Socioeconomic Disadvantage is a Leading Variable in Risk Score for Major Amputation Following Emergent Infrainguinal Arterial Bypass Surgery

Overview

Journal J Vasc Surg

Publisher Elsevier

Specialties Cardiology & Vascular Diseases
General Surgery

Date 2024 Jun 8

PMID 38851469

Authors

Meghan Cichocki

Rylie OMeara

Ian Kang

Zach Kittrell

Priya Rao

Lorela Weise

Trissa Babrowski

Michael Soult

Matthew Blecha

Affiliations

Soon will be listed here.

Abstract

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.

References

Holena D, Kaufman E, Hatchimonji J, Smith B, Xiong R, Wasser T . The impact of interhospital transfer on mortality benchmarking at Level III and IV trauma centers: A step toward shared mortality attribution in a statewide system. J Trauma Acute Care Surg. 2019; 88(1):42-50. PMC: 6923584. DOI: 10.1097/TA.0000000000002491. View

Phelos H, Kass N, Deeb A, Brown J . Social determinants of health and patient-level mortality prediction after trauma. J Trauma Acute Care Surg. 2021; 92(2):287-295. PMC: 8792275. DOI: 10.1097/TA.0000000000003454. View

Parker M, Penton A, McDonnell S, Kolde G, Babrowski T, Blecha M . Investigation of center-specific saphenous vein utilization rates in femoral popliteal artery bypass and associated impact of conduit on outcomes. J Vasc Surg. 2023; 78(6):1497-1512.e3. PMC: 10756644. DOI: 10.1016/j.jvs.2023.08.123. View

Kunitake R, Kornblith L, Cohen M, Callcut R . Trauma Early Mortality Prediction Tool (TEMPT) for assessing 28-day mortality. Trauma Surg Acute Care Open. 2018; 3(1):e000131. PMC: 5887834. DOI: 10.1136/tsaco-2017-000131. View

Aggarwal R, Hammond J, Joynt Maddox K, Yeh R, Wadhera R . Association Between the Proportion of Black Patients Cared for at Hospitals and Financial Penalties Under Value-Based Payment Programs. JAMA. 2021; 325(12):1219-1221. PMC: 7988363. DOI: 10.1001/jama.2021.0026. View

Holena D, Wiebe D, Carr B, Hsu J, Sperry J, Peitzman A . Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients. J Am Coll Surg. 2016; 224(3):255-263. PMC: 5328799. DOI: 10.1016/j.jamcollsurg.2016.11.016. View

Jarman M, Curriero F, Haut E, Porter K, Castillo R . Associations of Distance to Trauma Care, Community Income, and Neighborhood Median Age With Rates of Injury Mortality. JAMA Surg. 2018; 153(6):535-543. PMC: 5875389. DOI: 10.1001/jamasurg.2017.6133. View

LaMuraglia G, Conrad M, Chung T, Hutter M, Watkins M, Cambria R . Significant perioperative morbidity accompanies contemporary infrainguinal bypass surgery: an NSQIP report. J Vasc Surg. 2009; 50(2):299-304, 304.e1-4. DOI: 10.1016/j.jvs.2009.01.043. View

Boutrous M, Tian Y, Brown D, Freeman C, Smeds M . Area Deprivation Index Score is Associated with Lower Rates of Long Term Follow-up after Upper Extremity Vascular Injuries. Ann Vasc Surg. 2021; 75:102-108. DOI: 10.1016/j.avsg.2021.03.037. View

10.

Ramdev P, Rayan S, Sheahan M, Hamdan A, LoGerfo F, Akbari C . A decade experience with infrainguinal revascularization in a dialysis-dependent patient population. J Vasc Surg. 2002; 36(5):969-74. DOI: 10.1067/mva.2002.128297. View

11.

Kikta M, Goodson S, Bishara R, Meyer J, Schuler J, Flanigan D . Mortality and limb loss with infected infrainguinal bypass grafts. J Vasc Surg. 1987; 5(4):566-71. DOI: 10.1067/mva.1987.avs0050566. View

12.

Crawford R, Cambria R, Abularrage C, Conrad M, Lancaster R, Watkins M . Preoperative functional status predicts perioperative outcomes after infrainguinal bypass surgery. J Vasc Surg. 2010; 51(2):351-8. DOI: 10.1016/j.jvs.2009.08.065. View

13.

Sharrock M, Antoniou S, Antoniou G . Vein Versus Prosthetic Graft for Femoropopliteal Bypass Above the Knee: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Angiology. 2019; 70(7):649-661. DOI: 10.1177/0003319719826460. View

14.

Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan G, Katz L . Neighborhoods, obesity, and diabetes--a randomized social experiment. N Engl J Med. 2011; 365(16):1509-19. PMC: 3410541. DOI: 10.1056/NEJMsa1103216. View

15.

Blumenthal S, Fryhofer G, Serra-Lopez V, Pierrie S, Mehta S . Bias in Care: Impact of Ethnicity on Time to Emergent Surgery Varies Between Subspecialties. J Am Acad Orthop Surg Glob Res Rev. 2023; 7(6). PMC: 10266510. DOI: 10.5435/JAAOSGlobal-D-23-00060. View

16.

Brown J, Rosengart M, Billiar T, Peitzman A, Sperry J . Distance matters: Effect of geographic trauma system resource organization on fatal motor vehicle collisions. J Trauma Acute Care Surg. 2017; 83(1):111-118. PMC: 5478426. DOI: 10.1097/TA.0000000000001508. View

17.

Hood C, Gennuso K, Swain G, Catlin B . County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. Am J Prev Med. 2015; 50(2):129-35. DOI: 10.1016/j.amepre.2015.08.024. View

18.

Hawkins R, Mehaffey J, Charles E, Kern J, Schneider E, Tracci M . Socioeconomically Distressed Communities Index independently predicts major adverse limb events after infrainguinal bypass in a national cohort. J Vasc Surg. 2019; 70(6):1985-1993.e8. DOI: 10.1016/j.jvs.2019.03.060. View

19.

Trivedi A, Sequist T, Ayanian J . Impact of hospital volume on racial disparities in cardiovascular procedure mortality. J Am Coll Cardiol. 2006; 47(2):417-24. DOI: 10.1016/j.jacc.2005.08.068. View

20.

Kind A, Buckingham W . Making Neighborhood-Disadvantage Metrics Accessible - The Neighborhood Atlas. N Engl J Med. 2018; 378(26):2456-2458. PMC: 6051533. DOI: 10.1056/NEJMp1802313. View