Longer Operative Times are Associated with Poor Outcomes in Patients Undergoing Lower Extremity Endovascular Revascularization Procedures
Alexander Ostapenko, MD, Stephanie Stroever, PhD, MPH, Alan Dietzek, MD.
Danbury Hospital, Danbury, CT.
OBJECTIVES: Historically, longer operative times for open infrainguinal revascularization have been associated with higher perioperative complication rates, particularly with respect to surgical site infections and extended lengths of stay. We sought to determine if an associated existed between length of procedure and morbidity or mortality after lower extremity endovascular interventions.
METHODS: We conducted a cross-sectional retrospective analysis of the targeted Lower Extremity NSQIP database for 2012 to 2017. Primary outcome was death; secondary outcomes included myocardial infarction (MI), stroke, amputation, and unplanned return to the operating room (OR). We performed a univariate logistic regression analysis to determine if there were higher odds of having a longer operative time in patients who experienced an adverse outcome. Operative time was assessed as a categorical variable. We performed a multivariate analysis utilizing a logistic regression model to identify variables predictive of the outcomes of interest.
RESULTS: A total of 11,136 patients were included. There were 3,522 patients with claudication, 6,839 with critical limb ischemia (CLI), 613 were asymptomatic, and 162 with unknown disease. The number of patients with interventions in the femoropopliteal region was 8,632(77%); those with interventions in the tibial region numbered 2,407(22%). Mean operative time for all procedures was 108 minutes. On univariate analysis, operative time >240 minutes was a significant predictor of mortality (p=0.0018), amputation (p<0.001), MI (p<0.001), stroke (p=0.0223), and return to OR (p<0.001). Except for return to OR, none of the other outcomes reached statistical significance with operative times <240 minutes. For each outcome of interest, we utilized a forward selection method to identify confounders, and subsequently performed multivariate logistic regression. Confounders identified included ASA class, patient age, and CLI diagnosis. Mortality had two additional confounders: history of congestive heart failure and history of chronic obstructive pulmonary disease. Even after controlling for these confounders, operative time >240 minutes remained a significant predictor for each outcome of interest.
CONCLUSIONS: Prolonged operative times for endovascular procedures are associated with poor outcomes. After controlling for confounders, we demonstrate a statistically significant association between procedure length and the outcomes of interest. Specifically, operating times >240 minutes had significantly higher odds of mortality, MI, stroke, amputation and return to OR. Consequently, surgeons should weigh the benefits and types of endovascular interventions against the risks of prolonged procedures.
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