Long-term outcomes after lower extremity bypass in the actively smoking claudicant

An assessment of the BEST-CLI Trial demonstrates that infrainguinal bypass offers a potential advantage in smokers with chronic limb-threatening ischemia

OBJECTIVE

Smoking is an established risk factor in many pathologies of the cardiovascular system. The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial affords an in-depth evaluation into the effect of smoking on patients with chronic limb-threatening ischemia (CLTI). BEST-CLI's prospective, randomized design evaluated outcomes in patients suitable for both open or endovascular intervention and randomized patients between endovascular intervention (ENDO) vs open surgical bypass (OPEN). The outcomes are reported stratified by smoking status.

METHODS

In the BEST-CLI trial, patients were stratified by current smokers (CS) and nonsmokers (NS), which included both previous smokers or never smokers. Endpoints at 4 years include the primary trial outcomes (major adverse limb events [MALE] or all-cause death), as well as above-ankle amputation, all-cause death, major or minor reintervention, major adverse cardiac events (MACE), MALE, and MALE or perioperative death. Multivariable Cox regression models were created with NS serving as the reference group.

RESULTS

Patients received bypass using single-segment saphenous vein (n = 621), bypass using alternative conduits (n = 236), or endovascular procedures (n = 923). There were 641 CSs and 1137 NSs. In the combined cohort of patients receiving ENDO or OPEN, CS status was associated with a higher rate of MALE (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.05-1.55; P = .02) but a lower rate of all-cause death (HR, 0.80; 95% CI, 0.66-0.97; P = .02) when compared with NS status. In the OPEN group, CSs had a lower rate of all-cause death (HR, 0.74; 95% CI, 0.56-0.98; P = .04) than NSs and no significant difference in MALE (HR, 1.18; 95% CI, 0.85-1.63; P = .34). In the ENDO group, CSs had a higher rate of above-ankle amputation (HR, 1.51; 95% CI, 1.04-2.19; P = .03) and MALE (HR, 1.33; 95% CI, 1.04-1.69; P = .02). Additionally, on subset analysis of the entire cohort, it was found that, when comparing prior smokers to never-smokers, there was a 24% increase in reintervention (P = .05), and when comparing CSs to never smokers, there was a 27% increase in reintervention (P = .04).

CONCLUSIONS

CSs had worse limb outcomes in the BEST-CLI trial. CSs undergoing endovascular revascularization had higher rates of MALE and above-ankle amputations following adjustment. Current smoking did not impact MALE in patients with CLTI undergoing open surgical bypass.

The Effect of Smoking Cessation on Outcomes of Thoracic Endovascular Aortic Repair

BACKGROUND

Smoking is known to be a strong predictive factor for deleterious outcomes after surgical procedures; however, there is limited research that has focused on the effect of smoking cessation on the outcomes of thoracic endovascular aortic repair (TEVAR). Using a multi-institutional database, we aimed to determine if smoking cessation was associated with improved outcomes following TEVAR.

METHODS

Patients undergoing thoracic endovascular aortic repair in Vascular Quality Initiative from 2013 to 2023 were categorized into three groups: never smokers (NS), those who quit smoking (QS) >30 days prior, or current smokers (CS) who quit ≤30 days prior or never quit. Primary outcomes include perioperative death, stroke, myocardial infarction, and spinal cord ischemia. Secondary outcomes include cardiac and pulmonary complications, prolonged length of stay (≥2 days), and leg and bowel ischemia. A multivariate logistic regression analysis was conducted to control for confounding variables. A subanalysis was performed to determine the impact of smoking cessation by TEVAR indication: thoracic aortic aneurysm and type B aortic dissection. Long-term outcomes were analyzed using Kaplan-Meier and Cox regression models.

RESULTS

There were 1,435 (30.4%) patients in the NS group, 1,867 patients (39.6%) in the QS group, and 1,412 (30.0%) patients in the CS group. Patients in the QS group were older and had the highest rate of comorbidities including diabetes, myocardial infarction, and congestive heart failure. Multivariate analysis revealed that the CS group had no significant difference in odds of perioperative death (adjusted odds ratio (aOR) = 1.40; [95% confidence interval (CI): 0.86-2.25]; P = 0.2), stroke (aOR = 1.19; [95% CI: 0.71-1.99]; P = 0.5), myocardial infarction (aOR = 1.54; [95% CI: 0.74-3.17]; P = 0.2), and spinal cord ischemia (aOR = 1.52; [95% CI: 0.95-2.45]; P = 0.083) compared to QS. However, CS had increased odds of leg ischemia (aOR = 3.75; [95% CI: 1.79-8.25]; P < 0.001) and 1-year mortality (adjusted hazard ratio (aHR) = 1.34; [95% CI: 1.01-1.79] P = 0.042) compared to QS. When stratified by indication, thoracic aortic aneurysm CS compared to QS had higher rates of leg ischemia (aOR = 3.46; [95% CI: 1.28-10.1]; P = 0.017) and 3-year mortality (aHR = 1.44; [95% CI: 1.02-2.03]; P = 0.036). Type B aortic dissection CS had no significant difference in postoperative outcomes but showed increased odds of 1-year mortality (aHR = 2.51; [95% CI: 1.17-5.54]; P = 0.02) compared to QS.

CONCLUSION

CS had similar risk of death, stroke, myocardial infarction, and spinal cord ischemia when compared to QS, regardless of indication. However, there was a significantly increased risk of 1-year and 3-year mortality for CS which was not seen with QS when compared to NS. These results suggest surgery should not be delayed for smoking cessation; however, smoking cessation counseling may be important for improving long-term outcomes.

The effect of preoperative smoking status on carotid endarterectomy outcomes in asymptomatic patients

OBJECTIVE

The current medical landscape lacks comprehensive data regarding the impact of preoperative smoking status on both short and long-term outcomes for patients undergoing carotid endarterectomy (CEA). This study seeks to elucidate the influence of smoking cessation on in-hospital and long-term outcomes in this patient population.

METHODS

Data were collected from the Vascular Quality Initiative for all asymptomatic patients who underwent CEA from 2016 to 2023. Outcomes were compared across three different smoking status groups: never smoke (NS), current smoker (CS), and quit >30 days ago. Our primary outcomes included in-hospital stroke, death, and myocardial infarction. Secondary outcomes included 1-year and 3-year death. We used inverse probability of treatment weighting to balance the following preoperative factors: age, gender, race, ethnicity, body mass index, diabetes, coronary artery disease, prior congestive heart failure, renal dysfunction, chronic obstructive pulmonary disease, hypertension, prior coronary artery bypass grafting/percutaneous coronary intervention, prior CEA/carotid artery stenting, degree of stenosis, urgency, anesthesia type, and medications.

RESULTS

The final analysis included 85,237 CEA cases with 22,343 NS (26.2%), 41,731 who quit >30 days ago (49.0%) , and 21,163 CS (24.8%). Notably, NS tended to be older and more likely to be female. In contrast, patients who quit >30 days ago were more likely to have comorbidities, including obesity, coronary artery disease, prior congestive heart failure, and CKD, as well as prior procedures. Patients who are CS were more likely to have chronic obstructive pulmonary disease and stenosis of >80%. After inverse probability of treatment weighting, we found no statistical difference for in-hospital stroke, death, myocardial infarction outcomes across the three groups. However, the long-term outcomes revealed quit >30 days ago and CS compared with NS had higher odds of 1-year death (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.5; P < .001; OR, 1.4; 95% CI, 1.2-1.6; P < .001) and 3-year death (OR, 1.5; 95% CI, 1.3-1.6; P < .001; OR, 1.5; 95% CI, 1.4-1.7; P < .001), respectively. There was no significant difference in midterm mortality outcomes between those who quit >30 days ago and CS.

CONCLUSIONS

In this large national study, we found that smoking status did not emerge as a substantial determinant of adverse short-term outcomes for asymptomatic patients undergoing CEA. However, smoking did adversely affect midterm mortality in these patients. In light of these findings, our study suggests that delaying CEA for smokers may not be warranted. It is crucial to recognize that the complex relationship between smoking and surgical outcomes requires further exploration and validation through additional prospective studies.

Mortality and amputation outcomes of infrainguinal bypass versus endovascular therapy based on body mass index

OBJECTIVE

Obese patients have higher rates of cardiovascular disease and associated risk factors, but lower rates of peripheral artery disease and better outcomes after revascularization. This results in an obesity paradox, where obese patients have the lowest risk of adverse outcomes following treatment, while underweight and morbidly obese patients are at the highest risk. No previous studies have compared outcomes of endovascular vs open bypass within each body mass index (BMI) group. Our study aims to compare outcomes of peripheral vascular intervention (PVI) with infrainguinal bypass (IIB) stratified by patient BMI group.

METHODS

The Vascular Quality Initiative database was queried for patients presenting with claudication or chronic limb-threatening ischemia (CLTI) undergoing PVI or IIB (using the great saphenous vein) from 2012 to 2023. Patients were categorized into five BMI groups: underweight (BMI ≤ 18.5 kg/m2), normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), obese (BMI 30.0-39.9 kg/m2), and morbidly obese (BMI 40.0-49.9 kg/m2). Multivariable logistic compared 30-day mortality for IIB vs PVI within each BMI group. Cox regression, Kaplan-Meier survival analysis, and log-rank tests assessed 1-year mortality, 1-year amputation, and 1-year amputation/death rates. Subgroup analysis was performed by indication (CLTI or claudication).

RESULTS

There were 118,622 patients meeting the study criteria, including 3542 underweight (3%), 33,009 normal weight (28%), 40,582 overweight (34%), 36,494 obese (31%), and 4995 morbidly obese (4%) patients. There was no significant difference in 30-day mortality between PVI and IIB in underweight patients. IIB was associated with lower 30-day mortality in normal weight (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.33-0.62) and obese (aOR, 0.78; 95% CI, 0.24-0.75) patients. Bypass was associated with lower 1-year mortality in all BMI groups, except for morbidly obese patients. It was also associated with a lower risk of 1-year amputation for normal weight (aOR, 0.82; 95% CI, 0.70-0.96) and a lower risk of 1-year amputation/death for normal weight, overweight, and obese patients. Among CLTI patients, bypass was associated with decreased 30-day and 1-year mortality risks in all but underweight patients.

CONCLUSIONS

This study shows significant differences in 30-day and 1-year mortality, amputation, and amputation/death rates between PVI and IIB based on BMI depending on patient BMI. Bypass was associated with better outcomes for normal weight and obese patients, and for CLTI patients across most BMI groups. This finding suggests a long-term survival benefit after IIB compared with PVI, an effect potentiated by symptom severity, except for patients otherwise at a higher operative risk regardless of procedure choice.

Risk score for one-year mortality following emergent infra-inguinal bypass

OBJECTIVE

The purpose of this study is to identify variables that place patients at higher risk for mortality following emergent infra-inguinal bypass. Further, this study will create a risk score for mortality following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management.

METHODS

In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated: 30 day mortality following emergent infra-inguinal bypass; and 1-year mortality following emergent infra-inguinal bypass. The first step in analysis was univariable analysis for each outcome with χ2 analysis for categorical variables and Student t-test for comparison of means of ordinal variables. Next, binary logistic regression analysis was performed for each outcome utilizing variables that achieved a univariable P value ≤ .10. Factors with a multivariable P value ≤ .05 were included in the risk score, and points were weighted and assigned based on the respective regression beta-coefficient in the multivariable regression.

RESULTS

Variables with a significant multivariable association (P < .05) with 1-year mortality were: increasing age; body mass index less than 20 kg/m2; coronary artery disease; active hemodialysis at time of presentation; anemia at admission; prosthetic conduit for emergent bypass; postoperative myocardial infarction; postoperative acute renal insufficiency; perioperative stroke; baseline non-ambulatory status; new onset hemodialysis requirement perioperatively; need for bypass revision or thrombectomy during index admission; lack of statin prescription at discharge; lack of antiplatelet medication at discharge; and, lack of anticoagulation at time of hospital discharge. Pertinent negatives included all sociodemographic variables including rural living status, insurance status, and Area Deprivation Index home area. The risk score achieved an area under the curve of 0.820, and regression analysis of the risk score achieved an overall accuracy of 87.9% with 97.7% accuracy in predicting survival, indicating the model performs better in determining which patients will survive rather than precisely determining who will experience 1-year mortality.

CONCLUSIONS

Discharge medications are the primary modifiable variable impacting survival after emergent infra-inguinal bypass surgery. In the absence of contraindication, all these patients should be discharged on antiplatelet, statin, and anticoagulant medications after emergent infra-inguinal bypass as they significantly enhance survival. Social determinants of health do not impact survival among patients treated with emergent infra-inguinal bypass at Vascular Quality Initiative centers. A risk score for mortality at 1 year after emergent infra-inguinal bypass has been created that has excellent accuracy.

The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease

BACKGROUND

Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages.

METHODS

This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD.

RESULTS

CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates.

CONCLUSIONS

The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.

Clinical factors associated with ultrashort length of stay in patients undergoing lower extremity bypass for peripheral arterial disease

BACKGROUND

Length of stay (LOS) is a major driver of cost and resource utilization following lower extremity bypass (LEB). However, the variable comorbidity burden and mobility status of LEB patients makes implementing enhanced recovery after surgery pathways challenging. The aim of this study was to use a large national database to identify patient factors associated with ultrashort LOS among patients undergoing LEB for peripheral artery disease.

METHODS

All patients undergoing LEB for peripheral artery disease in the National Surgical Quality Improvement Project database from 2011 to 2018 were included. Patients were divided into two groups based on the postoperative length of stay : ultrashort (≤2 days) and standard (>2 days). Thirty-day outcomes were compared using descriptive statistics, and multivariable logistic regression was used to identify patient factors associated with ultrashort LOS.

RESULTS

Overall, 17,510 patients were identified who underwent LEB, of which 2678 patients (15.3%) had an ultrashort postoperative LOS (mean, 1.8 days) and 14,832 (84.7%) patients had a standard LOS (mean, 7.1 days). When compared to patients with a standard LOS, patients with an ultrashort LOS were more likely to be admitted from home (95.9% vs 88.0%; P < .001), undergo elective surgery (86.1% vs 59.1%; P < .001), and be active smokers (52.1% vs 40.4%; P < .001). Patients with an ultrashort LOS were also more likely to have claudication as the indication for LEB (53.1% vs 22.5%; P < .001), have a popliteal revascularization target rather than a tibial/pedal target (76.7% vs 55.3%; P < .001), and have a prosthetic conduit (40.0% vs 29.9%; P < .001). There was no significant difference in mortality between the two groups (1.4% vs 1.8%; P = .21); however, patients with an ultrashort LOS had a lower frequency of unplanned readmission (10.7% vs 18.8%; P < .001) and need for major reintervention (1.9% vs 5.6%; P < .001). On multivariable analysis, elective status (odds ratio , 2.66; 95% confidence interval [CI], 2.33-3.04), active smoking (OR, 1.18; 95% CI, 1.07-1.30), and lack of vein harvest (OR, 1.55; 95% CI, 1.41-1.70) were associated with ultrashort LOS. Presence of rest pain (OR, 0.57; 95% CI, 0.51-0.63), tissue loss (OR, 0.30; 95% CI, 0.27-0.34), and totally dependent functional status (OR, 0.54; 95% CI, 0.35-0.84) were associated negatively with an ultrashort LOS. When examining the subgroup of patients who underwent vein harvest, totally dependent (OR, 0.38; 95% CI, 0.19-0.75) and partially dependent (OR, 0.53; 95% CI, 0.32-0.88) functional status were persistently negatively associated with ultrashort LOS.

CONCLUSIONS

Ultrashort LOS (≤2 days) after LEB is uncommon but feasible in select patients. Preoperative functional status and mobility are important factors to consider when identifying LEB patients who may be candidates for early discharge.