Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative.
OBJECTIVE
Postoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes.


METHODS
The Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events.


RESULTS
The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary disease severity, degree of renal insufficiency, ambulatory status, transfer status, urgency, and operative type. The predicted compared with the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P < .0001) and a c-statistic = 0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs 1.2%; P < .0001; adjusted odds ratio, 5.85; P < .0001), and discharge to a nursing facility (57.8% vs 19.0%; P < .0001; adjusted odds ratio, 3.14; P < .0001).


CONCLUSIONS
RAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and postoperative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery.
Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: genovesee@upmc.edu.
Elizabeth A
EA
Genovese
Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Larry
L
Fish
Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Rabih A
RA
Chaer
Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Michel S
MS
Makaroun
Department of Surgery, Division of Vascular and Endovascular Surgery, University of California Los Angeles Health, Los Angeles, Calif.
Donald T
DT
Baril
D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000453:epidemiology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000453:epidemiology / Q000601:surgery*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008168:Lung / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge; D058729:Peripheral Arterial Disease / Q000453:epidemiology / Q000601:surgery*; D011237:Predictive Value of Tests; D058996:Quality Improvement / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards; D012119:Respiration; D012140:Respiratory Tract Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D012866:Skilled Nursing Facilities; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality / Q000592:standards