Selective Use of Anticoagulation or Dual Antiplatelet Therapy for Patients with Extra-anatomic Bypasses.

BACKGROUND: The benefit of long-term anticoagulation or dual antiplatelet therapy (DAPT) for patients with extra-anatomic bypasses to the lower extremity remains poorly defined. Our study analyzed the real-world use of antithrombotic therapy in patients with extra-anatomic bypass grafts to the lower extremity and compared graft and patient outcomes by antithrombotic regimen. METHODS: We studied patients who underwent axillofemoral or femoral-femoral bypass within the Vascular Quality Initiative with one-year follow-up data. Primary exposures were anticoagulation and DAPT, at the time of index procedure and one-year follow-up. Primary outcomes were major adverse limb events (MALE) defined as reintervention or above-ankle amputation, and primary patency. Secondary outcomes included perioperative blood transfusion requirements and the need for reoperation specifically for bleeding. We analyzed outcomes using the Kaplan-Meier estimation and examined factors associated with choice of antithrombotic therapy via logistic regression. RESULTS: Our cohort included 2,760 patients (axillofemoral bypass, n = 857; femoral-femoral bypass, n = 1,903) across 168 centers from 2009 to 2018. Mean age was 66.5 ± 10.5 years and 59% were male. Patients were infrequently prescribed long-term anticoagulation (19%) or DAPT (22%). One-year primary patency was 86% and was similar by anticoagulation (log-rank P = 0.12) and DAPT status (log-rank P = 0.26). Freedom from MALE was 87% at 1 year and was slightly inferior for patients on anticoagulation (88 vs. 83%, log-rank P = 0.001) but was similar by DAPT (log-rank P = 0.19). Transfusion was more common in patients who were anticoagulated than those who were not (30 vs. 25%, P < 0.01), but there was no increase in reoperation because of bleeding (anticoagulation 0.8 vs. 0.8, P = 0.98). Anticoagulation was more commonly prescribed according to disease severity, such as rest pain (adjusted odds ratio (OR): 1.6 (95% confidence interval (CI): 1.20-2.20), tissue loss (OR: 1.9, CI: 1.28-2.73), or acute limb ischemia (OR: 1.9, CI: 1.35-2.71) or prior bypass graft (OR: 2.6, CI: 2.07-3.35). Patients were more commonly prescribed DAPT according to comorbidities, including hypertension (OR: 1.4, CI: 1.04-1.94) and coronary artery disease (OR: 1.6, CI 1.26-1.95). CONCLUSIONS: Antithrombotics are selectively used in patients with extra-anatomic bypass to the lower extremity, the selection of which appears associated with disease severity for anticoagulants and patient comorbidities for DAPT. Primary patency and MALE rates are similar with focused utilization of anticoagulants or DAPT. Blood transfusions are more common among patients on antithrombotics without a difference in the need for reoperation for bleeding.

Peripheral arterial occlusive disease operative case volume in the final years of 5+2 and 0+5 vascular training paradigms.

BACKGROUND: Peripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons. Case volume for 0+5 integrated vascular surgery residents in the chief and junior years was compared with their 5+2 fellowship counterparts for the treatment of peripheral arterial occlusive disease. METHODS: In this retrospective review, operative volume for peripheral arterial occlusive disease cases in both vascular training paradigms was evaluated. "Surgeon chief" cases in the final year of residency training, and "surgeon junior" cases for postgraduate year 4 and below were gathered for the integrated vascular surgery residents group. Annual fellow's case volume was collected using cases logged as "surgeon fellow." Procedures were divided by the following anatomic region and compared: aortoiliac, femoropopliteal, and infrapopliteal. Student's t tests were used to assess these differences. RESULTS: An aggregate of 887 residents and fellows from 137 programs were identified. Vascular surgery fellows consistently performed 1.7-fold (P < .001) and 1.6-fold (P < .001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. They also performed 1.8-fold (P = .002) and 1.5-fold (P = .004) more peripheral endovascular cases than their 0+5 chief and junior counterparts respectively. With respect to endovascular treatment of peripheral arterial occlusive disease by subgroup, we found the overall volume of aortoiliac and femoropopliteal increased, whereas infrapopliteal case volume decreased. Vascular surgery fellows were performing many more of these cases per year than the integrated vascular surgery residents chiefs and junior residents. When looking at 3 index open procedures, aortobifemoral bypass, femoropopliteal bypass with vein, and infrapopliteal bypass with vein in the academic year 2017-2018, the vascular surgery fellow trainees performed more cases than the integrated vascular surgery residents chief and junior residents. CONCLUSION: Earlier studies have compared the operative volume of vascular surgery fellows and integrated vascular surgery residents in their entire tenure of training. Our study specifically evaluated the years of training that confer the greatest level of autonomy. Vascular surgery fellows are performing more endovascular and open cases than their 0+5 counterparts for peripheral arterial occlusive disease during the final phase of training. These findings suggest that current suspected equipoise of vascular surgery training paradigms may not reflect what is occurring in practice and therefore warrants further investigation.