Risk score for one-year mortality following emergent infra-inguinal bypass.

OBJECTIVE: The purpose of this study is to identify variables that place patients at higher risk for mortality following emergent infra-inguinal bypass. Further, this study will create a risk score for mortality following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management. METHODS: In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated: 30 day mortality following emergent infra-inguinal bypass; and 1-year mortality following emergent infra-inguinal bypass. The first step in analysis was univariable analysis for each outcome with χ2 analysis for categorical variables and Student t-test for comparison of means of ordinal variables. Next, binary logistic regression analysis was performed for each outcome utilizing variables that achieved a univariable P value ≤ .10. Factors with a multivariable P value ≤ .05 were included in the risk score, and points were weighted and assigned based on the respective regression beta-coefficient in the multivariable regression. RESULTS: Variables with a significant multivariable association (P < .05) with 1-year mortality were: increasing age; body mass index less than 20 kg/m2; coronary artery disease; active hemodialysis at time of presentation; anemia at admission; prosthetic conduit for emergent bypass; postoperative myocardial infarction; postoperative acute renal insufficiency; perioperative stroke; baseline non-ambulatory status; new onset hemodialysis requirement perioperatively; need for bypass revision or thrombectomy during index admission; lack of statin prescription at discharge; lack of antiplatelet medication at discharge; and, lack of anticoagulation at time of hospital discharge. Pertinent negatives included all sociodemographic variables including rural living status, insurance status, and Area Deprivation Index home area. The risk score achieved an area under the curve of 0.820, and regression analysis of the risk score achieved an overall accuracy of 87.9% with 97.7% accuracy in predicting survival, indicating the model performs better in determining which patients will survive rather than precisely determining who will experience 1-year mortality. CONCLUSIONS: Discharge medications are the primary modifiable variable impacting survival after emergent infra-inguinal bypass surgery. In the absence of contraindication, all these patients should be discharged on antiplatelet, statin, and anticoagulant medications after emergent infra-inguinal bypass as they significantly enhance survival. Social determinants of health do not impact survival among patients treated with emergent infra-inguinal bypass at Vascular Quality Initiative centers. A risk score for mortality at 1 year after emergent infra-inguinal bypass has been created that has excellent accuracy.

Socioeconomic disadvantage is a leading variable in risk score for major amputation following emergent infrainguinal arterial bypass surgery.

OBJECTIVE: The purpose of this study was to identify patients at particularly high risk for major amputation after emergent infrainguinal bypass to help tailor postoperative and long-term patient management. METHODS: In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infrainguinal artery bypass. Two primary outcomes were investigated: major ipsilateral amputation above the ankle level during the index hospitalization and major amputation above the ankle at any time after emergent infrainguinal bypass surgery (perioperative and postdischarge combined). Binary logistic regression analysis was performed for each outcome using variables that achieved a univariable P value of ≤.10. We then determined which variables have a multivariable association for the outcomes as defined by a regression P value of ≤.05. A risk score was then created for the outcome of amputation after emergent infrainguinal bypass using weighted beta-coefficient. Variables with a multivariable P value of ≤.05 were included in the risk score and weighted based on their respective regression beta-coefficient in a point scale. RESULTS: Overall, 17.1% of patients (368/2126) underwent major amputation at some point in follow-up after emergent infrainguinal artery bypass. The mean follow-up duration on the amputation variable was 261 days with the end point being time of amputation or time of last follow-up data on the amputation variable. Variables with a significant multivariable association (P < .05) with major amputation at any point after emergent infrainguinal arterial bypass were home status in top 10% (most deprived) of Area Deprivation Index, prior infrainguinal ipsilateral arterial bypass, prior ipsilateral endovascular arterial intervention, prosthetic bypass conduit, postoperative skin/soft tissue infection, and postoperative need to revise or thrombectomize bypass. Pertinent negatives on multivariable analysis included all baseline comorbidities, insurance status, race, and gender. There is steep progression in amputation rate ranging from 5% at scores of 0 and 1 to >60% for scores in of >10. Area under the curve analysis revealed a value of 0.706. CONCLUSIONS: Patients living in the most disadvantaged socioeconomic neighborhoods have an increased risk of amputation after emergent infrainguinal arterial bypass independent of baseline comorbidities and perioperative events. Baseline comorbidities are not impactful regarding amputation rates after emergent infrainguinal bypass surgery. The need for bypass revision or thrombectomy during the index hospitalization is the most impactful factor toward amputation after emergency bypass. A risk score with quality accuracy has been developed to help identify patients at particularly high likelihood of limb loss, which may aid in counseling regarding heightened vigilance in postoperative and long-term follow-up care.

The Impact of Sociodemographic Variables on Functional Recovery following Lower Extremity Amputation.

BACKGROUND: We hypothesize that sociodemographic variables, particularly disadvantaged financial environments, impact both rate of prosthetic utilization and the achievement of ambulation post major amputation. METHODS: All cases in the Vascular Quality Initiative amputation module were queried between April 2013 and January 2024. Inclusion was limited to patients who underwent below knee, through knee, and above knee amputation. Two primary outcomes were investigated: Nonambulatory status after amputation (minimum of 120 days follow-up); and, not having obtained a prosthetic limb (minimum of 90 days follow-up). The ambulation status and prosthetic status analyses had 6,984 and 6,793 patients meet inclusion, respectively. Multivariable binary logistic regression analysis was performed utilizing variables which achieved univariable significance (P < 0.05) for the outcomes. RESULTS: Mean follow-up for those meeting inclusion was 432 days. Among all patients meeting inclusion, 46.7% of patients did not acquire a prosthetic limb and 44.1% were nonambulatory. Sociodemographic factors with significant multivariable association for the outcome of no prosthetic limb acquisition in follow-up were as follows: advancing age (adjusted odds ratio [aOR] 1.011/year (1.006-1.016), P < 0.001); female sex (aOR 1.43 (1.28-1.61), P < 0.001); top 20% area deprivation index representing highest deprivation (aOR 1.24 (1.09-1.41) P = 0.001); race (P = 0.002) insurance status (P = 0.028) with protective status for commercial insurance (39% rate of no prosthetic) and non-US insurance (33%) versus Medicare (51%), Medicaid (48%), Veterans Affairs insurance (49%), Self-pay (42%), and Medicare Advantage (51%). There were numerous comorbidities which also had association with lack of prosthetic limb acquisition. Sociodemographic variables which achieved multivariable significance (P < 0.05) for the outcome of nonambulatory status after major amputation were as follows: female sex (aOR 1.37 (1.23-1.54), P < 0.001); Medicare insurance (P = 0.016); advancing age (aOR 1.009/year (1.004-1.014), P < 0.001); congestive heart failure (aOR 1.15 (1.02-1.31), P = 0.028); and, not living at home in follow-up (aOR (3.53 (2.99-4.17) P < 0.001). Physical therapy at any point after surgery (aOR 0.742 (0.662-0.832), P < 0.001) and commercial insurance (aOR 0.839 (0.737-0.956), P = 0.008) were protective. There were numerous comorbidities which also had association with nonambulatory status in follow-up. CONCLUSIONS: Living within the most financially disadvantaged areas and race both have a significant independent association with lack of prosthetic limb acquisition following major amputation. Black, Native American, and Pacific Islander demographic patients experience lack of acquisition at a higher rate than White and Asian patients independent of comorbidities and socioeconomic covariables. Female patients obtain a prosthetic limb and ambulate less frequently than males after major amputation, largely due to a higher rate of above knee amputation. Comorbidities and not socioeconomic variables are the leading drivers of nonambulation.