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Preoperative Immunomodulator Therapy And Risk Of Complications In Vascular Surgery
Ivan Y. Luu, BS, Alexander T. Hong, BS, Audrey Limb, BS, Kevin W. Sun, BS, Alyssa Pyun, MD, Ariela Zenilman, MD, Miguel Manzur, MD, Sukgu Han, MD, Tze-Woei Tan, MBBS, MPH.
University of Southern California, Los Angeles, CA, USA.
OBJECTIVES: Immunomodulating therapies are widely used for autoimmune and inflammatory disease, but their impact on perioperative outcomes in vascular surgery remains uncertain. This study evaluated the association between preoperative immunomodulator use and risks of cardiovascular, limb-related, and infectious complications after vascular procedures.
METHODS: This large multicenter cohort study analyzed included adults undergoing abdominal aortic aneurysm (AAA) repair, carotid artery endarterectomy or stenting, and lower extremity revascularization (LER) between 2016 and 2024. Exposure was defined as use of systemic immunomodulators, including corticosteroids, disease-modifying antirheumatic drugs, and biologics within 90 days before surgery. Propensity score-matched analysis was performed 1:1 based on demographics, comorbidities, medication use, and autoimmune and inflammatory diseases. Outcomes included major adverse cardiovascular events (MACE), major adverse limb events (MALE), and surgical site infection (SSI) within 1 year.
RESULTS: Among 17,627 patients who underwent AAA repair, 66,146 patients who underwent carotid revascularization, and 131,017 patients who underwent LER, 20.3%, 19.6%, and 28.0% were on immunomodulating therapy, respectively. After propensity-matching, immunomodulator exposure was associated with increased risk of MACE (RR 1.13, 95% CI 1.08-1.18), MALE (RR 1.05, 95% CI 1.04-1.07), and SSI (RR 1.33, 95% CI 1.24-1.42) in the LER cohort. Immunomodulator exposure was additionally associated with increased risk of MACE (RR 1.04, 95% CI 1.01-1.07) and SSI (RR 1.37, 95% CI 1.09-1.71) in the carotid cohort. Immunomodulator exposure was associated with increased MACE (RR 1.18, 95% CI 1.01-1.37) but no difference in SSI (RR 1.15, 95% CI 0.87-1.52) in the AAA cohort.
CONCLUSIONS: Immunomodulator use was associated with an increased risk of MACE, MALE, and SSI following LER and carotid revascularization. These findings suggest that perioperative risk stratification for vascular patients on immunosuppression should be procedure specific. Further research is required to understand the long-term impact of these medications on patient outcomes following vascular surgery.
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