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Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease.
J Vasc Surg. 2017 06; 65(6):1680-1689.JV

Abstract

OBJECTIVE

Concern over perioperative and long-term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI).

METHODS

Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently.

RESULTS

From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below-knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below-knee). Patients undergoing LEE had higher rates of female gender, hypertension, end-stage renal disease, and diabetes (all P ≤ .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P < .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P = .02). On risk-adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.13; P = .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23-0.45; P < .01) and no statistically significant difference in 30-day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17-1.97; P = .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37-1.52; P = .42,). Also in IC group, there was a trend for lower major amputation rates ≤30 days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB.

CONCLUSIONS

In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb-threatening IC.

Authors+Show Affiliations

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif.Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif.Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif.Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif.Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif.Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, Calif. Electronic address: rmfujita@uci.edu.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

28527930

Citation

Chen, Samuel L., et al. "Outcomes of Open and Endovascular Lower Extremity Revascularization in Active Smokers With Advanced Peripheral Arterial Disease." Journal of Vascular Surgery, vol. 65, no. 6, 2017, pp. 1680-1689.
Chen SL, Whealon MD, Kabutey NK, et al. Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease. J Vasc Surg. 2017;65(6):1680-1689.
Chen, S. L., Whealon, M. D., Kabutey, N. K., Kuo, I. J., Sgroi, M. D., & Fujitani, R. M. (2017). Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease. Journal of Vascular Surgery, 65(6), 1680-1689. https://doi.org/10.1016/j.jvs.2017.01.025
Chen SL, et al. Outcomes of Open and Endovascular Lower Extremity Revascularization in Active Smokers With Advanced Peripheral Arterial Disease. J Vasc Surg. 2017;65(6):1680-1689. PubMed PMID: 28527930.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease. AU - Chen,Samuel L, AU - Whealon,Matthew D, AU - Kabutey,Nii-Kabu, AU - Kuo,Isabella J, AU - Sgroi,Michael D, AU - Fujitani,Roy M, PY - 2016/10/30/received PY - 2017/01/02/accepted PY - 2017/5/22/entrez PY - 2017/5/22/pubmed PY - 2017/6/20/medline SP - 1680 EP - 1689 JF - Journal of vascular surgery JO - J Vasc Surg VL - 65 IS - 6 N2 - OBJECTIVE: Concern over perioperative and long-term durability of lower extremity revascularizations among active smokers is a frequent deterrent for vascular surgeons to perform elective lower extremity revascularization. In this study, we examined perioperative outcomes of lower extremity endovascular (LEE) revascularization and open lower extremity bypass (LEB) in active smokers with intermittent claudication (IC) and critical limb ischemia (CLI). METHODS: Active smokers undergoing LEE or LEB from 2011 to 2014 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) targeted vascular data set. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between LEE and LEB procedures. Subgroup analysis was performed for patients undergoing revascularization for IC and CLI independently. RESULTS: From 2011 to 2014, 4706 lower extremity revascularizations were performed in active smokers (37% of all revascularizations). In this group, 1497 were LEE (55.6% for CLI, 13.4% for below-knee pathology) and 3209 were LEB (68.9% CLI, 34.7% below-knee). Patients undergoing LEE had higher rates of female gender, hypertension, end-stage renal disease, and diabetes (all P ≤ .02). LEE patients also had a higher frequency of prior percutaneous interventions (22.7% vs 17.2%; P < .01) and preoperative antiplatelet therapy (82.3% vs 78.7%; P = .02). On risk-adjusted multivariate analysis, LEE patients had higher need for reintervention on the treated arterial segment than LEB (5.1% vs 5.2%; odds ratio [OR], 1.52; 95% confidence interval [CI], 1.08-2.13; P = .02) but had lower wound complications (3.1% vs 13.2%; OR, 0.32; 95% CI, 0.23-0.45; P < .01) and no statistically significant difference in 30-day mortality (0.6% vs 0.9%), myocardial infarction or stroke (1.1% vs 2.6%), or major amputation (3.2% vs 2.1%) in the overall cohort of active smokers. In the IC subgroup, myocardial infarction or stroke was significantly higher in the LEB group (1.9% vs 0.6%; OR, 1.83; 95% CI, 1.17-1.97; P = .03), although no difference was found in the CLI subgroup (2.8% vs 1.4%; OR, 0.75; 95% CI, 0.37-1.52; P = .42,). Also in IC group, there was a trend for lower major amputation rates ≤30 days in the LEE group, whereas in the CLI group, LEE had a trend toward higher risk of early amputation compared with LEB. CONCLUSIONS: In active smokers, LEB for IC and CLI requires fewer reinterventions but is associated with a higher rate of postoperative wound complications compared with LEE revascularization. However, the risk for limb amputation is higher in actively smoking patients when treated by LEE compared with LEB for CLI. Importantly, cardiovascular complications are significantly higher in actively smoking patients with IC undergoing LEB compared with LEE. This additional cardiovascular risk should be carefully weighed when proposing LEB for actively smoking patients with nonlimb-threatening IC. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/28527930/Outcomes_of_open_and_endovascular_lower_extremity_revascularization_in_active_smokers_with_advanced_peripheral_arterial_disease_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(17)30193-3 DB - PRIME DP - Unbound Medicine ER -