title: Index complications predict secondary complications after infrainguinal lower extremity bypass for critical limb ischemia.
abstract: Patients undergoing lower extremity bypass (LEB) are at high risk of perioperative complications that can lead to a cascade of secondary complications. Our goal was to understand the association of index complications with secondary complications after LEB.
  
  
  
  The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2012 was used to analyze secondary complications after five index complications after LEB: deep/organ space surgical site infection, urinary tract infection (UTI), myocardial infarction (MI), pneumonia, and acute renal failure (ARF). Index cohorts were developed with 5:1 propensity matching for comparison. This score was based on preoperative variables and event-free days.
  
  
  
  We evaluated 20,230 LEB patients. Postoperative index surgical site infection increased the risk of secondary ARF (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.1-15.0), pneumonia (OR, 2.7; 95% CI, 1.0-7.4), UTI (OR, 3.1; 95% CI, 1.3-7.5), cardiac arrest (OR, 4.4; 95% CI, 1.6-12.2), wound disruption (OR, 10.5; 95% CI, 6.7-16.6), unplanned intubation (OR, 5.1; 95% CI, 2.0-12.8), prolonged ventilation (OR, 5.9; 95% CI, 2.0-17.6), sepsis (OR, 16.2; 95% CI, 10.2-25.6), and mortality (OR, 3.5; 95% CI, 1.7-7.1). Postoperative index UTI was associated with pneumonia (OR, 5.6; 95% CI, 2.7-11.6), sepsis (OR, 7.8; 95% CI, 5.1-11.8), and mortality (OR, 2.7; 95% CI, 1.3-5.3). Postoperative index MI was associated with secondary ARF (OR, 8.7; 95% CI, 3.8-20.1), pneumonia (OR, 4.9; 95% CI, 2.7-8.8), cardiac arrest (OR; 7.4; 95% CI; 4.0-13.5), deep venous thrombosis (OR, 3.9; 95% CI, 1.7-9.1), unplanned intubation (OR, 12.2; 95% CI, 7.3-20.3), prolonged intubation (OR, 12.2; 95% CI, 6.4-23.2), sepsis (OR, 2.2; 95% CI, 1.2-3.8), and mortality (OR, 5.6; 95% CI, 3.6-8.5). Postoperative index pneumonia was associated with secondary ARF (OR, 25.5; 95% CI, 3.0-219.3), MI (OR, 7.6; 95% CI, 3.2-18.0), UTI (OR, 4.3; 95% CI, 2.0-9.0), cardiac arrest (OR, 5.2; 95% CI, 2.0-13.2), deep venous thrombosis (OR, 7.7; 95% CI, 2.1-27.4), unplanned intubation (OR, 14.7; 95% CI, 8.3-26.1), prolonged ventilation (OR, 26.0; 95% CI, 11.8-56.9), sepsis (OR, 7.2; 95% CI, 4.0-12.8), and mortality (OR, 6.0; 95% CI, 3.7-10.0). Last, postoperative index ARF was associated with increased risk of secondary pneumonia (OR, 7.16; 95% CI, 2.6-20.0), cardiac arrest (OR, 15.5; 95% CI, 1.6-150.9), unplanned intubation (OR, 6.2; 95% CI, 2.3-16.8), prolonged ventilation (OR, 8.8; 95% CI, 3.4-22.4), and mortality (OR, 8.8; 95% CI, 3.4-22.4).
  
  
  
  A postoperative index complication after LEB is significantly more likely to lead to serious secondary complications. Prevention and early identification of index complications and subsequent secondary complications could decrease morbidity and mortality.
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Peacock
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
authors.forename: Nishant K
authors.initials: NK
authors.lastname: Shah
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
authors.forename: Su Yeon
authors.initials: SY
authors.lastname: Lee
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kalish
authors.affiliation: Department of Biostatistics, Boston University, Boston, Mass.
authors.forename: Denis
authors.initials: D
authors.lastname: Rybin
authors.affiliation: Department of Biostatistics, Boston University, Boston, Mass.
authors.forename: Gheorghe
authors.initials: G
authors.lastname: Doros
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass. Electronic address: jeffrey.siracuse@bmc.org.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Siracuse
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D016017:Odds Ratio; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D011014:Pneumonia / Q000209:etiology; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D057216:Propensity Score; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014552:Urinary Tract Infections / Q000209:etiology; D058017:Vascular Grafting / Q000009:adverse effects* / Q000401:mortality