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Kirkham AM, Candeliere J, Fergusson D, Stelfox HT, Brandys T, McIsaac DI, Ramsay T, Roberts DJ. Prediction Models for Forecasting Risk of Development of Surgical Site Infection after Lower Limb Revascularization Surgery: A Systematic Review. Ann Vasc Surg 2024; 102:140-151. [PMID: 38307235 DOI: 10.1016/j.avsg.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Surgical site infections (SSIs) are a common and potentially preventable complication of lower limb revascularization surgery associated with increased healthcare resource utilization and patient morbidity. We conducted a systematic review to evaluate multivariable prediction models designed to forecast risk of SSI development after these procedures. METHODS After protocol registration (CRD42022331292), we searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies describing multivariable prediction models designed to forecast risk of SSI in adults after lower limb revascularization surgery. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risk of bias. A narrative synthesis was performed to summarize predictors included in the models and their calibration and discrimination, validation status, and clinical applicability. RESULTS Among the 6,671 citations identified, we included 5 studies (n = 23,063 patients). The included studies described 5 unique multivariable prediction models generated through forward selection, backward selection, or Akaike Information Criterion-based methods. Two models were designed to predict any SSI and 3 Szyilagyi grade II (extending into subcutaneous tissue) SSI. Across the 5 models, 18 adjusted predictors (10 of which were preoperative, 3 intraoperative, and 5 postoperative) significantly predicted any SSI and 14 adjusted predictors significantly predict Szilagyi grade II SSI. Female sex, obesity, and chronic obstructive pulmonary disease significantly predicted SSI in more than one model. All models had a "good fit" according to the Hosmer-Lemeshow test (P > 0.05). Model discrimination was quantified using the area under the curve, which ranged from 0.66 to 0.75 across models. Two models were internally validated using non-exhaustive twofold cross-validation and bootstrap resampling. No model was externally validated. Three studies had a high overall risk of bias according to the Prediction model Risk Of Bias ASsessment Tool (PROBAST). CONCLUSIONS Five multivariable prediction models with moderate discrimination have been developed to forecast risk of SSI development after lower limb revascularization surgery. Given the frequency and consequences of SSI after these procedures, development and external validation of novel prediction models and comparison of these models to the existing models evaluated in this systematic review is warranted.
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Affiliation(s)
- Aidan M Kirkham
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jasmine Candeliere
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Critical Care Medicine, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Kirkham AM, Candeliere J, Mai T, Nagpal SK, Brandys TM, Dubois L, Shorr R, Stelfox HT, McIsaac DI, Roberts DJ. Risk Factors for Surgical Site Infection after Lower Limb Revascularisation Surgery: a Systematic Review and Meta-Analysis of Prognostic Studies. Eur J Vasc Endovasc Surg 2024; 67:455-467. [PMID: 37925099 DOI: 10.1016/j.ejvs.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE To systematically review and meta-analyse adjusted risk factors for surgical site infection (SSI) after lower limb revascularisation surgery. DATA SOURCES MEDLINE, Embase, Evidence Based Medicine Reviews, and the Cochrane Central Register of Controlled Trials (inception to 28 April 2022). REVIEW METHODS Systematic review and meta-analysis conducted according to PRISMA guidelines. After protocol registration, databases were searched. Studies reporting adjusted risk factors for SSI in adults who underwent lower limb revascularisation surgery for peripheral artery disease were included. Adjusted odds ratios (ORs) were pooled using random effects models. GRADE was used to assess certainty. RESULTS Among 6 377 citations identified, 50 studies (n = 271 125 patients) were included. The cumulative incidence of SSI was 12 (95% confidence interval [CI] 10 - 13) per 100 patients. Studies reported 139 potential SSI risk factors adjusted for a median of 12 (range 1 - 69) potential confounding factors. Risk factors that increased the pooled adjusted odds of SSI included: female sex (pooled OR 1.41, 95% CI 1.20 - 1.64; high certainty); dependent functional status (pooled OR 1.18, 95% CI 1.03 - 1.35; low certainty); being overweight (pooled OR 1.82, 95% CI 1.29 - 2.56; moderate certainty), obese (pooled OR 2.20, 95% CI 1.44 - 3.36; high certainty), or morbidly obese (pooled OR 1.65, 95% CI 1.08 - 2.52; moderate certainty); chronic obstructive pulmonary disease (pooled OR 1.42, 95% CI 1.17 - 1.71; high certainty); chronic limb threatening ischaemia (pooled OR 1.67, 95% CI 1.22 - 2.29; moderate certainty); chronic kidney disease (pooled OR 2.13, 95% CI 1.18 - 3.83; moderate certainty); intra-operative (pooled OR 1.23, 95% CI 1.02 - 1.49), peri-operative (pooled OR 1.92, 95% CI 1.27 - 2.90), or post-operative (pooled OR 2.21, 95% CI 1.44 - 3.39) blood transfusion (moderate certainty for all); urgent or emergency surgery (pooled OR 2.12, 95% CI 1.22 - 3.70; moderate certainty); vein bypass and or patch instead of endarterectomy alone (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty); an operation lasting ≥ 3 hours (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty) or ≥ 5 hours (pooled OR 1.60, 95% CI 1.18 - 2.17; moderate certainty); and early or unplanned re-operation (pooled OR 4.50, 95% CI 2.18 - 9.32; low certainty). CONCLUSION This systematic review identified evidence informed SSI risk factors following lower limb revascularisation surgery. These may be used to develop improved SSI risk prediction tools and to identify patients who may benefit from evidence informed SSI prevention strategies.
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Affiliation(s)
- Aidan M Kirkham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jasmine Candeliere
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Trinh Mai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy M Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Luc Dubois
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Critical Care Medicine, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Derek J Roberts
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.
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Parker M, Penton A, McDonnell S, Kolde G, Babrowski T, Blecha M. Investigation of center-specific saphenous vein utilization rates in femoral popliteal artery bypass and associated impact of conduit on outcomes. J Vasc Surg 2023; 78:1497-1512.e3. [PMID: 37648090 PMCID: PMC10756644 DOI: 10.1016/j.jvs.2023.08.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate variation in great saphenous vein (GSV) use among the various centers participating in the Vascular Quality Initiative infrainguinal bypass modules. Further, differences in outcomes in femoral-popliteal artery bypass with single segment GSV conduit vs prosthetic conduit will be documented. Center GSV use rate impact on outcomes will be investigated. METHODS Primary exclusions were patients undergoing redo bypass, urgent or emergent bypass, and those in whom prosthetic graft was used while having undergone prior coronary artery bypass grafting. The distribution of GSV use across the 260 centers participating in Vascular Quality Initiative infrainguinal bypass module was placed into histogram and variance in mean GSV use evaluated with analysis of variance analysis. Centers that used GSV in >50% of bypasses were categorized as high use centers and centers that used the GSV in <30% of cases were categorized as low use centers. Baseline differences in patient characteristics and comorbidities in those undergoing bypass with GSV vs prosthetic conduit were analyzed with χ2 testing and the Student t test, as were those undergoing treatment in high vs low use centers. Multivariable time-dependent Cox regression analyses were then performed for the primary outcomes of major amputation ipsilateral to the operative side and mortality in long-term follow-up. High vs low use center was a dichotomous variable in these regressions. Secondary outcomes of freedom from graft infection and freedom from loss of primary patency were performed with Kaplan-Meier analysis. RESULTS Among centers with >50 patients meeting inclusion criteria for this study, GSV use ranged from 15% to 93% (analysis of variance P < .001). When considering all centers irrespective of number of patients, the range was 0% to 100%. On Kaplan-Meier analysis, GSV conduit use was associated with improved freedom from loss of primary or primary assisted patency, improved freedom from major amputation after index hospitalization, improved freedom from graft infection after the index hospitalization, and improved freedom from mortality in long-term follow-up (log-rank P < .001 for all four outcomes). Both low use center (hazard ratio, 1.35; P < .001) and prosthetic graft use (hazard ratio, 1.24; P < .001) achieved multivariable significance as risks for mortality in long-term follow-up. Other variables with a multivariable mortality association are presented in the manuscript. Low use center and prosthetic bypass were significant univariable but not multivariable risks for major amputation after index hospitalization. CONCLUSIONS There is remarkably wide variation in GSV use for femoral popliteal artery bypass among various medical centers. GSV use is associated with enhanced long-term survival as well as freedom from loss of bypass patency and graft infection. The data herein indicate institutional patterns of prosthetic conduit choice, which has the potential to be altered to enhance outcomes.
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Affiliation(s)
- Michael Parker
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Ashley Penton
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Shannon McDonnell
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Grant Kolde
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Trissa Babrowski
- University of Chicago Medical Center, Pritzker School of Medicine, Section of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Matthew Blecha
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL.
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Tresson P, Quiquandon S, Rivoire E, Boibieux A, Vanhems P, Bordet M, Long A. American Society of Anesthesiologists-Physical Status Classification As An Independent Risk Factor of Surgical Site Infection After Infra-Inguinal Arterial Bypass. Ann Surg 2023; 277:e1157-e1163. [PMID: 35417113 DOI: 10.1097/sla.0000000000005182] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The present study aimed to assess whether high-risk American Society of Anesthesiologists (ASA)-Physical Status was an independent risk factor for the development of surgical site infection (SSI) after infra-inguinal lower extremity bypass (LEB). SUMMARY OF BACKGROUND DATA The ASA-Physical Status Classification System assesses the overall physical status preoperatively. ASA-Physical Status is associated with postoperative morbidity and mortality. However, limited data are available on how ASA-Physical Status Class affects the development of SSI after infra-inguinal LEB. METHODS Patients who had undergone infra-inguinal LEB from January 1, 2015 to December 31, 2018, for obliterative arteriopathy or popliteal aneurysm at our university hospital were included. SSI risk factors were identified using multivariable logistic regression. The length of hospital stay, major limb events (MALE), major adverse cardiovascular events (MACE), and all-cause mortality were compared for patients with SSI versus those without SSI 3 months and 1- year of follow-up after the index surgery. RESULTS Among the 267 patients included, 30 (11.2%) developed SSI during the 3-month period and 32 (12%) at 1 year. ASA-Physical Status ≥3 [odds ratio (OR): 3.7, 95% confidence interval CI) 1.5-11.1], emergency surgery (OR: 2.7, 95% CI 1.2-6.0), general anesthesia (OR: 2.8, 95% CI 1.3-6.1), and procedure performed by a junior surgeon (OR: 2.7, 95% CI 1.3-6.0) were independently associated with SSI. At 3 months and 1 year, SSI was significantly associated with MALE (including surgical wound debridement, subsequent thrombectomy, major amputation), length of hospital stay, and all-cause mortality. CONCLUSION The ASA-Physical Status should be considered in medical management when an infra-inguinal LEB is considered in frail patients, to prevent surgical complications.
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Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, France
- Centre rHodANien d'isChemie intEStinale (CHANCES Network), Hospices Civils de Lyon, France
| | - Samuel Quiquandon
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Emeraude Rivoire
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - André Boibieux
- Centre de Référence des Infections Vasculaire Complexes (CRIVasc Network), Lyon, France
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses Lyon cedex, France
| | - Philippe Vanhems
- Hospices Civils de Lyon, Hopital Edouard Herriot, Service d'Hygiéne, Epidémiologie et Prévention, Lyon cedex, France
- CIRI, Centre International de Recherche en Infectiologie, Laboratoire des Pathogénes Emergents-Fondation Mérieux, Université Lyon, Inserm, ENS de Lyon, France
| | - Marine Bordet
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Anne Long
- Centre rHodANien d'isChemie intEStinale (CHANCES Network), Hospices Civils de Lyon, France
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
- Université de Lyon, University Claude Bernard Lyon 1, Lyon, France
- Univ Lyon, University Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
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Jacob-Brassard J, Al-Omran M, Salata K, Hussain MA, Kayssi A, Roche-Nagle G, de Mestral C. A survey of Canadian surgeons on the indications for home care nursing following vascular surgery. Can J Surg 2021; 64:E149-E154. [PMID: 33666391 PMCID: PMC8064247 DOI: 10.1503/cjs.001220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background Recent evidence suggests that home care nursing is variably prescribed after vascular surgery, and may reduce emergency department visits and hospital readmissions. We therefore sought to characterize the indications for home care nursing following vascular surgery from the surgeon’s perspective. Methods An online survey was distributed to the 141 members of the Canadian Society for Vascular Surgery with questions related to home care nursing after carotid endarterectomy (CEA), endovascular aortic aneurysm repair (EVAR), open abdominal aortic aneurysm (AAA) repair and open or hybrid revascularization for peripheral arterial disease (PAD). We included all questionnaires in our analysis; the frequency denominator changes according to the number of respondents who completed each survey item. Results There were 46 survey respondents (33% of 141) from across the country. A total of 28 (62% of 45) worked in a teaching hospital. Home care nursing was routinely prescribed by 5%, 10%, 31% and 41% of respondents following CEA, EVAR, open AAA repair and open or hybrid revascularization for PAD, respectively. Across all procedure types, the same procedure-related criteria were most often deemed to warrant a prescription for home care nursing: surgical site infection, wound complications (e.g., open wound, lymphatic leak) and use of negative-pressure wound therapy. Across all procedure types, lack of social support, physical frailty and cognitive impairment were most frequently identified as patient-specific considerations for prescribing home care nursing. Few respondents reported restrictions or standards that informed their prescribing practice. Conclusion Most surgeon respondents agreed on the indications for home care nursing after vascular surgery. However, evidence-based standards to guide patient selection for home care nursing after vascular surgery are needed.
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Affiliation(s)
- Jean Jacob-Brassard
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
| | - Mohammed Al-Omran
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
| | - Konrad Salata
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
| | - Mohamad A Hussain
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
| | - Ahmed Kayssi
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
| | - Graham Roche-Nagle
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
| | - Charles de Mestral
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Jacob-Brassard, Al-Omran, Salata, Hussain, Kayssi, Roche-Nagle); the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ont. (Al-Omran, Salata, Hussain, de Mestral); the Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ont. (Kayssi); and the Peter Munk Cardiac Center of the University Health Network, Toronto, Ont. (Roche-Nagle)
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Abstract
Objective: In paramalleolar bypass for critical limb-threatening ischemia (CLTI), excessive skin tension may occur for the closure of surgical wounds around the ankle. Furthermore, these surgical incisions are often proximal to infectious ischemic ulcers. Wound dehiscence caused by skin tension and surgical site infection carries a risk of graft exposure, anastomotic disruption, or graft insufficiency. Patients and Methods: Tension-free wound management was adopted in eight patients who underwent paramalleolar bypass for CLTI. Tension-free closure was adopted for surgical incisions for distal anastomotic site of the paramalleolar bypass, whereas the incisions for saphenous vein harvest were left open. A relief incision was made as needed. The opened incisions were covered with artificial dermis. Results: All surgical incisions and ischemic wounds healed successfully within 1.8 months after bypass. Two postoperative graft stenoses occurred, which were rescued by additional endovascular intervention. Secondary graft patency, wound healing, and limb salvage rates were 100% during an average follow-up period of 30 months. Conclusion: Tension-free wound closure using artificial dermis was effective in selected cases of paramalleolar bypass for CLTI.
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Affiliation(s)
| | - Ikuro Kitano
- Department of Vascular Surgery, Shinsuma General Hospital
| | - Yoriko Tsuji
- Department of Plastic Surgery, Shinsuma General Hospital
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Braet DJ, Taaffe JP, Dombrovskiy VY, Bath J, Kruse RL, Vogel TR. Modified frailty index as an indicator for outcomes, discharge status, and readmission after lower extremity bypass surgery for critical limb ischemia. JOURNAL OF VASCULAR NURSING 2020; 38:171-175. [PMID: 33279105 DOI: 10.1016/j.jvn.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/08/2020] [Accepted: 08/23/2020] [Indexed: 12/19/2022]
Abstract
Frailty has been associated with poor postoperative outcomes. This study evaluated the 5-factor modified frailty index (mFI-5) to assess complications, mortality, discharge disposition, and readmission in patients undergoing lower extremity (LE) bypass for critical limb ischemia (CLI).The National Surgical Quality Improvement Program vascular module (2011-2017) was utilized to identify patients undergoing LE bypass for CLI. Adverse events included infectious complications, bleeding complications, prolonged ventilation, amputation, readmission, and death. Patients were divided into groups based on mFI-5 scores: mFI1 (0), mFI2 (0.2), mFI3 (0.4), and mFI4 (0.6-1). Data were analyzed using the Cochran-Mantel-Haenszel statistic for general association and multivariable logistic regression. About 11,530 patients undergoing bypass for CLI were identified (42% rest pain and 58% tissue loss; 23% mFI1, 31% mFI2, 27% mFI3, and 19% mFI4; 64% men and 36% women). An increase in mFI-5 was associated with higher 30-day mortality (mFI1 = 0.62%; mFI12 = 1.45%; mFI13 = 1.35%; and mFI14 = 3.09%; P < .0001). After adjustment for age, mFI4 was associated with increased mortality compared with mFI1 (odds ratio, 3.80; 95% confidence interval, 1.69-8.54). Increased mFI-5 was associated with bleeding complications, wound infections, urinary tract infections, prolonged ventilation, sepsis, unplanned reoperations, and discharge to nonhome destination (all P < .01). Compared with mFI1 (13.5%), mFI4 was associated with increased 30-day readmission (24.8%, P < .0001). In patients undergoing LE bypass for CLI, higher mFI-5 was associated with increased postoperative complications, in-hospital and 30-day mortality, nonhome discharge, and 30-day readmission. The mFI-5 as an easily calculated tool can identify patients at high risk for inferior outcomes. It should be incorporated into discharge planning after LE bypass for CLI.
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Affiliation(s)
- Drew J Braet
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - John P Taaffe
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Viktor Y Dombrovskiy
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jonathan Bath
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine Columbia, Missouri
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, Missouri.
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Khoury MK, Rectenwald JE, Tsai S, Kirkwood ML, Ramanan B, Timaran CH, Modrall JG. Outcomes after Open Lower Extremity Revascularization in Patients with Critical Limb Ischemia. Ann Vasc Surg 2020; 67:417-424. [PMID: 32339678 DOI: 10.1016/j.avsg.2020.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND For decades, open intervention was the treatment of choice in patients requiring lower extremity revascularization. In the endovascular era, however, open and endovascular revascularization are options. The implications of prior revascularization on the outcomes for subsequent revascularization are not known. In the present study, we evaluated 30-day outcomes after open lower extremity revascularization for critical limb ischemia (CLI) in those who had previous interventions. METHODS The 2012-2017 open lower extremity bypass Participant User Data Files from the National Surgical Quality Improvement Program were used to identify a cohort of patients with CLI. Patients whose operation was considered emergent were excluded from the analysis. Patients were stratified on whether they had a previous open or endovascular intervention or undergoing a primary revascularization. The primary outcome measure was 30-day major adverse limb events (MALEs). Secondary outcomes included major adverse cardiac events (MACEs) and wound complications. RESULTS A total of 12,668 patients met study criteria with 59.6% (n = 7,549) undergoing a primary open revascularization, 22.4% (n = 2,839) having a prior endovascular intervention, and 18.0% (n = 2,280) having a prior open revascularization. There were notable differences in the baseline characteristics between the 3 groups. In addition, there were differences in the reason for intervention (rest pain versus tissue loss), type of revascularization, and type of conduit used between the 3 groups. After adjustment, a prior open revascularization was significantly associated with 30-day MALE when compared with a primary revascularization (adjusted odds ratio, 1.69; 95% confidence interval, 1.47-1.94; P < 0.001) and prior endovascular intervention (adjusted odds ratio, 1.76; 95% confidence interval, 1.46-2.12; P < 0.001). There were no differences in outcomes between primary revascularization and prior endovascular patients. There were no differences between MACEs or wound complications between the 3 groups. CONCLUSIONS A prior endovascular intervention does not seem to accrue any additional short-term risk when compared with primary revascularization, suggesting an endovascular-first approach may be a safe strategy in patients with CLI. However, a prior open intervention is significantly associated with 30-day MALE in patients undergoing redo open revascularization, which may be related to the rapid decline in patients once they have exhausted their best open revascularization option.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Southwestern Medical Center, University of Texas, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - John E Rectenwald
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, Southwestern Medical Center, University of Texas, Dallas, TX; Department of Surgery, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, Southwestern Medical Center, University of Texas, Dallas, TX
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Southwestern Medical Center, University of Texas, Dallas, TX; Department of Surgery, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, Southwestern Medical Center, University of Texas, Dallas, TX
| | - J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Southwestern Medical Center, University of Texas, Dallas, TX; Department of Surgery, Dallas Veterans Affairs Medical Center, Dallas, TX.
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Kilpadi DV, Olivie M. Evaluation of closed incision negative pressure therapy systems on the closure of incisional space model. J Wound Care 2019; 28:850-860. [PMID: 31825775 DOI: 10.12968/jowc.2019.28.12.850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The objective of this study was to compare the ability of foam dressing-based and non-foam-based closed incision negative pressure therapy (ciNPT) systems to close isolated incisional deficits in a tissue model. METHODS Similarly sized foam-based and non-foam-based absorbent ciNPT dressings were applied to ~36cm long, ~3mm and ~6mm wide simulated incisions in gel sheets covered with drape (n=6 dressings/group/experimental condition spread over three respective therapy units). Changes in incision widths were measured directly or with overlying solid gel sheeting (to mimic tissue resistance), at five equally spaced locations before, immediately upon and one hour after initiating negative pressure using associated therapy units. RESULTS Foam-based ciNPT closed simulated incisions more often than non-foam-based ciNPT in all tested conditions (p<0.05). While foam-based ciNPT almost completely closed the ~3mm wide incisional spaces, unlike non-foam-based ciNPT, the biggest differences between the two groups were observed with the ~6mm incisional width, which allowed maximal inward-stretching of the appositional faces without complete closure. The additional gel layer blunted closure in both groups, but much more with non-foam-based ciNPT. There was minimal impact of negative pressure duration on these results. CONCLUSION Foam-based ciNPT closed incisional widths in simulated tissue significantly more compared with non-foam-based ciNPT. Different ciNPT systems should not be considered necessarily equivalent in performance.
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Bui UT, Finlayson K, Edwards H. Risk factors for infection in patients with chronic leg ulcers: A survival analysis. Int J Clin Pract 2018; 72:e13263. [PMID: 30239088 DOI: 10.1111/ijcp.13263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/30/2018] [Accepted: 08/27/2018] [Indexed: 12/25/2022] Open
Abstract
AIM This study aimed to validate the relationships between possible predictive factors and clinically diagnosed infection in adult patients with chronic leg ulcers. METHODS This study used a sample of 636 adult participants whose ulcers were diagnosed as either venous, arterial or mixed aetiology leg ulcers and had no clinical signs of infection at recruitment. Data were extracted from recruitment to 12 weeks from six longitudinal prospective studies from 2004 to 2015. Survival analysis was used to investigate mean time-to-infection, including the Kaplan-Meier method and the Cox proportional-hazards regression model. RESULTS The sample included 74.7% venous, 19.6% mixed and 5.7% arterial leg ulcers. There were 101 (15.9%) participants diagnosed with infection at least once within 12 weeks of follow-up. Mean time-to-infection was 10.89 weeks (95% CI = 10.66-11.12). After adjustment for potential confounders, a Cox proportional hazards regression model found that depression, using walking aids, calf ankle ratio <1.3, wound area ≥10 cm2 and ulcers with slough tissue at recruitment were significant risk factors for wound infection. CONCLUSION This study has validated the predictive ability of factors which have been found in a cross-sectional study to be significantly associated with infection in patients with leg ulcers, including venous leg ulcers, arterial leg ulcers and mixed aetiology leg ulcers. Results showed that patients with chronic leg ulcers, who either presented with depression, used walking aids, had a calf ankle ratio <1.3, a wound area ≥10 cm2 or an ulcer with slough tissue, had greater likelihood of developing infection compared to those without these factors.
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Affiliation(s)
- Ut T Bui
- Faculty of Health, School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld, Australia
- Wound Management Innovation Cooperative Research Centre, West End, Qld, Australia
| | - Kathleen Finlayson
- Faculty of Health, School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld, Australia
- Wound Management Innovation Cooperative Research Centre, West End, Qld, Australia
| | - Helen Edwards
- Faculty of Health, School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld, Australia
- Wound Management Innovation Cooperative Research Centre, West End, Qld, Australia
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Ma J, Zhao J, Bai Q, He S, Yu J, Gou Y. [Application of VSD in 6 Cases of Postoperative Infection
-A Clinical Experience Sharing]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2018; 21:343-347. [PMID: 29587923 PMCID: PMC5973333 DOI: 10.3779/j.issn.1009-3419.2018.04.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
背景与目的 手术切口感染是胸外科术后常见并发症之一,其危害与感染程度、部位等相关,轻者致局部疼痛、住院时间延长、费用增加,重者可导致严重感染,甚至感染性休克、危及生命。因此,妥善处理切口感染,有利于促进恢复、降低疾病负担、奠定进一步治疗良好基础。切口感染传统外科处理措施包括彻底引流、加强换药、使用抗生素等,存在治疗过程长、治疗效果不确切等不足。本研究对我科6例胸部手术术后发生感染患者尝试性使用负压封闭引流装置(vacuum sealing drainage, VSD)的经验进行总结,以期改进传统应对患者胸部手术术后感染的处理模式。 方法 对我院近一年来出现胸部手术术后切口感染或手术切口瘘的患者相关临床数据进行回顾和总结,选择了其中6例使用VSD材料治疗术后感染的患者,对其使用VSD处理的过程和最终临床结果进行总结讨论。 结果 本研究中所有患者在使用VSD后6 h-10 h内发热、伤口渗出症状消失。7天-10天后拔除引流装置,5例患者创面感染情况明显改善,伤口分泌物消失,手术切缘肉芽组织生长良好,二期手术关闭胸腔和皮肤。1例患者感染严重,去除VSD后分泌物仍较多,效果不明显,再次放置VSD装置,7天后去除VSD装置,患者手术切口无渗出,肉芽组织生长良好,二期手术关闭胸腔和皮肤。所有6例患者最终感染症状缓解,症状改善,手术切口愈合良好出院。2例食管癌患者中,平均手术时间427.5 min,术后平均住院天数40天,术后平均换药次数8.5次,住院期间平均总花费111, 893.47元;4例慢性脓胸患者中,平均手术时间192.5 min,术后平均住院天数27.75天,术后平均换药次数5.5次,住院期间平均总花费48, 237.71元。 结论 VSD在处理胸外科手术术后切口感染患者中效果良好,减少了患者的痛苦和负担,保证了发生术后感染患者的生活质量。
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Affiliation(s)
- Jilong Ma
- Gansu University of Traditional Chinese Medicine, Lanzhou 730000, China.,Gansu Provincial Hospital, Lanzhou 730000, China
| | - Jing Zhao
- The first people's Hospital of Lanzhou, Lanzhou 730000, China
| | - Qizhou Bai
- Gansu Provincial Hospital, Lanzhou 730000, China
| | | | - Jun Yu
- Gansu Provincial Hospital, Lanzhou 730000, China
| | - Yunjiu Gou
- Gansu Provincial Hospital, Lanzhou 730000, China
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Erben Y, Mena-Hurtado CI, Miller SM, Jean RA, Sumpio BJ, Velasquez CA, Mojibian H, Aruny J, Dardik A, Sumpio BE. Increased mortality in octogenarians treated for lifestyle limiting claudication. Catheter Cardiovasc Interv 2018; 91:1331-1338. [DOI: 10.1002/ccd.27523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/15/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Young Erben
- Section of Vascular and Endovascular Surgery, Department of Surgery; Yale University School of Medicine; New Haven Connecticut
| | - Carlos I. Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine; Yale University School of Medicine; New Haven Connecticut
| | - Samuel M. Miller
- Warren Alpert Medical School at Brown University; Providence Rhode Island
| | - Raymond A. Jean
- Department of Surgery; Yale University School of Medicine; New Haven Connecticut
- National Clinician Scholars Program, Department of Internal Medicine; Yale School of Medicine; New Haven Connecticut
| | - Brandon J. Sumpio
- Department of Surgery; Yale University School of Medicine; New Haven Connecticut
| | | | - Hamid Mojibian
- Section of Vascular Interventional Radiology, Department of Radiology; Yale University School of Medicine; New Haven Connecticut
| | - John Aruny
- Section of Vascular Interventional Radiology, Department of Radiology; Yale University School of Medicine; New Haven Connecticut
| | - Alan Dardik
- Section of Vascular and Endovascular Surgery, Department of Surgery; Yale University School of Medicine; New Haven Connecticut
| | - Bauer E. Sumpio
- Section of Vascular and Endovascular Surgery, Department of Surgery; Yale University School of Medicine; New Haven Connecticut
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Rodríguez-Acelas AL, de Abreu Almeida M, Engelman B, Cañon-Montañez W. Risk factors for health care-associated infection in hospitalized adults: Systematic review and meta-analysis. Am J Infect Control 2017; 45:e149-e156. [PMID: 29031433 DOI: 10.1016/j.ajic.2017.08.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/25/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Health care-associated infections (HAIs) are a public health problem that increase health care costs. This article aimed to systematically review the literature and meta-analyze studies investigating risk factors (RFs) independently associated with HAIs in hospitalized adults. METHODS Electronic databases (MEDLINE, Embase, and LILACS) were searched to identify studies from 2009-2016. Pooled risk ratios (RRs) or odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated and compared across the groups. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS Of 867 studies, 65 met the criteria for review, and the data of 18 were summarized in the meta-analysis. The major RFs independently associated with HAIs were diabetes mellitus (RR, 1.76; 95% CI, 1.27-2.44), immunosuppression (RR, 1.24; 95% CI, 1.04-1.47), body temperature (MD, 0.62; 95% CI, 0.41-0.83), surgery time in minutes (MD, 34.53; 95% CI, 22.17-46.89), reoperation (RR, 7.94; 95% CI, 5.49-11.48), cephalosporin exposure (RR, 1.77; 95% CI, 1.30-2.42), days of exposure to central venous catheter (MD, 5.20; 95% CI, 4.91-5.48), intensive care unit (ICU) admission (RR, 3.76; 95% CI, 1.79-7.92), ICU stay in days (MD, 21.30; 95% CI, 19.81-22.79), and mechanical ventilation (OR, 12.95; 95% CI, 6.28-26.73). CONCLUSIONS Identifying RFs that contribute to develop HAIs may support the implementation of strategies for their prevention, therefore maximizing patient safety.
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Dickas D, Verrel F, Kalff J, Koscielny A. Axillobifemoral Bypasses: Reappraisal of an Extra-Anatomic Bypass by Analysis of Results and Prognostic Factors. World J Surg 2017; 42:283-294. [PMID: 28741197 DOI: 10.1007/s00268-017-4150-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Axillobifemoral bypass (AFB) is method of second choice. It is reserved for patients at high operative risk or to bypass infected vessels or grafts. In this study, we analyzed prognostic factors for AFB patency and limb salvage rate to facilitate the choice of procedure. METHODS Between Jan 2006 and Aug 2013, 45 patients underwent AFB surgery in our department, 24 for critical limb ischemia (CLI) and 23 for infection. Endpoints of study were graft occlusion, graft infection, amputation and patient's death. Prognostic factors were compared by univariate analysis for each indication group. Mean follow-up was 40.2 (±23.2) months. RESULTS Complication rate was significantly higher in infection group (88.0 vs. 54.4%, p = 0.003) and in emergency surgery (83.3 vs. 56.9%, p = 0.023). Overall primary patency rate after AFB procedures was 66.7% after 1, 3, and 5 years, while secondary patency rate was 91.1% after 1 year, 82.2% after 3 years and 80.0% after 5 years. The primary and secondary patency rates did not significantly differ between the both groups (p = 0.059 and p = 0.136). Following prognostic factors showed a statistically significant influence on patency rates in CLI group: >1 previous vascular surgical intervention, patch angioplasty at the distal anastomosis site, complications after previous vascular surgery, and perioperative intake of platelet aggregation inhibitor. Only the employed bypass material had a statistical significant influence on the secondary patency rates in the infection group. Overall limb salvage rate was 82.2% after 1 year, 80.0% after 3 years and 77.8% after 5 years. There were statistically significant differences in the limb salvage rates depending on emergency surgery and a 3-vessel-run-off in the lower leg in both indication groups. CONCLUSION AFB have acceptable patency and limb salvage rates. AFB is a good alternative in patients with CLI at high operative risk or with infections of aortoiliac segments, even with endovascular approaches. They remain essential tools in vascular surgeon's repertoire.
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Affiliation(s)
- D Dickas
- Department for General, Vascular, and Thoracic Surgery, University of Bonn Medical School, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - F Verrel
- Department for General, Vascular, and Thoracic Surgery, University of Bonn Medical School, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - J Kalff
- Department for General, Vascular, and Thoracic Surgery, University of Bonn Medical School, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - A Koscielny
- Department for General, Vascular, and Thoracic Surgery, University of Bonn Medical School, Sigmund-Freud-Straße 25, 53127, Bonn, Germany.
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