Direction of Groin Incision and its Effect on Post-Operative Outcomes Following Femoral to Above-Knee Popliteal Bypass
Katie M. Shean, MD1, Sarah E. Deery, MD1, Thomas F.X. O'Donnell, MD1, Sara L. Zettervall, MD1, Peter A. Soden, MD1, Nikhil Kansal, MD2, Michael A. Ricci, MD3, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2St. Elizabeth's Medical Center, Boston, MA, USA, 3Central Maine Medical Center, Lewiston, ME, USA.
Background: Wound infections are a concern following infrainguinal bypass operations. Limited studies have evaluated direction of groin incision as a possible contributor, however the results have been contradictory. Therefore, this study aims to evaluate incisional direction as a variable and its effect on patient outcomes after lower extremity bypass.
Methods: Patients with peripheral vascular disease who underwent femoral to above-knee popliteal artery bypass using PTFE graft between 2010 and 2015 were identified in the Vascular Quality Initiative (VQI). Patients were compared by direction of groin incision: vertical or transverse. Patients without a defined direction of incision, asymptomatic patients and those with a graft origin other than common femoral artery, superficial femoral artery or profunda artery were excluded. Patient characteristics, operative details, and outcomes were compared between the incisional direction groups using univariate analysis. Multivariable logistic regression was utilized to account for patient demographics and operative details.
Results: 2587 patients underwent bypass, of which 1758 (68%) had a vertical incision and 829 (32%) had a transverse one. Claudication was the indication for surgery in 45% of patients in both groups. Concomitant endarterectomy was performed in similar percentages between the groups (vertical: 34% vs. transverse: 32%, P=.04). Patients with a vertical incision were less often white (80% vs. 85%, P=.002), obese (27% vs. 31%, P=.04) and more often on pre-operative ASA/P2Y12 antagonist (82% vs. 76%, P<.001). Operative time was higher in the vertical incision population (162 minutes vs. 141 minutes, P<.001). No statistical difference was seen in wound infections (vertical: 2% vs. transverse: 2%, P=.9) or graft infections (vertical: 0.5% vs. transverse: 0%, P=.06). Other important 30-day outcomes, including 30-day mortality and stroke, were similar across the populations (Table 1). Following multivariable adjustment, no post-operative complications were found to be statistically significant.
Conclusion: Incisional direction is not an independent predictor of major adverse outcomes following lower extremity bypass, including 30-day mortality and wound complications. These results are specific to femoral to above-knee popliteal bypass using PTFE as the conduit. Additional studies should be performed to evaluate the effects of incisional direction on alternate bypass locations and conduit types.
| Outcome Number (%) | Vertical 1758 (68) | Transverse 829 (32) | P- Value |
| 30-day Mortality | 223 (13) | 95 (12) | 0.4 |
| Operative Time, median (Q1/Q3) | 162 (120/216) | 141 (105/191) | <0.001 |
| Length of Stay, median (Q1/Q3) | 4 (2/7) | 4 (2/7) | 0.9 |
| Wound Complication | 39 (2) | 17 (2) | 0.9 |
| Graft Infection | 8 (0.5) | 0 | 0.06 |
| Stroke | 14 (1) | 5 (1) | 0.8 |
| Myocardial Infarction | 34 (2) | 16 (2) | 1 |
| Post-op Complication | 370 (21) | 163 (21) | 0.6 |
| Respiratory Complication | 40 (2) | 15 (2) | 0.6 |
| Transfusion | 150 (9) | 51 (6) | 0.07 |
| Amputation | 78 (4) | 38 (5) | 0.8 |
| Return to OR | 104 (6) | 53 (6) | 0.7 |
| LTF Revisions | 124 (7) | 53 (6) | 0.6 |
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