title: Elevated C-reactive protein levels are associated with postoperative events in patients undergoing lower extremity vein bypass surgery.
abstract: OBJECTIVE
  Inflammatory markers such as high-sensitivity C-reactive protein (hsCRP) are associated with an increased risk of cardiovascular events and with the severity of peripheral arterial disease. The effects of inflammation on the development of vein graft disease remain speculative. We hypothesized that high levels of inflammatory markers would identify patients at increased risk for adverse events (graft failure, major cardiovascular events) after lower extremity bypass surgery.
  
  
  METHODS
  Patients (n = 91) scheduled to undergo lower extremity bypass using autogenous vein were enrolled into a prospective study at two institutions. Exclusion criteria included the presence of major infection. A baseline plasma sample was obtained on the morning of lower extremity bypass. Biomarkers for inflammation included hsCRP, fibrinogen, and serum amyloid A (SAA). Values between patients with and without critical limb ischemia were compared. Proportions of events among dichotomized populations (upper limit of normal of each laboratory assay) were compared by log-rank test.
  
  
  RESULTS
  Of the patients undergoing lower extremity bypass, 69% were men, 53% were diabetic, 81% were smokers, and their mean ankle-brachial index was 0.51 +/- 0.19. The indication for lower extremity bypass was critical limb ischemia in 55%. There were no perioperative deaths and two early graft occlusions. During a mean follow-up of 342 days (range, 36-694 days) there were four deaths, 27 graft-related events, and 10 other cardiovascular events. No relationships were found between events and demographics, comorbidities, baseline ankle-brachial index, or statin use. High-sensitivity CRP (P = .005), fibrinogen (P < .001), and SAA (P = .0001) levels were associated with critical limb ischemia at presentation. Among patients with an elevated hsCRP (>5 mg/L) immediately before surgery, major postoperative vascular events occurred in 60% (21/35), compared with a 32% (18/56) rate in those with a baseline CRP <5 mg/L (P = .004, log-rank test). On multivariable analysis, only elevated hsCRP correlated with adverse graft-related or cardiovascular events (P = .018).
  
  
  CONCLUSIONS
  The inflammatory biomarkers of hsCRP, fibrinogen, and SAA correlate with peripheral arterial disease severity at presentation in patients undergoing lower extremity bypass. Patients with elevated hsCRP are at increased risk for postoperative vascular events, most of which are related to the vein graft. These findings suggest a potential relationship between inflammation and outcomes after lower extremity vein bypass surgery.
authors.affiliation: Division of Vascular Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Owens
authors.forename: Paul M
authors.initials: PM
authors.lastname: Ridker
authors.forename: Michael
authors.initials: M
authors.lastname: Belkin
authors.forename: Allen D
authors.initials: AD
authors.lastname: Hamdan
authors.forename: Frank
authors.initials: F
authors.lastname: Pomposelli
authors.forename: Frank
authors.initials: F
authors.lastname: Logerfo
authors.forename: Mark A
authors.initials: MA
authors.lastname: Creager
authors.forename: Michael S
authors.initials: MS
authors.lastname: Conte
mesh_terms: D001157:Arterial Occlusive Diseases / Q000097:blood* / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D002097:C-Reactive Protein / Q000378:metabolism*; D005260:Female; D005263:Femoral Artery; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery; D011184:Postoperative Period; D011446:Prospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014680:Veins / Q000637:transplantation*
chemical_list: D002097:C-Reactive Protein