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Infrainguinal endovascular intervention in functionally dependent patients
Muhammad H. Zubair, MD, Sophia G. Afridi, MD, Timothy J. Fuller, MD, Patrick E. Muck, MD.
TriHealth - Good Samaritan Hospital, Cincinnati, OH, USA.
OBJECTIVE: Majority of patients who undergo infraingunal intervention for critical limb ischemia (CLI) are functionally dependent. Patients with functional dependence tend to fare worse with open infrainguinal bypasses. Few studies have evaluated the post endovascular outcomes in patients with CLI. Considering the minimally invasive nature of endovascular therapy and the predictable decrease in surgical morbidity, we evaluated the outcomes of functionally dependent patients with endovascular treatment of lower limb CLI.
METHODS: Patients undergoing endovascular infraingunal intervention were identified from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2010. Demographics and outcome variables, including mortality, graft patency and need for amputation within 30 days, were compared between functionally dependent and independent patients. The Comprehensive Risk Assessment for Bypass (CRAB) score was calculated using NSQIP variables.
RESULTS: A total of 1,368 patients were included for analysis, of which 170 (12.4%) were funtionally dependent (Table 1). Patients with functional dependence had significantly higher CRAB score (11.7 ± 4.3 vs 3.67 ± 3.3; p<0.0001). Mortality within 30 days (8.8% vs 2.3%; p<0.0001) and major amputation (5.9% vs 0.6%; p<0.0001) were significantly greater for functionally dependent patients. A higher but not significant failure of intervention (3.5% vs 2.5%; p=0.4), deep surgical site infections (4.1% vs 0.8%; p=0.003), pneumonia (5.9% vs 1.8%; p=0.003), deep vein thrombosis (2.9% vs 0.5%; p=0.007), prolonged mechanical ventilation (9.4% vs 2.6%; p<0.00001), urinary tract infection (6.5% vs 1.5%; p<0.00001), sepsis (13.5% vs 2.8%; p<0.00001), and septic shock (5.3% vs 1.1%; p=0.001) was observed in patients with functional dependence.
CONCLUSIONS: Preoperative functional dependence should be given consideration while making decisions for infrainguinal lower limb interventions. A higher preop CRAB score is associated with functional dependence and may help in making this distinction in future prospective studies. | | | | | | Table 1: Demographics and perioperative variables | Total n=1366 | Independent n=1196 | Dependent n=170 | p | | Age, mean (SD) years | 69.38 (10.9) | 69.16 (10.8) | 71.01 (11.5) | 0.04 | | CRAB score, mean (SD) | 4.67 (4.4) | 3.67 (3.3) | 11.7 (4.3) | <0.00001 | | BMI, mean (SD) | 26.99 (6.78) | 27.17 (6.89) | 25.69 (5.81) | 0.009 | | Length of total hospital stay, mean (SD) days | 6.39 (11.7) | 5.23 (8.9) | 14.54 (21.7) | <0.00001 | | Pre-operative serum creatinine, mean (SD) mg/dl | 1.37 (1.3) | 1.33 (1.2) | 1.66 (1.8) | 0.003 | | Pre-operative serum albumin, mean (SD) mg/dl | 3.62 (0.6) | 3.73 (0.5) | 3.13 (0.7) | <0.00001 | | Pre-operative WBC, mean (SD) 1000cells/ul | 8.34 (3.4) | 8.10 (3.1) | 10.01 (4.8) | <0.00001 | | Pre-operative hematocrit, mean (SD) 1000cells/ul | 37.98 (5.8) | 38.54 (5.5) | 34.01 (6.4) | <0.00001 | | Pre-operative platelet count, mean (SD) 1000cells/ul | 242.07 (89.59) | 239.67 (83.5) | 258.75 (122.6) | 0.01 | | Pre-operative PTT, mean (SD) seconds | 34.83 (14.27) | 34.04 (13) | 40.03 (19.6) | <0.00001 | | Pre-operative INR, mean (SD) | 1.13 (0.3) | 1.12 (0.3) | 1.25 (0.4) | <0.00001 | | Number of RBC units given intraoperative, mean (SD) | 0.5 (1.2) | 0.44 (1.1) | 0.9 (1.7) | <0.00001 | | Male, n (%) | 463 (33.9) | 385 (32.2) | 78 (45.9) | 0.002 | | White, n (%) | 1069 (78.3) | 945 (79) | 124 (72.9) | 0.07 | | Diabetes, n (%) | 382 (28) | 318 (26.5) | 160 (37.6) | <0.00001 | | Current smoker, n (%) | 554 (40.6) | 491 (41.1) | 63 (37.1) | 0.3 | | EtOH > 2 drinks/day 2 wk before admission, n (%) | 85 (6.2) | 76 (6.4) | 9 (5.3) | 0.7 | | Dyspnea, n (%) | 298 (21.8) | 241 (20.2) | 57 (33.2) | <0.00001 | | Ventilator dependent, n (%) | 17 (1.2) | 4 (0.3) | 13 (7.6) | <0.00001 | | COPD, n (%) | 239 (17.5) | 199 (16.6) | 40 (23.5) | 0.03 | | Current Pneumonia, n (%) | 4 (0.3) | 1 (0.1) | 3 (1.8) | 0.007 | | Congestive heart failure, n (%) | 37 (2.7) | 23 (1.9) | 14 (8.2) | <0.00001 | | Hypertension, n (%) | 1150 (84.2) | 1008 (84.3) | 142 (83.5) | 0.8 | | Acute Renal failure, n (%) | 18 (1.3) | 10 (0.8) | 8 (4.7) | 0.001 | | Impaired sensorium, n (%) | 17 (1.2) | 4 (0.3) | 13 (7.6) | <0.00001 | | Hemiplegia, n (%) | 34 (2.5) | 19 (1.6) | 15 (8.8) | <0.00001 | | History of TIA, n (%) | 84 (6.1) | 79 (6.6) | 5 (2.9) | 0.06 | | CVA/Stroke with defecit, n (%) | 91 (6.7) | 61 (5.1) | 30 (17.6) | <0.00001 | | CVA/Stroke with no defecit, n (%) | 92 (6.7) | 81 (6.8) | 11 (6.5) | 1 | | | | | |
| | | | | | Disseminated cancer, n (%) | 10 (0.7) | 8 (0.7) | 2 (1.2) | 0.3 | | Paraplegia, n (%) | 8 (0.6) | 7 (0.6) | 1 (0.6) | 1 | | Open wound/wound infection, n (%) | 213 (15.6) | 143 (12) | 70 (41.2) | <0.00001 | | Steroid use, n (%) | 44 (3.2) | 35 (2.9) | 9 (5.3) | 0.1 | | >10% weight loss in 6 months, n (%) | 24 (1.8) | 12 (1) | 12 (7.1) | <0.00001 | | Bleeding diathesis, n (%) | 349 (25.5) | 282 (23.6) | 67 (39.4) | <0.00001 | | Transfusion >4U of PRBC 72 hrs pre op, n (%) | 12 (0.9) | 8 (0.7) | 4 (2.4) | 0.051 | | Chemotherapy for malignancy, n (%) | 9 (0.7) | 7 (0.6) | 2 (1.2) | 0.3 | | Radiotherapy for malignancy, n (%) | 4 (0.3) | 2 (0.2) | 2 (1.2) | 0.07 | | Prior operation in last 30 days, n (%) | 60 (4.4) | 39 (3.3) | 21 (12.4) | <0.00001 |
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