The effect of congestive heart failure on perioperative outcomes in patients undergoing lower extremity revascularization.
BACKGROUND
As the management of peripheral arterial disease evolves, determining the factors affecting the outcome of lower extremity interventions is important. The presence of peripheral arterial disease is associated with a twofold increase in the prevalence of congestive heart failure (CHF), with reports of increased perioperative complications. This study evaluated CHF as a predictor of acute postoperative complications in patients undergoing lower extremity bypass.


METHODS
The study group consisted of all patients entered in a prospective, multicenter database (American College of Surgeons National Surgical Quality Improvement Program) undergoing infrainguinal bypass (IIB) from 2005 to 2010. Patients with a new diagnosis of CHF ≤30 days before surgery were compared with those without such a diagnosis. Patency rates at 30 days, morbidity, and mortality were compared between groups using a multivariate logistic regression analysis controlling for covariates.


RESULTS
There were 18,645 IIB patients, of which 488 (2.6%) had history of CHF. CHF patients were older and had higher rates of comorbidities than those without CHF. In univariate analysis, IIB graft failure was not significantly different for patients with CHF (6.8%) vs those without (5.2%; P = .13). There was no difference in patency for femoral popliteal grafts (no CHF, 96.5%; CHF, 96.3%; P = .89) or for femoral-tibial grafts (no CHF, 91.9%; CHF, 89.3%; P = .20). However, CHF was significantly associated with postsurgery cardiac events (P = .007), pneumonia, prolonged intubation, reintubation, sepsis, return to the operating room, 30-day mortality, and length of stay >9 days (all P < .0001). After adjusting for covariates associated with CHF, compared with patients without CHF, those with CHF had an 82% higher odds of postoperative pneumonia (95% confidence interval [CI], 13%-94%; P = .014), an 87% increase in the odds of prolonged intubation (95% CI, 16%-201%; P = .011), a 73% increase in the odds of reintubation (95% CI, 12%-167%; P = .014), a 55% increase in the odds of sepsis or septic shock (95% CI, 11%-118%; P = .011), a 29% increase in the odds of returning to the operating room (95% CI, 4%-61%; P = .022), a 121% increase in the odds of 30-day mortality (95% CI, 56%-214%; P < .0001), and a 102% increase in the odds of postsurgery length of stay >9 days (95% CI, 64%-148%; P < .0001).


CONCLUSIONS
Recently diagnosed or exacerbated CHF does not affect acute IIB graft patency. However, CHF may increase the complication rates for perioperative pneumonia, prolonged intubation, reintubation, sepsis, return to the operating room, extended length of stay, and mortality. Therefore, before pursuing lower extremity interventions in patients with a history of CHF, one should incorporate an individualized approach to optimize the success of the revascularization while minimizing medical comorbidities.
Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, D.C.. Electronic address: amdur@gwu.edu.
Richard L
RL
Amdur
Division of Cardiology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, D.C.
Bernard
B
Ashby
Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, D.C.
Richard
R
Neville
Division of Cardiology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, D.C.
Aundrea
A
Tunstall
Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, D.C.
Bao-Ngoc
BN
Nguyen
Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, D.C.
Anton
A
Sidawy
D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D006333:Heart Failure / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D058017:Vascular Grafting / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D014654:Vascular Patency