Society For Clinical Vascular Surgery

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Impact of Ankle-Brachial Index and Clinical Status on Outcomes Following Lower Extremity Bypass
Thomas FX O'Donnell, MD1, Sarah E. Deery, MD, MPH1, Marc L. Schermerhorn, MD2, Jeffrey J. Siracuse, MD3, Daniel J. Bertges, MD4, Alik Farber, MD3, Robert T. Lancaster, MD, MPH1, Virendra I. Patel, MD, MPH1.
1Massachusetts General Hospital, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Boston Medical Center, Boston, MA, USA, 4University of Vermont Medical Center, Burlington, VT, USA.

Objective: Ankle-brachial index (ABI) is a common method of graft surveillance after infrainguinal bypass surgery (LEB), and is recommended by the SVS. Several studies failed to show benefit of ABI surveillance, but were limited by sample size, and the practice remains variable.
Methods: We identified all patients who underwent LEB for occlusive disease from the Vascular Study Group of New England Registry (VSGNE) between 2003-2016. Postoperative changes were defined as: improvement for ABI >0.15 or clinical status improved (i.e. symptoms improved from rest pain to asymptomatic, etc), no change if ABI was within 0.15 or no change in clinical status, or worsened if ABI decreased > 0.15 or clinical status deteriorated. We determined the independent effect of these changes on rates of limb events and mortality. Additionally, we compared the practice of ABI surveillance to follow-up without ABI using propensity scores with inverse probability weights.
Results: We identified 7,994 patients undergoing their first intervention in the VSGNE, 2,251 of whom (29%) had both preoperative and discharge ABIs. Overall, 5,369 (67%) of the bypasses used vein, and 4,539 (57%) were femoropopliteal. The majority of bypasses were performed for chronic limb-threatening ischemia (63%). At discharge, ABI remained stable in 22%, improved in 69% and worsened in 9%, while clinical status remained stable in 12%, improved in 77% and worsened in 12%. In univariate analysis, clinical status was associated with mortality, amputation and major adverse limb events (MALE), but ABI change was only associated with mortality (all P < .01). After multivariable adjustment, ABI change was not associated with mortality, amputation, reintervention or MALE (P > .05), and the addition of ABI change to the models did not improve the fit of the model (likelihood ratio P > .05). Forgoing ABI surveillance in follow-up was associated with higher rates of patency loss (P = .02), but not reinterventions (P = .57), or untreated patency loss (P = .17).
Conclusion: A change in clinical status, but not ABI, was associated with adverse outcomes after LEB. In this group of VSGNE patients with follow-up, clinical status alone was a sufficient method of graft surveillance.

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