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The impact of congestive heart failure on the acute post operative outcomes in patients undergoing lower extremity revascularization
Bernard Ashby, Richard Neville, Richard Amdur, Aundrea Tunstall, Bao-Ngoc H Nguyen, Anton Sidawy
George Washington University, Washington, DC

Background: As the management of peripheral vascular disease (PVD) evolves it is important that we determine what factors affect the outcome of lower extremity interventions. The presence of PVD is associated with a 2-fold increase in the prevalence of congestive heart failure (CHF) and it is well known that patients with CHF are at risk for perioperative complications. It was recently demonstrated that CHF is associated with reduced patency after endovascular intervention for PVD at 1 year. However, the impact of CHF on patients undergoing infrainguinal bypass for PVD has not been extensively studied. The goal of this study is to evaluate CHF as predictor of acute post operative outcomes in patients undergoing lower extremity revascularization.
Methods: The study group consisted of all patients entered in a prospective, multicenter database (ACS-NSQIP) undergoing infrainguinal bypass from 2005-2010 (n = 30,596). Patients with CHF within 30 days prior to surgery (n = 899) were compared to those without a CHF diagnosis (n = 29,697). Thirty-day graft patency, morbidity, and mortality were compared between groups using a multivariate logistic regression analysis controlling for covariates.
Results: Infrainguinal bypass graft failure was not significantly different for patients with CHF (4.9%) versus those without (4.5%, p=0.55). There was no difference in patency for femoral-popliteal grafts (No CHF 96.3%, CHF 96.1%, p=0.86) nor femoral-tibial grafts (No CHF 91.8%, CHF 89.3%, p=0.2). The variables of CHF and loss of patency had no significant association (phi=0.003). The prediction model for post-operative pneumonia was significant (p<0.0001) with prediction accuracy (c=0.71). CHF was associated with 71% higher odds of post-operative pneumonia compared to those without CHF (OR=1.71, 95%, CI 1.26 - 2.31, p=0.0005) after correction for covariates. CHF was also associated with pulmonary embolism after accounting for covariates with CHF increasing the odds of pulmonary embolism 3 fold (OR=2.91, 95% confidence interval 1.19 - 7.07; p=.02). CHF was independently associated with a 41% increase in the odds of prolonged intubation (OR=1.41, 95% CI 1.07 - 1.85; p=.014) and a 65% increase in re-intubation (OR=1.65, 95% CI,1.24 - 2.19; p=.0006). There was a trend toward an increased incidence of cardiac arrest (p=.09), and a significant association with 30 day mortality (OR=1.90, 95% CI, 1.52-2.38, p<0.0001).
Conclusions: A history of CHF does not impact acute infrainguinal bypass graft patency. However, it does increase the complication rate of peri-operative pneumonia, pulmonary embolism, prolonged intubation, re-intubation, and mortality. Therefore, lower extremity intervention in patients with a history of CHF should incorporate an individualized approach to optimize success of the revascularization while minimizing medical comorbidities.


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