Planned Vascular Surgery Involvement in Cases where Vascular Expertise is Needed is Associated with Improved Patient Outcomes
Emma Rooney, Catherine McGeoch, Yazan Duwaryi, Bradley G Leshnower, Anuj Mahajan, Guillermo Escobar, Mustafa Khader, Olamide Alabi, William D Jordan, Jr.
Emory University, Atlanta, GA
Introduction: In the current healthcare environment, other surgical specialties often call vascular surgery for planned or unplanned operative consultation. Vascular surgeons participate in a wide range of cases as co-surgeons, involving arterial and venous pathologies. Vascular surgery is a vital service line to allow safe, complex surgical care. Our aim is to understand the intraoperative and postoperative outcomes when vascular surgeons are involved as operative consultants.
Methods: We performed a retrospective analysis of patients in three non-trauma hospitals in our healthcare system who underwent a surgical operation where a non-vascular surgeon as listed as the primary surgeon and a vascular surgeon as secondary surgeon between September 1, 2018, and June 30, 2021. Demographics, comorbidities, procedure details, and postoperative outcomes were analyzed. We compared patients who underwent planned combined operations (planned cases), to those who received unplanned intraoperative consultations (unplanned cases). We also performed separate subgroup analysis for cardiothoracic surgery patients (Group A) and non-cardiothoracic surgery patients (Group B). Hypotension was defined as systolic blood pressure < 100mmHg prior to vascular surgery entering the operating room. Malignancy was defined as having an active neoplastic process at the time of surgery. Postoperative ischemic complications were defined as end organ ischemia requiring intervention. Postoperative renal replacement was defined as a new postoperative dialysis requirement.
We compared data using the chi-square analysis for categorical variables and independent sample t-test for continuous variables. IBM SPSS Version 28.0 was used for statistical analysis. A p-value of less than 0.05 was considered statistically significant. We excluded cases that were 100% planned cases with vascular surgery support such as spine exposure (n=153). We also excluded cases where vascular surgery participation was separate from the primary procedure, such as combined carotid endarterectomy (CEA) with coronary artery bypass graft (CABG) (n=30), inferior vena cava filter placement or removal (n=17), or tunneled catheter placement or removal (n=13).
Results: We initially identified 458 patients who had combined vascular surgery involvement; of these, 245 patients met our inclusion criteria. Of this cohort, 168 were planned cases (69%), and 77 were unplanned cases (31%). The overall cohort was 60% (n=146) male and 40% (n=99) female with a mean age of 54.8 ± 15.1 years. Consulting surgical services included cardiothoracic surgery (n=144), surgical oncology (n=22), urology (n=18), general Surgery (n=17), neurosurgery (n=12), otolaryngology (n=8), gynecology (n=5), transplant surgery (n=2), and plastic surgery (n=2). The most common operation performed with cardiothoracic surgery was thoracic endovascular aortic repair (n=63), followed by open thoracoabdominal aortic aneurysm repair (n=19).
The mean total operative time for planned cases was shorter than for unplanned cases (247 vs. 334 minutes, p < 0.001). Malignancy was more common in unplanned cases (p<0.001). Cardiothoracic
surgery had the largest proportion of unplanned cases (35%), followed by urology (19%). There were no differences between planned or unplanned cases for intraoperative fluid resuscitation volume, blood transfusion, or albumin administration. The unplanned cases were more likely to require prolonged ventilator use greater than 48 hours (p = 0.027). Despite the higher rate of prolonged ventilator use, there were no differences between the two groups in ICU or overall length of stay. 30-day postoperative mortality was 14.9% in planned cases, and 11.7% in unplanned cases (p = 0.502) (Table 1).
For Group A (cardiothoracic surgery cases), there were 117 planned cases (81%) and 27 unplanned cases (19%). The unplanned cases involved patients who were younger and had higher rates of obesity, diabetes, and congestive heart failure. The planned cases involved shorter total operative times (245 min vs. 330 min, p = 0.033), and had a lower serum lactic acid prior to vascular surgery arrival in the operating room (1.7 vs. 3.3 mmol/L, p = 0.018). Postoperatively, planned cases involved lower rates of renal replacement therapy (16.2% vs. 40.7%, p = 0.005), and lower rates of prolonged ventilator use (18.8% vs. 63%, p<0.001), as well as shorter length of stay (10.9 vs. 19.9 days, p = 0.003). There were no differences noted in postoperative 30-day readmission or 30-day mortality (Table 1).
For Group B (non-cardiothoracic surgery cases), there were 51 planned cases (50%) and 50 unplanned cases (50%). The planned cases involved patients who were more likely to be younger (50 vs. 57 years, p= 0.016) and less likely to have active malignancy (41% vs. 66%, p = 0.012). The planned cases also received fewer packed red blood cell transfusions prior to vascular surgery arrival in the operating room (0.37 vs. 1.5 units, p = 0.008), and received smaller volume of crystalloid resuscitation during the case (3937 vs. 4433 ml, p = 0.042). The planned cases were more likely to have a postoperative ischemic complication (5 vs. 0, p = 0.023), but there were no differences between planned and unplanned cases for postoperative renal replacement therapy, prolonged ventilator use, ICU length of stay, overall length of stay, postoperative 30-day readmission, or 30-day mortality (Table 1).
Conclusions: In non-trauma hospitals, vascular surgery is a vital co-surgeon for planned combined operations and unplanned intraoperative consultations by other surgical services. Despite the urgency of the unplanned cases, vascular surgery involvement leads to similar outcomes as planned cases. This rescue from major complications reflects the ability of vascular surgeons to support a healthcare system with complex multi-specialty surgical care.
Table 1: Comparison of patient factors, medications, intraoperative, and postoperative findings between planned and unplanned cases for the Total Cohort, Cardiothoracic subgroup (Group B), and Non-cardiothoracic subgroup (Group C)
| Total Cohort | Planned (n=168) | Unplanned (n=77 | P-Value | |
| Malignancy | 27 (16.1%) | 33 (42.9%) | <0.001 | |
| Aspirin | 65 (38.7%) | 13 (16.9%) | <0.001 | |
| Operative time (min) | 247 ± 89.7 | 334 ± 56.6 | <0.001 | |
| Systolic Blood Pressure | 121.9 ± 27.3 | 114.3 ± 24.6 | <0.001 | |
| Hypotension (pre-arrival) | 56 (33.3%) | 48 (62.3%) | <0.001 | |
| ICU Length of stay (Mean Days) | 8.76 ± 3.24 | 9.2 ± 3.87 | 0.66 | |
| Postoperative ventilator >48 hours | 31 (18.5%) | 24 (31.2%) | 0.027 | |
| 30-day readmission | 21 (12.5%) | 13 (16.9%) | 0.357 | |
| 30-day mortality | 25 (14.9%) | 9 (11.7%) | 0.502 | |
| Group A: Cardiothoracic | Planned (n=117) | Unplanned (n=27) | P-Value | |
| Age (mean years) | 57.22 ± 14.8 | 49.00 ± 14.0 | 0.006 | |
| BMI (mean) | 28.2 ± 6.6 | 34.8 ± 10.7 | <0.001 | |
| Diabetes | 14 (12.0%) | 10 (37.0%) | 0.002 | |
| Heart Failure | 25 (21.4%) | 13 (48.1%) | 0.004 | |
| Aspirin | 56 (47.9%) | 4 (14.8%) | 0.002 | |
| Operative time (min) | 245.5 ± 94.8 | 330.1 ± 79.0 | 0.033 | |
| Hypotension (pre-arrival) | 32 (27.6%) | 13 (48.1%) | 0.038 | |
| Lactate (mmol/L) | 1.72 ± 1.2 | 3.25 ± 1.8 | 0.018 | |
| ICU Length of stay (Mean Days) | 8.76 ± 4.06 | 9.2 ± 4.68 | 0.66 | |
| Postoperative renal replacement | 19 (16.2%) | 11 (40.7%) | 0.005 | |
| Postoperative ventilator >48 hours | 22 (18.8%) | 17 (63.0%) | <0.001 | |
| Overall length of stay (Mean Days) | 10.91 ± 4.72 | 19.96 ± 6.7 | 0.003 | |
| 30-day readmission | 11 (9.4%) | 2 (7.4%) | 0.744 | |
| 30-day mortality | 30 (17.1%) | 7 (25.9%) | 0.289 | |
| Group B: Non-cardiothoracic | Planned (n=51) | Unplanned (n=50) | P-Value | |
| Age (mean years) | 50.22 ± 16.6 | 57.56 ± 13.2 | 0.016 | |
| Malignancy | 21 (41.2%) | 33 (66.0%) | 0.012 | |
| Operative time (min) | 337.44 ± 84.6 | 368.63 ± 44.8 | 0.011 | |
| Pre-arrival PRBC transfusion (mean number of units) | 0.37 ± 0.21 | 1.53 ± 0.86 | 0.008 | |
| Fluid Volume (ml) | 3937.04 ± 760.22 | 4433.33 ± 1421.73 | 0.042 | |
| Hypotension (pre-arrival) | 24 (47.1%) | 35 (70.0%) | 0.019 | |
| ICU Length of stay (Mean Days) | 5.90 ± 3.68 | 3.12 ± 1.61 | 0.24 | |
| Ischemia | 5 (9.8%) | 0 (0.0%) | 0.023 | |
| Postoperative renal replacement | 7 (13.7%) | 2 (4.0%) | 0.086 | |
| Postoperative ventilator >48 hours | 9 (17.6%) | 7 (14.0%) | 0.62 | |
| Overall length of stay (Mean Days) | 13. 5 ± 7.1 | 12.46 ± 6.86 | 0.78 | |
| 30-day readmission | 10 (19.6%) | 11 (22.0%) | 0.767 | |
| 30-day mortality | 5 (9.8%) | 2 (4.0%) | 0.251 | |
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