Interfacility transfer is associated with higher postoperative amputation in patients undergoing lower extremity bypass for acute limb ischemia: A multi-institutional study from Vascular Quality Initiative
Sina Zarrintan, Munir Moacdieh, Shima Rahgozar, Daniel Willi-Permor, Nadin Elsayed, Mahmoud Malas
University of California, San Diego, LA JOLLA, CA
INTRODUCTION: Patients with acute limb ischemia (ALI) should undergo an urgent/emergent vascular procedure without delay to prevent limb loss. However, interfacility transfer (IFT) is inevitable in certain circumstances particularly when optimal surgical service is unavailable. IFT can delay the surgical care and compromise the outcomes. We aimed to investigate the impact of IFT on postoperative outcomes of lower extremity bypass (LEB) in patients presenting with ALI.
METHODS: The Vascular Quality Initiative Database was queried for patients presenting with ALI and undergoing LEB between January 2003 to June 2022. The patients were stratified by IFT status. The primary outcome was postoperative major amputation (MA). The secondary outcomes were postoperative complications, 30-day mortality, prolonged length of stay (PLOS), major adverse cardiovascular events (MACE) and major adverse limb events (MALE). MACE was defined as any in-hospital myocardial infarction, stroke or death. MALE was defined as untreated loss of patency, reintervention on the revascularized segment, or major amputation. Logistic regression was used for multivariate analyses.
RESULTS: A total of 8,338 patients were analyzed (No IFT=6,680, 80.1%; IFT=1,658, 19.9%). Median age was 66 (59, 74) and 65 (58, 74) years in patients in non-IFT and IFT cohorts (P=0.028), respectively. Patients who underwent LEB after being transferred were more likely to undergo urgent or emergent revascularization (P<0.001). Moreover, they had higher rates of MA (8.2% vs. 4.6%; P<0.001), respiratory complications, PLOS, 30-day mortality, MACE, and MALE (Tab. 1). After adjusting for potential confounders, transfer was associated with higher rates of MA (aOR=1.45, 95% CI: 1.12-1.89; P=0.006) and PLOS (aOR=1.18, 95% CI: 1.01-1.37; P=0.033) (Tab. 1). In sub-analysis based on the day of the week bypass was performed, the association of transfer with increased rates of MA and PLOS was persisted only in bypasses performed on weekdays. Predictors of transfer were ASA class IV/V, anemia, obesity, current smoking, ALI resulting from lower extremity aneurysm, urgent/emergent bypass and performing bypass on weekends. The overall one-year survival was similar in patients with and without IFT (85.7% vs. 87.1%, respectively).
CONCLUSIONS: Patients presenting with ALI requiring transfer for LEB are more likely to have lower extremity aneurysms as the primary cause of ischemia. Additionally, they have poor general condition presenting with higher ASA Class. Transferred patients are more likely to require urgent and emergent bypass and to undergo bypass on weekends. They are also more likely to experience limb loss and PLOS. Although transfer of patients with ALI is inevitable in certain situation, every effort should be made to manage these patients at the initial institution and transfer should be limited to conditions where neither vascular nor general surgery service is available.
| Univariate Analysis | Logistic Regression | ||||
| Outcome | Not Transferred N=6,680 (80.1%) | Transferred N=1,658 (19.9) | P-Value | aOR (95% CI) (Reference = Not Transferred) | P-Value |
| Major Amputation | 304 (4.6) | 135 (8.2) | <0.001 | 1.45 (1.12-1.89) | 0.006 |
| Myocardial Infarction | 233 (3.5) | 60 (3.6) | 0.789 | 0.84 (0.62-1.13) | 0.239 |
| Respiratory Complications | 267 (4.0) | 86 (5.2) | 0.030 | 0.93 (0.67-1.30) | 0.676 |
| Stroke | 62 (1.0) | 21 (1.3) | 0.188 | 0.99 (0.59-1.65) | 0.965 |
| PLOS (>7 days) | 2,079 (31.1) | 678 (40.9) | <0.001 | 1.18 (1.01-1.37) | 0.033 |
| 30-Day Mortality | 229 (3.4) | 84 (5.1) | 0.002 | 1.04 (0.74-1.46) | 0.824 |
| In-Hospital MACE | 399 (6.1) | 127 (8.0) | 0.007 | 0.89 (0.69-1.14) | 0.349 |
| In-Hospital MALE | 911 (13.8) | 278 (17.1) | 0.001 | 1.05 (0.87-1.26) | 0.633 |
Back to 2024 Posters