Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
J Vasc Surg. 2010 Feb;51(2):351-8; discussion 358-9. doi: 10.1016/j.jvs.2009.08.065.
Infrainguinal surgical bypass (BPG) is a durable method for lower extremity revascularization, but is accompanied by significant 30-day morbidity and mortality (MM). The goal of this study is to relate preoperative functional status, a defined metric in the National Surgical Quality Improvement Program (NSQIP) database, to perioperative MM.
Between January 1, 2005 and December 31, 2007, all patients who underwent BPG from the NSQIP private sector database were reviewed. The primary end-point was 30-day MM. Patients were stratified by preoperative functional status: independent (IND) vs dependent (DEP). Associated patient demographic/clinical data were analyzed using univariate and multivariate methods. Composite odds ratios were constructed with clusters of high-risk comorbidities.
There were 5639 BPG patients (4600 [81.6%] IND and 1039 [18.4%]) DEP. DEP patients were significantly older (71.6 +/- 11.8 vs 66.8 +/- 11.8 years; P < .0001), had more chronic obstructive pulmonary disease (COPD) (16.7% vs 11.4%; P < .0001), diabetes (54.2% vs 40.7%; P < .0001), dialysis dependence (16.4% vs 5.6%; P < .0001), and critical limb ischemia (64.6% vs 44.0%; P < .0001). DEP patients had a higher incidence of death (6.1% vs 1.5%; P < .0001) and major complications (30.3% vs 14.2%; P < .0001). DEP was an independent predictor of major complications (odds ratio [OR]: 2.0; 95% confidence interval [CI]: [1.7-2.4]; P < .0001) major systemic complications (2.5 [1.9-3.2]; P < .0001), major operative site complications (1.6 [1.4-1.9]; P < .0001) and death (2.3[1.6-3.4]; P < .0001). The combination of DEP with emergency surgery, Cr > 1.8, or rest pain increased the odds of major complications by five, seven, or 11-fold, respectively. The combination of DEP with hemodialysis, emergency surgery, or age > or = 80 years increased the odds of death by 13, 38, or 87-fold, respectively.
Preoperative DEP is significantly correlated with all adverse 30-day outcomes in BPG patients. Furthermore, when combined in high-risk composites with specific preoperative clinical variables, DEP is associated with prohibitive MM, thereby identifying patient cohorts that may be unsuitable for BPG.
下肢血运重建的 Infrainguinal 手术旁路（Bypass）是一种持久的方法，但伴随着显著的 30 天发病率和死亡率（MM）。本研究的目的是将术前功能状态（国家手术质量改进计划（NSQIP）数据库中的一个定义指标）与围手术期 MM 相关联。
在 2005 年 1 月 1 日至 2007 年 12 月 31 日期间，从 NSQIP 私营部门数据库中回顾了所有接受 Bypass 的患者。主要终点是 30 天 MM。根据术前功能状态将患者分层：独立（IND）与依赖（DEP）。使用单变量和多变量方法分析相关患者的人口统计学/临床数据。用高风险合并症的簇构建复合优势比。
有 5639 例 Bypass 患者（4600 例[81.6%]IND 和 1039 例[18.4%]DEP）。DEP 患者年龄明显较大（71.6 +/- 11.8 岁 vs 66.8 +/- 11.8 岁；P <.0001），患有更多慢性阻塞性肺疾病（COPD）（16.7% vs 11.4%；P <.0001）、糖尿病（54.2% vs 40.7%；P <.0001）、透析依赖（16.4% vs 5.6%；P <.0001）和严重肢体缺血（64.6% vs 44.0%；P <.0001）。DEP 患者的死亡率（6.1% vs 1.5%；P <.0001）和主要并发症（30.3% vs 14.2%；P <.0001）发生率更高。DEP 是主要并发症（优势比[OR]：2.0；95%置信区间[CI]：[1.7-2.4]；P <.0001）、主要全身性并发症（2.5 [1.9-3.2]；P <.0001）、主要手术部位并发症（1.6 [1.4-1.9]；P <.0001）和死亡（2.3[1.6-3.4]；P <.0001）的独立预测因子。DEP 与急诊手术、Cr > 1.8 或静息痛相结合，使主要并发症的几率分别增加了 5 倍、7 倍或 11 倍。DEP 与血液透析、急诊手术或年龄 > 80 岁相结合，使死亡率分别增加了 13 倍、38 倍或 87 倍。
术前 DEP 与 Bypass 患者所有不良 30 天结局显著相关。此外，当与特定术前临床变量的高危复合因素结合使用时，DEP 与过高的 MM 相关，从而确定了可能不适合 Bypass 的患者队列。
