Impact of the Timing of Foot Tissue Resection on Outcomes in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

Abstract

The objective of this study is to describe utilization of revascularization and tissue resection in patients with chronic limb-threatening ischemia (CLTI) and determine whether the timing of resection impacts outcomes. Revascularizations for CLTI were queried (ACS-NSQIP 2011-2015). Outcomes included 30-day major adverse limb events (MALE), major adverse cardiac events (MACE), length of stay (LOS), operative time, 30-day readmissions, and wound infections. Groups included revascularization alone, revascularization/tissue resection during the same procedure (concurrent), or revascularization/delayed tissue resection (delayed). Resections were debridement or transmetatarsal amputations. Multivariate logistic regression determined risk-adjusted effects of tissue resection on outcomes. There was no difference in overall 30-day MACE or MALE between groups (P = .70 and P = .35, respectively). Length of stay (6.1 days revascularization alone vs 7.8 days concurrent vs 8.7 days delayed, P < .0001) was longer in patients who underwent any tissue resection. Highest 30-day readmission and operative time was the concurrent group (P = .02 and P < .0001, respectively). Wound infection was highest in the delayed group (1.4% revascularization alone vs 1.3% concurrent vs 6.2% delayed, P < .0001). After risk adjustment, timing of resection did not impact LOS for concurrent and delayed groups compared to revascularization alone (both P < .0001). Debridement and minor amputations can be done concurrently in patients undergoing revascularization for CLTI.

Keywords

tissue resection revascularization length of stay major adverse limb events major adverse cardiac events limb ischemia

Get full access to this article

View all access options for this article.

References

Murabito

Evans

Nieto

Larson

Levy

Wilson

. Prevalence and clinical correlates of peripheral arterial disease in the Framingham Offspring Study. Am Heart J. 2002;143:961–5.

Criqui

Langer

Fronek

Feigelson

Klauber

McCann

Browner

. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–6.

Criqui

Aboyans

. Epidemiology of peripheral artery disease. Circ Res. 2015;116:1509–26.

Conte

Bradbury

Kolh

, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69:3S–125S e40.

Adam

Beard

Cleveland

, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366:1925–34.

Abu Dabrh

Steffen

Undavalli

Asi

Wang

Elamin

Conte

Murad

. The natural history of untreated severe or critical limb ischemia. J Vasc Surg. 2015;62:1642–51 e3.

Steg

Bhatt

Wilson

, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007;297:1197–206.

Caro

Migliaccio-Walle

Ishak

Proskorovsky

. The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database. BMC Cardiovasc Disord. 2005;5:14.

Norgren

Hiatt

Dormandy

Nehler

Harris

Fowkes

; TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45 Suppl S:S5–67.

10.

Armstrong

Ryan

Baker

Martinsen

Kotlarz

Gunnarsson

. Risk of major amputation or death among patients with critical limb ischemia initially treated with endovascular intervention, surgical bypass, minor amputation, or conservative management. J Med Econ. 2017;20:1148–54.

11.

Teraa

Conte

Moll

Verhaar

. Critical Limb Ischemia: Current Trends and Future Directions. J Am Heart Assoc. 2016;5:e002938.

12.

Crawford

Cambria

Abularrage

Conrad

Lancaster

Watkins

LaMuraglia

. Preoperative functional status predicts perioperative outcomes after infrainguinal bypass surgery. J Vasc Surg. 2010;51:351–8; discussion 8-9.

13.

Dosluoglu

Wang

Defranks-Anain

Rainstein

Nader

. A simple subclassification of American Society of Anesthesiology III patients undergoing peripheral revascularization based on functional capacity. J Vasc Surg. 2008;47:766–72; discussion 22-3.

14.

Golomb

Dang

Criqui

. Peripheral arterial disease: morbidity and mortality implications. Circulation. 2006;114:688–99.

15.

Fleisher

Fleischmann

Auerbach

, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215–45.

16.

Stoffers

Rinkens

Kester

Kaiser

Knottnerus

. The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease. Int J Epidemiol. 1996;25:282–90.

17.

Duncan

Wijeysundera

. Preoperative Cardiac Evaluation and Management of the Patient Undergoing Major Vascular Surgery. Int Anesthesiol Clin. 2016;54:1–32.

18.

Roddy

O’Donnell

Jr Iafrati

Isaacson

Bailey

Mackey

. Reduction of hospital resources utilization in vascular surgery: a four-year experience. J Vasc Surg. 1998;27:1066–75; discussion 76-7.

19.

Freeman

Gibbons

. Perioperative cardiovascular assessment of patients undergoing noncardiac surgery. Mayo Clin Proc. 2009;84:79–90.

20.

Bode

Jr Lewis

Zarich

, et al. Cardiac outcome after peripheral vascular surgery. Comparison of general and regional anesthesia. Anesthesiology. 1996;84:3–13.

21.

Marso

Hiatt

. Peripheral arterial disease in patients with diabetes. J Am Coll Cardiol. 2006;47:921–9.

22.

Mehaffey

Hawkins

Fashandi

Cherry

Kern

Kron

Upchurch

Jr Robinson

. Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention. J Vasc Surg. 2017;66:1109–16 e1.

23.

Mehaffey

Shannon

Hawkins

Fashandi

Tracci

Kron

Upchurch

Jr Robinson

. National Utilization and Outcomes of Redo Lower Extremity Bypass Versus Endovascular Intervention After a Previous Failed Bypass. Ann Vasc Surg. 2018;47:18–23.

24.

Tukiainen

Biancari

Lepantalo

. Lower limb revascularization and free flap transfer for major ischemic tissue loss. World J Surg. 2000;24:1531–6.

25.

Laurent

Millon

Richer de Forges

Artru

Lermusiaux

. Pedicled flaps in association with distal bypass for lower-limb salvage. Ann Vasc Surg. 2012;26:205–12.

26.

Serletti

Hurwitz

Jones

Herrera

Reading

Ouriel

Green

. Extension of limb salvage by combined vascular reconstruction and adjunctive free-tissue transfer. J Vasc Surg. 1993;18:972–8; discussion 8-80.

27.

Gooden

Gentile

Mills

, et al. Free tissue transfer to extend the limits of limb salvage for lower extremity tissue loss. Am J Surg. 1997;174:644–8; discussion 8-9.

28.

Jansen

de Vries

Cullen

Donaldson

Hunink

. Cost-identification analysis of revascularization procedures on patients with peripheral arterial occlusive disease. J Vasc Surg. 1998;28:617–23.

29.

Fanari

Weintraub

. Cost-effectiveness of medical, endovascular and surgical management of peripheral vascular disease. Cardiovasc Revasc Med. 2015;16:421–5.

30.

Eneroth

Apelqvist

Troeng

Persson

. Operations, total hospital stay and costs of critical leg ischemia. A population-based longitudinal outcome study of 321 patients. Acta Orthop Scand. 1996;67:459–65.

31.

Silber

Rosenbaum

Zhang

Even-Shoshan

. Estimating anesthesia and surgical procedure times from medicare anesthesia claims. Anesthesiology. 2007;106:346–55.

32.

Cheng

Clymer

Chen

Sadeghirad

Ferko

Cameron

Hinoul

. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res. 2018;229:134–144.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.14 MB