Postoperative complications after lower extremity arterial bypass increase the risk of new deep venous thrombosis

A Meta-Analysis to Derive Population-Based Quality Benchmarks of the Incidence of Surgical Site Infection after Lower Limb Revascularization Surgery

BACKGROUND

The reported incidence of surgical site infection (SSI) after lower limb revascularization surgery varies. We conducted a systematic review and meta-analysis of population-based studies reporting the incidence of SSI in adults who underwent these surgeries in high-income countries to derive SSI quality benchmarks.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception-to-April 28th, 2022) for population-based studies estimating the cumulative incidence of SSI among adults who underwent lower limb revascularization surgery for peripheral artery disease (PAD) in high-income countries. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risks of bias. We used random-effects models to pool data and GRADE to assess certainty.

RESULTS

Among 6,258 citations, we included 53 studies (n = 757,726 patients); 8 of which (n = 435,769 patients) reported nonoverlapping data that were meta-analyzed. The pooled cumulative incidence of any SSI was 6.0 in 100 patients [95% confidence interval (CI) = 4.3-8.0 in 100 patients; n = 8 studies; n = 435,769 patients; moderate certainty]. The cumulative incidence of Szilagyi grade I (cellulitis), grade II (subcutaneous tissue), and grade III (prosthetic graft) SSI was 6.5 in 100 patients (95% CI = 4.3-8.6 in 100 patients; n = 2 studies; n = 39,645 patients; low certainty), 2.1 in 100 patients (95% CI = 2.0-2.3 in 100 patients; n = 2 studies; low certainty), and 0.4 in 100 patients (95% CI = 0.4-0.4 in 100 patients; n = 1 study; n = 333,275 patients; low certainty), respectively. The pooled cumulative incidence of any early (in-hospital/≤30-days) and late (>30-days) SSI was 6.2 in 100 patients (95% CI = 4.4-8.0 in 100 patients; n = 7 studies; n = 431,273 patients; moderate certainty) and 3.7 in 100 patients (95% CI = 2.2-5.2 in 100 patients; n = 2 studies; n = 10,565 patients; low certainty), respectively.

CONCLUSIONS

This systematic review derived population-based benchmarks of the incidence of any SSI; Szilagyi I, II, and III SSI; and early and late SSI after lower limb revascularization surgery. These may be used by practicing surgeons and healthcare leaders/administrators to guide quality improvement efforts in the United States and perhaps other countries.

Daly/Cost comparison in the management of peripheral arterial disease at 17 Belgian hospitals

OBJECTIVE

Peripheral arterial disease (PAD) is a manifestation of atherosclerosis that affects the lower extremities and afflicts more than 200 million people worldwide. Because of limited resources, the need to provide quality care associated with cost control is essential for health policies. Our study concerns an interhospital comparison among seventeen Belgian hospitals that integrates the weighting of quality indicators and the costs of care, from the hospital perspective, for a patient with this pathology in 2018.

METHODS

The disability-adjusted life years (DALYs) were calculated by adding the number of years of life lost due to premature death and the number of years of life lost due to disability for each in-hospital stay. The DALY impact was interpreted according to patient safety indicators. We compared the hospitals using the adjusted values ​​of costs and DALYs for their case mix index, obtained by relating the observed value to the predicted value obtained by linear regression.

RESULTS

We studied 2,437 patients and recorded a total of 560.1 DALYs in hospitals. The in-hospital cost average [standard deviation (SD)] was €8,673 (€10,893). Our model identified the hospitals whose observed values were higher than predicted; six needed to reduce the costs and impacts of DALYs, six needed to improve one of the two factors, and four seemed to have good results. The average cost (SD) for the worst performing hospitals amounted to €27,803 (€28,358).

CONCLUSIONS

Studying the costs of treatment according to patient safety indicators permits us to evaluate the entire chain of care using a comparable unit of measurement.

Analysis of risk factors of lower extremity deep venous thrombosis in patients undergoing hepatobiliary surgery

This study analyzed records of 200 patients who underwent hepatobiliary surgery to identify factors that contribute to lower extremity venous thromboembolism (VTE). 19 patients (9.50%) developed lower extremity deep vein thrombosis. Univariate analysis revealed significant differences between the study group and the control group in terms of age, body mass index, previous thromboembolic history, hypertension, type 2 diabetes, hyperlipidemia, smoking history, times of lower extremity venipuncture, operation time, postoperative bedrest time, postoperative platelet count, postoperative D-dimer level, and postoperative C-reactive protein level (P<0.05). Multivariable logistic regression analysis identified age ≥60 years, body mass index ≥24 kg/m2, previous history of thromboembolism, hypertension, type 2 diabetes mellitus, hyperlipidemia, smoking history, number of lower extremity venipunctures ≥5, operation time ≥2 hours, postoperative bedrest time ≥48 hours, postoperative blood platelet count ≥300×109/L, postoperative D-dimer level ≥200 g/L, and postoperative C-reactive protein ≥8.0 mg/L as significant predisposing factors for lower extremity VTE. The study concludes that patients undergoing hepatobiliary surgery are at an increased risk of developing lower extremity VTE, and prevention strategies must be tailored to each patient's unique set of risk factors. This includes careful management of postoperative bed rest, monitoring of platelet count, D-dimer and C-reactive protein levels, controlling hypertension, type 2 diabetes mellitus, hyperlipidemia, and cessation of smoking. This study highlights the importance of early identification of patients at high risk of lower extremity VTE following hepatobiliary surgery and comprehensive prevention measures.

Long term clinical and functional venous outcomes after endovascular transvenous femoro-popliteal bypass

BACKGROUND

Peripheral artery disease is widespread in Western societies affecting around 13% of the population above 50 years of age. Despite recent improvements of endovascular treatment, open surgical bypass is still recommended as the treatment of choice for long segment TASC D lesions. The DETOUR procedure was introduced as an endovascular alternative in cases of long-segment superficial femoral artery occlusion. This unconventional technique raises several questions regarding the effect of the bypass graft on femoral venous physiology.

METHODS

We conducted a 3-year follow-up study of subjects enrolled and treated in the prospective, multicenter DETOUR study at the Pauls Stradins clinical university hospital, Riga, Latvia. In total, 52 consecutive patients (54 procedures) were enrolled in this study from 2015 until 2019. We performed Venous Clinical Severity Score (VCSS) and Villalta (VS) Score assessments, Duplex ultrasound measuring femoral and popliteal vein diameters, venous occlusion plethysmography and digital photoplethysmography to assess and compare venous physiology at baseline and at follow-up visits every 6 months.

RESULTS

At baseline mean femoral vein diameter was 11.1 mm (SD=1.5). At 36-months following intraluminal stent-graft placement, mean femoral vein diameter was 11.1 mm (SD=1.7) with no evidence of enlargement of the femoral vein (P=0.2). Popliteal vein diameter was not significantly changed during 24-months of follow-up (P=0.12) but showed a small (0.02 mm) statistically significant decrease in diameter at 36-months compared to baseline. During the study period, only one patient (1.9%) developed clinically significant ipsilateral DVT 1-month after surgery. Clinically silent femoral venous thrombosis was documented in 8 legs during 36-month follow-up. In one case the thrombus was occlusive and in 7 cases the thrombus was non-occlusive. At baseline, 48 of 52 patients (92%) had no or minor venous symptoms ([VCSS 0-2] with clinically significant venous symptoms in only 4 patients [VCSS≥3]). At one-month follow-up, the venous clinical severity score increased in all patients compared to baseline. At 6-month follow-up, the VCSS had returned to baseline in the majority of patients with no significant changes during the 3-year follow-up period. At baseline, all patients had a VS of 0-2 indicating minor or no venous symptoms (mean 0.4 [SD 0.7]). At the 1-month follow-up visit 3 patients (5.8%) had a VS≥3 (two patients had a score of 3 and one patient a score of 4), indicating significant venous symptoms. At the 6-month visit and thereafter, all the VS in all patients had returned to baseline. Transvenous endovascular procedure did not significantly alter venous physiology in treated leg.

CONCLUSIONS

Percutaneous transvenous femoropopliteal bypass provided safe and effective lower-extremity revascularization with minimal effect on long-term venous function. The femoral and popliteal vein remained patent with no compensatory enlargement in response to the presence of the bypass graft within the femoral vein. During 3-year follow-up there were no significant changes in venous symptom scores or physiologic function.

Peripheral Artery Disease and Subsequent Risk of Infectious Disease in Older Individuals: The ARIC Study

OBJECTIVE

To quantify the association of peripheral artery disease (PAD) with infection risk because PAD has been understudied despite recognition of atherosclerotic cardiovascular disease as a risk factor for infection.

METHODS

Among 5082 participants of the Atherosclerosis Risk in Communities study (aged 71 to 90 years during 2011-2013), we assessed the association of PAD status, based on clinical history and ankle-brachial index (ABI), with infection-related hospitalization (through December 2019) using multivariable Cox regression. We also cross-classified participants by PAD and coronary heart disease (CHD)/stroke status at baseline, with implications for polyvascular disease.

RESULTS

During the median follow-up of 6.5 years, there were 1677 infection-related hospitalizations. Peripheral artery disease (clinical history or ABI ≤0.90) was independently associated with the risk of overall infection (adjusted hazard ratio [HR], 1.66 [95% CI, 1.42 to 1.94] vs ABI of 1.11 to 1.20), as was borderline low ABI of 0.91 to 1.00 (adjusted HR, 1.75 [95% CI, 1.47 to 2.07]). Results were consistent across major types of infection (ie, cellulitis, bloodstream infection, pneumonia, and urinary tract infection). For overall infection, PAD plus CHD/stroke had the highest HR of hospitalized infection (1.9), and PAD alone and CHD/stroke alone showed similar HRs of 1.6. For subtypes of infection, PAD alone had the highest HR of approximately 2 for bloodstream infection; PAD alone and PAD plus CHD/stroke had a similar risk of urinary tract infection with HR of approximately 1.7.

CONCLUSION

Peripheral artery disease and borderline low ABI were robustly associated with infection-related hospitalization of older adults. The contribution of PAD to infection risk was comparable to that of CHD/stroke, warranting clinical attention to PAD for the prevention of infectious diseases.

Peripheral artery disease and the risk of venous thromboembolism

Summary: Background: Peripheral artery disease (PAD) impacts 3–12% of patients worldwide and is characterized by endothelial dysfunction and inflammatory pathways which are also common to venous thromboembolism (VTE), but there is a paucity of evidence regarding VTE risk in PAD patients. We investigated whether PAD is an independent risk factor for VTE. Patients and methods: We reviewed medical records of patients undergoing ABI studies at Mayo Clinic from 01/1996-02/2020. We classified patients by ABI (low [<1.0], normal [1.0–1.4], or elevated [>1.4]), as well as by specific low ABI subgroup: severely reduced (ABI: 0.00–0.39), moderately reduced (0.40–0.69), mildly reduced (0.70–0.90), and borderline reduced (0.91–0.99). The primary outcome was incident VTE event (acute lower extremity deep vein thrombosis or pulmonary embolism) after ABI measurement. Multivariable Cox proportional regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI) after adjusting for age, sex, active smoking, cancer, previous VTE, thrombophilia, anticoagulation, and revascularization. Results: 39,834 unique patients (mean age 66.3±14.3 years, median follow-up 34 months) were identified. 2,305 VTE events occurred in patients without PAD (13.0%), 2,218 in low ABI patients (13.0%), and 751 in elevated ABI patients (14.8%). After risk factor adjustment, VTE risk was modestly increased for PAD overall (HR: 1.12, 95% CI [1.06, 1.18]), including low ABI (HR: 1.11, 95% CI [1.04, 1.18]) and elevated ABI groups (HR: 1.15, 95% CI [1.04, 1.26]), compared to patients without PAD. The greatest VTE risk was in severely low ABI patients (HR: 1.46, 95% CI [1.31, 1.64]). Conclusions: In a large longitudinal cohort, we present strong clinical evidence of PAD, with low and elevated ABI, as an independent VTE risk factor, with the highest risk seen in patients with severely low ABI. Continued research is required to further investigate this relationship and its intersection with functional performance status to optimize VTE risk reduction or anticoagulation strategies in the PAD population.

Perioperative allogenic blood transfusion increases the incidence of postoperative deep vein thrombosis in total knee and hip arthroplasty

Background

Excessive blood loss caused by total joint arthroplasty (TJA) often increases the requirement for blood transfusion, which is associated with adverse outcomes. The purpose of this study was to determine the relationship between perioperative transfusion and postoperative DVT in TJA.

Methods

This retrospective study reviewed medical records of 715 patients, who consecutively underwent primary unilateral total knee arthroplasty (TKA) or total hip arthroplasty (THA) at our institution between September 2015 and March 2017. Demographic, clinical and surgical parameters were introduced into the univariate analysis to find risk factors for DVT within postoperative 30 days. In order to identify if allogenic blood transfusion was independently associated with DVT, a multivariate logistic regression analysis was conducted to adjust for gender, age, body mass index (BMI), diagnosis, and type of surgery.

Results

The incidence of perioperative allogenic blood transfusion was 12.4% (n = 89). Fifty-seven patients (8.0%) developed DVT after surgery. Univariate analysis demonstrated that there were differences between DVT group and non-DVT group in gender (P = 0.045), age (P < 0.001), BMI (P = 0.026), primary diagnosis (P = 0.001), type of surgery (P < 0.001), and transfusion rates (P = 0.040). After adjustment by using multivariate logistic regression analysis, transfusion appeared to be the independent risk factor for DVT in TJA (P = 0.001; OR = 3.9, 95%CI 1.8–8.4).

Conclusion

We found that perioperative allogenic blood transfusion was significantly associated with DVT following TJA. In order to reduce the risk of DVT and other adverse outcomes, methods to decrease transfusion rates should be used in clinical practice.

Acupuncture for perioperative care of total hip arthroplasty: A systemic review of controlled trials and meta-analysis

INTRODUCTION

This protocol is intended to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of acupuncture in perioperative care of total hip arthroplasty patients.

METHODS AND ANALYSIS

The following databases will be searched from their inception to November 2018 without language restrictions: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, Oriental Medicine Advanced Searching Integrated System, Korean Traditional Knowledge Portal, KoreaMed, DBPIA, Research Information Service System, including the China National Knowledge Infrastructure. Any randomized controlled trials related to perioperative care of total hip arthroplasty will be included. The primary outcomes of this study are dosage of analgesics and pain intensity. For secondary outcomes, Harris hip score, incidence of postoperative cognitive dysfunction, mini-mental state exam score, incidence of deep vein thrombosis, D-dimer and fibrinogen level, adverse events will be assessed. Data analysis and synthesis will be carried out using RevMan version 5.3. The methodological quality will be assessed by the Cochrane Collaboration risk of bias tool.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018112123.