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Development of Secondary Complications after Postoperative Index Complication for Lower Extremity Bypass Patients
Matthew R. Peacock, Alik Farber, M.D., Mohammad H. Eslami, M.D., Jeffrey A. Kalish, M.D., Denis Rybin, M.S., Gheorghe Doros, Ph.D., Nishant K. Shah, Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.

Objectives: Patients undergoing lower extremity bypass (LEB) are at high risk of perioperative complications. These index complications can lead to a cascade of secondary complications. Our goal was to understand how index complications alter the pattern and risk of secondary complications after LEB.
Methods: The 2005-2012 ACS-NSQIP database was used to analyze the associations of secondary complications with five index complications: acute renal failure (ARF), myocardial infarction (MI), pneumonia, deep/organ surgical site infection (SSI), and urinary tract infection (UTI) after LEB. Index cohorts were developed with 1:3 propensity matching based on preoperative variables.
Results: There were 20,230 LEB analyzed. Patients with index ARF had higher subsequent pneumonia (12.5% vs. 2.3%, P<.001), cardiac arrest (8.0% vs. 0.4%, P<.001), unplanned intubation (21.6% vs. 1.1%, P<.001), prolonged ventilation (28.4% vs. 1.5%, P<.001), and mortality (23.9% vs. 1.9%, P<.001). Patients with index MI had higher subsequent ARF (5% vs. 0.6%, P<.001), pneumonia (7.7% vs. 1.0%, P<.001), UTI (3.3% vs. 1.2%, P<.02), cardiac arrest (9.8% vs. 1.3%, P<.001), deep vein thrombosis (DVT) (3.0% vs. 0.7%, P=.003), unplanned intubation (18.4% vs. 1.6%, P<001), prolonged intubation (12.5% vs. 1.2%, P<.001), sepsis (8.6% vs. 2.0%, P<001), and mortality (16% vs. 2.8%, P<.001). Index pneumonia led to higher subsequent ARF (2.7% vs. 0.4%, P=.003), MI (6.6% vs. 0.6%, P<.001), UTI (6.9% vs. 2.2%, P=.001), cardiac arrest (6.6% vs. 0.8%, P<.001), pulmonary embolism (PE) (1.5% vs. 0%, P=.004), DVT (4.2% vs. 1.0%, P=.002), unplanned intubation (29.3% vs. 0.8%, P<.001), prolonged intubation (26.3% vs. 0.8%, P<.001), sepsis (19.3% vs. 2.7%, P<.001), and mortality (18.1% vs. 3.6%, P<.001). SSI had higher subsequent ARF (1.1% vs. 0.1%, P=.004), UTI (1.9% vs. 0.8%, P=.04), cardiac arrest (1.8% vs. 0.3%, P=.001), wound disruption (13.9% vs. 0.7%, P<.001), DVT (1.2% vs. 0.2%, P=.007), unplanned intubation (2.6% vs. 0.4%, P<.001), prolonged ventilation (2.3% vs. 0.3% P<.001), sepsis (19.2% vs. 1.2%, P<.001), and mortality (3.0% vs. 1.1%, P=.003). Index UTI led to higher subsequent pneumonia (5.6% vs. 0.6%, P<.001), unplanned intubation (4.2% vs. 1.0%, P<.001), prolonged ventilation, sepsis (3.9% vs. 0.6%, P<.001), wound disruption (3.7% vs. 1.6%, P=.03), and mortality (4.2% vs. 2.0%, P=.03).
Conclusion: LEB patients that develop postoperative index complications are significantly more likely to develop certain secondary complications. Early identification and treatment of subsequent complications could decrease morbidity and mortality.


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