Optimising fitness for major vascular surgery

Functional Impairment is Associated with Poor Long-Term Outcomes after Arteriovenous Access Creation

BACKGROUND

Functional impairment affects outcomes after a variety of procedures. However, the impact of functional impairment on outcomes of arteriovenous (AV) access creation is unclear. We aimed to evaluate the association of patients' ability to ambulate and perform activities of daily living (ADL) with AV access outcomes.

METHODS

We retrospectively reviewed patients undergoing AV access creation at an urban, safety-net hospital from 2014 to 2022. We evaluated associations of impaired ambulatory and assisted ADL status with 90-day readmission, 1-year primary patency, and 5-year mortality.

RESULTS

Among the 689 patients receiving AV access, mean age was 59.6 ± 13.9 years, 59% were male, and 60% were Black. Access types included brachiocephalic (42%), brachiobasilic (26%), radiocephalic (14%), other autogenous (5%) fistulas, and prosthetic grafts (13%). Impaired ambulatory status was identified in 35% and assisted ADL status, when assessed, was identified in 21% of patients. Ninety-day readmission was more likely in patients with impaired ambulatory (58% vs. 39%, P < 0.001) and assisted ADL (56% vs. 41%, P = 0.004) status. On Kaplan-Meier analysis, 1-year primary patency was lower for patients with impaired ambulatory status (44% ± 3% vs. 29% ± 3%, P = 0.001), but was not significantly different for patients with assisted ADL status (41% ± 3% vs. 32% ± 5%, P = 0.12). Five-year survival was lower for patients with impaired ambulatory status (53% ± 5% vs. 74% ± 4%, P < 0.001), but was not significantly different for patients with assisted ADL status (45% ± 9% vs. 71% ± 4%, P = 0.1). On multivariable analysis, increased likelihood of 90-day readmission was significantly associated with impaired ambulatory status (odds ratio (OR) 2.03, 95% confidence interval (CI) 1.4-2.94, P < 0.001) and assisted ADL status (OR 1.66, 95% CI 1.07-2.57, P = 0.02). One-year primary patency was not significantly associated with impaired ambulatory (hazard ratio (HR) 1.25, 95% CI 0.98-1.6, P = 0.07) or assisted ADL status (HR 1.13, 95% CI 0.87-1.48, P = 0.36). Increased likelihood of 5-year mortality was associated with impaired ambulatory (HR 1.65, 95% CI 1.04-2.62, P = 0.04) and assisted ADL status (HR 2.63, 95% CI 1.35-5.11, P = 0.004).

CONCLUSIONS

Impaired ambulatory and assisted ADL statuses were associated with increased readmissions and long-term mortality after AV access creation. Approximately half of patients with functional impairment were not alive at 5 years. Setting outcome expectations as well as prospectively examining the impact of physical therapy and visiting nursing services for functionally impaired patients undergoing AV access creation are warranted.

Association between Masseter Muscle Area and Thickness and Outcome after Carotid Endarterectomy: A Retrospective Cohort Study

Low muscle mass is associated with adverse outcomes after surgery. This study examined whether facial muscles, such as the masseter muscle, could be used as a proxy for generalized low muscle mass and could be associated with deviant outcomes after carotid endarterectomy (CEA). As a part of the Vascular Ageing study, patients with an available preoperative CT-scan, who underwent an elective CEA between December 2009 and May 2018, were included. Bilateral masseter muscle area and thickness were measured on preoperative CT scans. A masseter muscle area or thickness of one standard deviation below the sex-based mean was considered low masseter muscle area (LMA) or low masseter muscle thickness (LMT). Of the 123 included patients (73.3% men; mean age 68 (9.7) years), 22 (17.9%) patients had LMA, and 18 (14.6%) patients had LMT. A total of 41 (33.3%) patients had a complicated postoperative course and median length of hospital stay was four (4–5) days. Recurrent stroke within 5 years occurred in eight (6.6%) patients. Univariable analysis showed an association between LMA, complications and prolonged hospital stay. LMT was associated with a prolonged hospital stay (OR 8.78 [1.15–66.85]; p = 0.036) and recurrent stroke within 5 years (HR 12.40 [1.83–84.09]; p = 0.010) in multivariable logistic regression analysis. Masseter muscle might be useful in preoperative risk assessment for adverse short- and long-term postoperative outcomes.

Preoperative exercise training for adults undergoing elective major vascular surgery: A systematic review

Patients undergoing major vascular surgery may have an increased risk of postoperative complications due to poor 'fitness for surgery'. Prehabilitation aims to optimise physical fitness and risk factors before surgery to improve outcomes. The role of exercise-based prehabilitation in vascular surgery is currently unclear. Therefore, the aim of this systematic review was to assess the benefits and harms of preoperative exercise training in adults undergoing elective vascular surgery. We searched MEDLINE, Embase, CINAHL, and CENTRAL databases, trial registries, and forward and backward citations for studies published between January 2008 and April 2021. We included randomised trials that compared patients receiving exercise training with those receiving usual care or no training before vascular surgery. Outcomes included mortality, complications, and health-related quality of life (HRQOL). Three trials with 197 participants were included. All studies involved people undergoing abdominal aortic aneurysm (AAA) repair. Low-certainty evidence could not differentiate between rates of all-cause mortality. Moderate-certainty evidence indicated that postoperative cardiac and renal complications were less likely to occur in people who participated in preoperative exercise training compared with those who did not. Low-certainty evidence also indicated better postoperative HRQOL outcomes in people who undertook prehabilitation. There were no serious exercise-related adverse events. The evidence on preoperative exercise training for AAA patients is promising, but currently insufficiently robust for this intervention to be recommended in clinical guidelines. High-quality trials are needed to establish its clinical and cost-effectiveness. Research is also needed to determine the feasibility and effects of prehabilitation before lower-limb revascularisation. Trial registration: PROSPERO ID: CRD42021245933.

Outcomes of Vascular and Endovascular Interventions Performed During the Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE

The aim of the COVER Study is to identify global outcomes and decision making for vascular procedures during the pandemic.

BACKGROUND DATA

During its initial peak, there were many reports of delays to vital surgery and the release of several guidelines advising later thresholds for vascular surgical intervention for key conditions.

METHODS

An international multi-center observational study of outcomes after open and endovascular interventions.

RESULTS

In an analysis of 1103 vascular intervention (57 centers in 19 countries), 71.6% were elective or scheduled procedures. Mean age was 67 ± 14 years (75.6% male). Suspected or confirmed COVID-19 infection was documented in 4.0%. Overall, in-hospital mortality was 11.0% [aortic interventions mortality 15.2% (23/151), amputations 12.1% (28/232), carotid interventions 10.7% (11/103), lower limb revascularisations 9.8% (51/521)]. Chronic obstructive pulmonary disease [odds ratio (OR) 2.02, 95% confidence interval (CI) 1.30-3.15] and active lower respiratory tract infection due to any cause (OR 24.94, 95% CI 12.57-241.70) ware associated with mortality, whereas elective or scheduled cases were lower risk (OR 0.4, 95% CI 0.22-0.73 and 0.60, 95% CI 0.45-0.98, respectively. After adjustment, antiplatelet (OR 0.503, 95% CI: 0.273-0.928) and oral anticoagulation (OR 0.411, 95% CI: 0.205-0.824) were linked to reduced risk of in-hospital mortality.

CONCLUSIONS

Mortality after vascular interventions during this period was unexpectedly high. Suspected or confirmed COVID-19 cases were uncommon. Therefore an alternative cause, for example, recommendations for delayed surgery, should be considered. The vascular community must anticipate longer term implications for survival.