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Outcomes Following Open Lower Extremity Revascularization for Patients with Critical Limb Ischemia and Previous Interventions
Mitri K Khoury, John G Modrall
University of Texas, Southwestern, Dallas, TX

INTRODUCTION: Open intervention was historically the treatment of choice in patients requiring lower extremity revascularization. However, in the endovascular era, open or endovascular revascularization may be options. In the current study, we examined the outcomes of open lower extremity revascularization for critical limb ischemia (CLI) after prior open or endovascular interventions.
METHODS: The 2012-2017 open lower extremity bypass Participant User Data Files (PUFs) from the National Surgical Quality Improvement Program (NSQIP) was used to identify a cohort of patients who had previously undergone lower extremity revascularization (open or endovascular) on the ipsilateral extremity. Exclusion criteria were emergent operations, absence of CLI, or missing data for key variables. Patients were stratified based on whether they had a previous open or endovascular intervention. The primary outcome measure was 30-day major amputation, which was defined as being a transtibial or more proximal amputation. A multivariate analysis was conducted to determine if a previous open or endovascular intervention was a predictor of 30-day amputation. Secondary outcomes included 30-day mortality, major re-interventions, and wound complications.
RESULTS: A total of 4,708 patients met the inclusion criteria with 54.6% (n=2,573) undergoing a previous open revascularization and 45.4% (n=2,135) having a prior endovascular lower extremity revascularization. There was no significant difference in 30-day mortality between patients with a previous open versus endovascular intervention (2.0% versus 2.6%, P=0.17). There were notable differences in regards to demographics and comorbidities between the two groups. The type of open procedure differed between patients who had a previous open or endovascular intervention: femoral endarterectomy/profundoplasty (1.9% versus 1.2%, P=0.06), open bypass using saphenous vein (44.4% versus 63.3%, P<0.01), and open bypass using alternative conduit (prosthesis/spliced vein/composite) (53.7% versus 34.9%, P<0.01). Operative times were similar between patients with previous open and endovascular interventions (238 minutes [IQR 174-326] versus 235 minutes [IQR 170-317], P=0.17). There were no differences in regards to the wound infection/complication rates (13.9% versus 15.2%, P=0.23) but patients with a prior open intervention were more likely to require a major reintervention within 30 days (7.5% versus 5.1%, P<0.01) and major amputation (5.0% versus 3.1%, P<0.01) than those with a prior endovascular intervention. After adjustment, multivariate analysis suggested that a prior open procedure was significantly associated with major amputation (OR 1.66, 95% CI 1.23-2.25, P<0.01).
CONCLUSIONS: A prior open intervention is significantly associated with 30-day major amputation in patients undergoing redo lower extremity revascularization when compared to a prior endovascular intervention. This observation may be related to the extent of peripheral arterial disease (PAD), but may also represent a potential shortcoming of an open-first approach. Future studies should be aimed at defining the optimal sequencing of open and endovascular surgical options in patients with PAD.


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