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High Rates of Recurrent Revascularization in Acute Limb Ischemia – A National Surgical Quality Improvement Program Study

      Background

      We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI.

      Methods

      A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012 to 2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection.

      Results

      A total of 2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. A total of 13.8% required reoperation and 7.9% required readmission within 30 days. A total of 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. A total of 58.7% of patients were female and either overweight or obese. Younger age (odds ratio OR 0.991 [0.984–0.999], P = 0.02), underweight patients (OR 1.159 [0.667–2.01], P = 0.05), pre-operative steroid use (OR 1.61 [1.07–2.41], P = 0.02), and perioperative transfusion (OR 2.02 [1.04–3.95], P = 0.04) predicted reoperations.

      Conclusions

      This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.
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      References

        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • et al.
        • TASC II Working Group
        Inter-society consensus for the management of peripheral arterial disease (TASC II).
        J Vasc Surg. 2007; 45: S5-S67
        • Creager M.A.
        • Kaufman J.A.
        • Conte M.S.
        Clinical practice. Acute limb ischemia.
        N Engl J Med. 2012; 366: 2198-2206
        • Dormandy J.
        • Heeck L.
        • Vig S.
        Acute limb ischemia.
        Semin Vasc Surg. 1999; 12: 148-153
        • Holscher C.M.
        • Canner J.K.
        • Garonzik wang J.M.
        • et al.
        Temporal trends and hospital costs associated with an endovascular-first approach for acute limb ischemia.
        J Vasc Surg. 2019; 70: 1506-1513
        • Criqui M.
        • Aboyans V.
        Epidemiology of peripheral arterial disease.
        Circ Res. 2015; 116: 1509-1526
        • Wang J.C.
        • Kim A.H.
        • Kashyap V.S.
        Open surgical or endovascular revascularization for acute limb ischemia.
        J Vasc Surg. 2016; 63: 270-278
        • Taha A.G.
        • Byrne R.M.
        • Avgerinos E.D.
        • et al.
        Comparative effectiveness of endovascular versus surgical revascularization for acute lower extremity ischemia.
        J Vasc Surg. 2015; 61: 147-154
        • De Athayde Soares R.
        • Matielo M.F.
        • Brochado Neto F.C.
        • et al.
        Analysis of the results of endovascular and open surgical treatment of acute limb ischemia.
        J Vasc Surg. 2019; 69: 843-849
        • Davis F.M.
        • Albright J.
        • Gallagher K.
        • et al.
        Early outcomes following endovascular, open surgical, and hybrid revascularization for lower extremity acute limb ischemia.
        Ann Vasc Surg. 2018; 51: 106-112
        • Grip O.
        • Wanhainen A.
        • Michaëlsson K.
        • et al.
        Open or endovascular revascularization in the treatment of acute lower limb ischaemia.
        Br J Surg. 2018; 105: 1598-1606
        • Wang S.K.
        • Murphy M.P.
        • Gutwein A.R.
        • et al.
        Perioperative outcomes are adversely affected by poor pretransfer adherence to acute limb ischemia practice guidelines.
        Ann Vasc Surg. 2018; 50: 46-51
        • Genovese E.A.
        • Chaer R.A.
        • Taha A.G.
        • et al.
        Risk factors for long-term mortality and amputation after open and endovascular treatment of acute limb ischemia.
        Ann Vasc Surg. 2016; 30: 82-92
        • Liang S.
        • Zhou L.
        • Ye K.
        • et al.
        Limb salvage after percutaneous mechanical thrombectomy in patients with acute lower limb ischemia: a retrospective analysis from two institutions.
        Ann Vasc Surg. 2019; 58: 151-159
        • van der Slegt J.
        • Flu H.C.
        • Veen E.J.
        • et al.
        Adverse events after treatment of patients with acute limb ischemia.
        Ann Vasc Surg. 2015; 29: 293-302
        • Byrne R.M.
        • Taha A.G.
        • Avgerinos E.
        • et al.
        Contemporary outcomes of endovascular interventions for acute limb ischemia.
        J Vasc Surg. 2014; 59: 988-995
        • Hess C.
        • Wang T.Y.
        • Fu J.W.
        • et al.
        Long-Term outcomes and associations with major adverse limb events after peripheral artery revascularization.
        J Am Coll Cardiol. 2020; 75: 498-508
        • Bellosta R.
        • Luzzani L.
        • Natalini G.
        • et al.
        Acute limb ischemia in patients with COVID-19 pneumonia.
        J Vasc Surg. 2020; 72: 1864-1872
        • Sánchez J.B.
        • Alcalde J.D.C.
        • Isidro R.R.
        • et al.
        Acute limb ischemia in a Peruvian cohort infected by COVID-19.
        Ann Vasc Surg. 2020; 72: 196-204
        • Perini P.
        • Nabulsi B.
        • Massoni C.B.
        • et al.
        Acute limb ischaemia in two young, non-atherosclerotic patients with COVID-19.
        Lancet. 2020; 395: 1546
        • Baumgartner I.
        • Norgren L.
        • Fowkes F.G.R.
        • et al.
        Cardiovascular outcomes after lower extremity endovascular or surgical revascularization: the EUCLID trial.
        J Am Coll Cardiol. 2018; 72: 1563-1572
        • Baumgartner I.
        • Norgren L.
        • Fowkes F.G.R.
        • et al.
        Cardiovascular outcomes after lower extremity endovascular or surgical revascularization: the EUCLID trial.
        J Am Coll Cardiol. 2018; 72: 1563-1572
        • Siada S.S.
        • Al-Musawi M.H.
        • Wohlauer M.V.
        Acute limb ischemia: an administrative code combination with near perfect diagnostic specificity.
        J Vasc Surg. 2020; 72: e141-e142
        • Hess C.N.
        • Debus E.S.
        • Nehler M.R.
        • et al.
        Reduction in acute limb ischemia with rivaroxaban versus placebo in peripheral artery disease after lower extremity revascularization: insights from voyager pad.
        Circulation. 2021; 144: 1831-1841
        • Roe Matthew T.
        • Anita Y.
        • Chen Elizabeth R.
        • et al.
        Patterns of transfer for patients with non-ST-segment elevation acute coronary syndrome from community to tertiary care hospitals.
        Am Heart J. 2008; 156: 185-192
        • Mell Matthew W.
        • Starnes Benjamin W.
        • Kraiss Larry W.
        • et al.
        Western vascular society guidelines for transfer of patients with ruptured abdominal aortic aneurysm.
        J Vasc Surg. 2017; 65: 603-608
        • Levine G.N.
        • Eric R.B.
        • John A.B.
        • et al.
        2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of cardiology/American heart association task force on clinical practice guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery.
        Circulation. 2016; 10: e123-e155
        • Roe Matthew T.
        • Messenger John C.
        • Weintraub William S.
        • et al.
        Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention.
        J Am Coll Cardiol. 2010; 56: 254-263
        • Bonaca Marc P.
        • Gutierrez J. Antonio
        • Creager Mark A.
        • et al.
        Acute limb ischemia and outcomes with vorapaxar in patients with peripheral artery disease: results from the trial to assess the effects of vorapaxar in preventing heart attack and stroke in patients with atherosclerosis-thrombolysis in myocardial infarction 50 (TRA2°P-TIMI 50).
        Circulation. 2016; 133: 997-1005
        • Roe M.T.
        • Armstrong P.W.
        • Fox K.A.A.
        • et al.
        Prasugrel versus clopidogrel for acute coronary syndromes without revascularization.
        N Engl J Med. 2012; 367: 1297-1309
        • McManus David D.
        • Gore Joel
        • Yarzebski Jorge
        • et al.
        Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI.
        Am J Med. 2011; 124: 40-47
        • Powell Janet T.
        • Sweeting Michael J.
        • Thompson Matthew M.
        • et al.
        • IMPROVE Trial Investigators
        Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial.
        BMJ. 2014; 348: f7661
        • Madenci Arin L.
        • Ozaki C. Keith
        • Gupta Naren
        • et al.
        Perioperative outcomes of elective inflow revascularization for lower extremity claudication in the American College of Surgeons National Surgical Quality Improvement Program database.
        Am J Surg. 2016; 212: 461-467.e2
        • Zhang Jennifer Q.
        • Thomas Curran
        • McCallum John C.
        • et al.
        Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
        J Vasc Surg. 2014; 59: 1331-1339
        • Aziz Faisal
        • Chu Youngmin
        • Erik B.
        • et al.
        Lower extremity bypass surgery on patients transferred from other hospitals is associated with increased morbidity and mortality.
        Ann Vasc Surg. 2017; 41: 205-213.e2
        • O’Keeffe Shane D.
        • Davenport Daniel L.
        • Minion David J.
        • et al.
        Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization.
        J Vasc Surg. 2010; 51 (621.e1-621.e3): 616-621
        • Wong Cynthia
        • Haley Augustine
        • Asem Saleh
        • et al.
        Use of the national surgical quality initiative program in vascular surgery research.
        Ann Vasc Surg. 2019; 61: 434-444.e12
        • Mell Matthew W.
        • Wang Nancy E.
        • Morrison Doug E.
        • et al.
        Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm.
        J Vasc Surg. 2014; 60: 553-557
        • Olinic D.M.
        • Tataru D.A.
        • Homorodean C.
        • et al.
        Antithrombotic treatment in peripheral artery disease.
        VASA. 2018; 47: 99-108
        • Hess C.N.
        • Norgren L.
        • Ansel G.M.
        A structured review of antithrombotic therapy in peripheral artery disease with a focus on revascularization: a TASC (InterSociety consensus for the management of peripheral artery disease) initiative.
        Circulation. 2017; 135: 2534-2555
        • Eikelboom J.W.
        • Connolly S.J.
        • Bosch J.
        • et al.
        Rivaroxaban with or without aspirin in stable cardiovascular disease.
        N Engl J Med. 2017; 377: 1319-1330