requiring unplanned reoperations was significantly higher than for patients who did not require reoperations (10.3% versus 4.0%). Unplanned reoperation rates can be an indicator of quality of care. However, a prospective, well-defined registry is essential to ensure an accurate assessment of the quality of care provided.

Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: A contemporary series

BACKGROUND

Percutaneous endovascular therapy is becoming a primary option for managing infrainguinal occlusive disease. This study examined the results of femoropopliteal percutaneous transluminal angioplasty (PTA) with intermediate (mean, 24 months) follow-up in a contemporary series of patients presenting with critical limb ischemia or claudication.

METHODS

Femoropopliteal PTA was performed on 238 consecutive limbs (208 patients) from January 2002 to July 2004. Study end points, including primary patency, assisted patency, and limb salvage (Society of Vascular Surgery reporting standards), were assessed by Kaplan-Meier life-table analysis, and factors predictive of hemodynamic or clinical failure, or both, were evaluated by univariate and multivariate methods.

RESULTS

Clinical and demographic features included a mean age, 72 years; male (62%); critical limb ischemia (46%); diabetes mellitus (49%); and renal insufficiency (creatinine >or= 1.5 mg/dL) (29%). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A (11%), B (43%), C (41%), and D (5%). PTA was confined to the femoropopliteal segment in 77 patients (33%), and 161 (67%) underwent concurrent interventions in other anatomic locations. Femoropopliteal interventions included angioplasty only in 183 (78%), and the remaining 53 (22%) received at least one stent. Technical success was achieved in 97% of patients, with no deaths and a major morbidity rate of 3%. The 36-month actuarial primary patency was 54.3%, and assisted patency was 92.6% (37 peripheral reinterventions), resulting in a limb preservation rate of 95.4% in all patients regardless of clinical presentation. Interval conversion to bypass surgery occurred in 19 patients (8%). Comparison between critical limb ischemia and claudication revealed a primary patency of 40.8% vs 64.8%, assisted patency of 93.8% vs 92.6%, and limb salvage of 89.7% vs 100%, respectively. Negative predictors of primary patency determined by multivariate analysis included history of congestive heart failure (P = .02) and TASC C/D (P = .02). However, further evaluation of TASC C/D vs A/B revealed an assisted patency of 89.7% vs 94.3% (P = .37) and limb salvage of 94.3% vs 96.4% (P = .58).

CONCLUSIONS

Femoropopliteal PTA can be performed with a low perioperative morbidity and mortality. Intermediate primary patency is directly related to TASC classification. Although secondary intervention is often necessary to maintain patency in TASC C/D lesions, these data suggest that it would be appropriate to use PTA as initial therapy for chronic femoropopliteal occlusive disease regardless of clinical classification at presentation or TASC category of lesion severity.

Contemporary Series of Morbidity and Mortality after Lower Limb Amputation

OBJECTIVES

This study was performed in order to assess morbidity and mortality associated with major lower extremity amputation according to an extensive complication registration system used in our hospital.

METHODS

All consecutive patients who underwent lower limb major extremity amputation were included from January 1996 until December 2002. Complications were prospectively registered according to our standard complication registration system.

RESULTS

In 97 patients 122 amputations were performed including 45 above (AKA) and 77 below (BKA) knee amputations. The conversion rate from below to above knee amputation was 14%. In 65 patients 107 complications occurred (67%). The incidence of wound infection was 10% in the BKA group and 2% in the AKA group. The most frequently reported complications were pressure sores (8%) or originating from the urinary tract (13%). The hospital mortality for BKA was 9% and for AKA 18%. Long-term survival was 62% at 1 year, 50% at 2 years and 29% at 5 years.

CONCLUSIONS

An extensive registration system provides us with a detailed insight into the incidence, consequence and cause of complications. Major lower extremity amputations are still associated with considerable morbidity and mortality.

Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study

OBJECTIVE

To evaluate whether hyperglycaemia in the first 48 h after infrainguinal vascular surgery is a risk factor for post-operative infection, independent from factors associated with insulin resistance and surgical stress.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

Patients who underwent infrainguinal vascular surgery in our hospital between March 1998 and March 2003 were included. Glucose values until 48 h after surgery were retrieved from laboratory reports. Post-operative infections, treated with antibiotics, during hospital stay were scored until 30 days after surgery. Data were analysed with univariate and multivariate logistic regression analyses.

RESULTS

At least one post-operative glucose value was retrieved for 211/275 (77%) patients. The incidence of post-operative infections was 84/275 (31%). When corrected for factors associated with insulin resistance and surgical stress, post-operative glucose levels were found to be an independent risk factor for post-operative infections (odds ratio top quartile versus lowest quartile: 5.1; 95% confidence interval: 1.6-17.1; P=0.007).

CONCLUSION

Post-operative glucose levels appear to be an independent risk factor for infections after infrainguinal vascular surgery. This finding requires confirmation in a prospective study.