title: Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization.
abstract: Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment.
  
  
  
  Patients undergoing nonemergent infrainguinal bypass between 2011 and 2014 were identified in the National Surgical Quality Improvement Program Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared with those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass with prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes.
  
  
  
  A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs 7.4%; odds ratio [OR], 1.4 [95% confidence interval (CI), 1.1-1.7]) and claudication (5.2% vs 2.5%; OR, 2.1 [95% CI, 1.3-3.5]). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: OR, 1.4 [95% CI, 1.1-1.8]; claudication: OR, 2.1 [95% CI, 1.3-3.5]), bleeding (CLTI: OR, 1.4 [95% CI, 1.2-1.6]; claudication: OR, 1.7 [95% CI, 1.3-2.4]), and unplanned reoperation (CLTI: OR, 1.2 [95% CI, 1.0-1.4]; claudication: OR, 1.6 [95% CI, 1.1-2.1]), whereas major amputation was increased in CLTI patients only (OR, 1.3 [95% CI, 1.01-1.8]). Postoperative mortality was not significantly different in patients undergoing secondary compared with primary bypass (CLTI: 1.7% vs 2.2% [P = .22]; claudication: 0.4% vs 0.6% [P = .76]). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs 4.9%; OR, 1.5 [95% CI, 1.0-2.2]) but fewer wound infections (7.3% vs 12%; OR, 0.6 [95% CI, 0.4-0.8]) compared with patients with prior endovascular intervention.
  
  
  
  Prior revascularization, in both patients with CLTI and patients with claudication, is associated with worse perioperative outcomes compared with primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of the selection of patients for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
authors.forename: Thomas C F
authors.initials: TCF
authors.lastname: Bodewes
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Klaas H J
authors.initials: KHJ
authors.lastname: Ultee
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, George Washington University Medical Center, Washington, D.C.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Zettervall
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Katie E
authors.initials: KE
authors.lastname: Shean
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Jones
authors.affiliation: Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
authors.forename: Frans L
authors.initials: FL
authors.lastname: Moll
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000000981:diagnostic imaging / Q000601:surgery*; D007511:Ischemia / Q000000981:diagnostic imaging / Q000601:surgery*; D023821:Limb Salvage; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010359:Patient Readmission; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications / Q000601:surgery; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D058017:Vascular Grafting / Q000009:adverse effects