Society For Clinical Vascular Surgery

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Postoperative Outcomes after Reoperative Aortoiliac Intervention in the American College of Surgeons National Surgical Quality Improvement Database
Senthil Jayarajan, M.D., John G. Maijub, M.D., Claudiu A. Vlada, Patrick J. Geraghty, M.D., Luis A. Sanchez, M.D., Jeffrey Jim, M.D.
Washington University in St. Louis School of Medicine, St. Louis, MO, USA.

OBJECTIVES:With evolving therapeutic options for patients with aortoiliac occlusive disease and an aging population, operating on patients with prior interventions in this area will become more frequent. Our aim is to better understand outcomes of reoperative aortoiliac interventions.
METHODS: The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed for all patients undergoing aortoiliac occlusive disease intervention in 2015. Specifically, patients with no prior intervention, prior open aortoiliac surgery (OPEN), or prior endovascular aortoiliac procedures (ENDO) were categorized accordingly. Univariate and multivariate analyses were performed to evaluate preoperative characteristics and postoperative outcomes.
RESULTS: A total of 1,648 patients undergoing any aortoiliac intervention for occlusive disease were reviewed. 1,027 patients had no previous surgery. There were 382 patients in the OPEN group, and 239 patients in the ENDO group. On univariate analysis, claudication and rest pain were the most common indications for intervention (Table I). OPEN patients had higher rates of amputation, transfusion requirement, reintervention, readmission, reoperation, and major morbidity. ENDO patients had the highest rate of post-procedure thrombectomy (Table II). Multivariate analysis demonstrated increase risk for death at 30 days for those patients with American Society of Anesthesiologists (ASA) classification of IV/V, (OR: 2.21, P=0.0057), increased operative time (OR: 2.00, P=0.0157), and BMI<18 (OR: 1.668, P=0.0154). Prior open surgery was also an independent risk factor for reoperation (OR: 2.01, P<0.001), bleeding complication (OR: 1.302, p=0.001), and major morbidity. Previous endovascular surgery was not found to be a risk factor for reoperation (OR: 0.926, P=0.05) and portends less risk of bleeding complications (OR: 0.553, P<0.001).
CONCLUSIONS: Patients with prior open aortoiliac occlusive surgery, long operative times, and poor surgical fitness are at increased risk for reoperation, bleeding complications and overall major morbidity. In addition, increased operative times and poor ASA classification place these patients at higher risk for death at 30 days. The endovascular-first approach does not have an increased risk of major morbidity when compared to those patients with no prior intervention.

Table I. Patient Demographics and Operation Indication
No Prior Surgery (N=1027)OPEN (N=382)ENDO (N=239)P Value
BMI 26.427.426.9*0.0098
Hypertension767 (74.7%)303 (79.3%)195 (81.6%)*0.03
Diabetes Mellitus224 (21.8%)125 (32.7%)75 (31.4%)*<0.001
Current Smoker600 (58.4%)194 (50.8%)130 (54.4%)*0.0316
ASA IV/V288 (28%)136 (35.6%)66 (27.6%)*0.0164
Asymptomatic80 (7.8%)30 (7.8%)11 (4.6%)*<0.001
Claudication475 (46.3%)118 (30.9%)98 (41%)*<0.001
Rest Pain297 (28.9%)156 (40.1%)93 (38.9%)*<0.001
Tissue Loss155 (15.1%)70 (18.3%)36 (15.1%)*<0.001

Table II. Patient Outcomes
No Prior Surgery (N=1027)OPEN (N=382)ENDO (N=239)P Value
Length of Stay (Days)*0.015
Amputation7 (0.7%)16 (4.2%)1 (0.4%)*<0.0001
Transfusion197 (19.2%)95 (24.9%)32 (13.4%)*0.0019
Major Reintervention29 (2.8%)29 (7.6%)9 (3.8%)*0.0003
Thrombectomy275 (26.8%)71 (18.6%)80 (33.5%)*0.0001
Readmission75 (7.3%)50 (13.1%)22 (9.2%)*0.0032
Reoperation126 (12.3%)85 (22.3%)27 (11.3%)*<0.0001
Major Morbidity163 (15.9%)98 (25.7%)38 (15.9%)*<0.0001

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