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Procedural Predictors and Related Resource Drain of Lower Extremity Ischemia after Aortic Surgery
Background:
There is limited data regarding lower extremity ischemia following aortic aneurysm repair. This study’s aim was to assess for factors associated with lower extremity ischemia following open abdominal aortic aneurysm repair (AAA) and Endovascular abdominal aortic aneurysm repair (EVAR).
METHODS:
The National Surgical Quality Improvement Program database and vascular procedure Specific data was abstracted for the years 2011-2012. Cases entered for AAA and EVAR were evaluated for factors associated with lower extremity ischemia (LEI). Student’s T-Test, Chi-squared, and Fisher’s exact test were used to assess for statistical significance with two-tailed alpha set to p<0.05. Binary logistic regression was then performed in EVAR retaining factors meeting p<0.05.
Results:
Overall, 3734 cases were analyzed comprising 949 AAA, and 2785 EVAR cases. LEI incidence was 1.8% (n=68), 2.4% (n=23) in AAA versus 1.6% (n=45) after EVAR, p=0.108. Patient factors associated with LEI included: male sex (p=0.047), preoperative sepsis (p=0.003), preoperative transfusion (p=0.018), and operative time (p<0.001). Procedural factors associated with LEI following EVAR included renal stenting (p=0.021), Iliac branched device usage (p=0.003) conduit access vessel repair (p=0.039), prior abdominal surgery (p=0.036), presenting with ruptured aneurysm (p=0.002), and thrombotic surgical indication (p<0.001). On multivariable analysis the following factors remained significant: iliac-branched device (OR 2.94, CI 1.49-5.77, p=0.002), prior aortic abdominal surgery (OR 1.98, CI 1.09-3.40, p=0.04), presentation with rupture & hypotension (OR 5.17, 2.18-12.30, p<0.001), and thrombosis as surgical indication (OR 10.64, 3.76-30.07). No procedure specific variables were associated with LEI following AAA. LEI was associated with other adverse outcomes including increased length of stay (15.4 vs 8.2 days, p=0.001), increased ICU length of stay (6.6 vs 3.9 days, p<0.001), other major complications (45.6% vs. 12.8%, p<0.001), and death (23.5% vs. 5.5%, p<0.001)
Conclusion:
Lower extremity ischemia following abdominal aortic aneurysm repair, although rare, devours healthcare resources. Surgeons should be particularly vigilant for LEI when performing AAA repair with the use of iliac-branched devices and on patient’s who have undergone prior abdominal surgery.