Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah; Specialty Care Center of Innovation and IDEAS Center 2.0, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.
Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
J Vasc Surg. 2019 Feb;69(2):545-554. doi: 10.1016/j.jvs.2018.05.222. Epub 2018 Aug 11.
Optimizing medical management through glucose control, smoking cessation, and drug therapy (ie, antiplatelet and statin agents) is recommended as first-line therapy for patients with claudication. The aims of this study were to determine how frequently veterans with claudication received optimal medical management (OMM) before undergoing elective open lower extremity bypass procedures nationwide and whether preoperative OMM was associated with improved surgical outcomes.
We reviewed all patients within the Veterans Affairs (VA) Surgical Quality Improvement Program database who underwent elective open lower extremity bypass procedures for claudication at nationwide VA medical centers from 2005 until 2015. We defined OMM as a claudicant's having documentation of receiving all of the following within 12 months before surgery: prescriptions for antiplatelet, statin, and smoking cessation therapy (if a smoker) and monitoring of hemoglobin A (if diabetic). Outcome measures included occurrence of any 30-day VA Surgical Quality Improvement Program complication, amputation-free survival, and 30-day and 1-year mortality. We used multivariate regression and Cox proportional hazards models incorporating inverse probability treatment weighting to analyze the effect of OMM on outcome measures after adjusting for patient-level confounding.
Among 10,271 lower extremity bypass procedures performed, 2265 (22%) were undertaken in claudicants with a median age of 63 years (interquartile range, 58-68 years). Of claudicants, 839 (37%) were diabetic, and 1333 (59%) patients smoked within 12 months before surgery. OMM was achieved in only 581 (26%) claudicants before they underwent surgery, although adherence to individual components was variable: antiplatelet, 55%; statin, 63%; smoking cessation, 58%; and hemoglobin A monitoring, 92%. In risk-adjusted analyses, there were no statistically significant differences in complication rates, amputation-free survival, or mortality outcomes among patients who received OMM compared with non-OMM patients.
Only a quarter of veterans with claudication were documented as receiving OMM within the year before undergoing open lower extremity bypass across nationwide VA medical centers, highlighting the need for strategies to ensure that medical therapy is intensified before surgical revascularization. Nevertheless, our data showed that documentation of preoperative OMM did not lead to improved short- or long-term postoperative outcomes in these patients, suggesting that more objective measures of medical management are needed to ensure that peripheral arterial disease goals are achieved.
通过血糖控制、戒烟和药物治疗（即抗血小板和他汀类药物）来优化医学管理，这被推荐为跛行患者的一线治疗方法。本研究的目的是确定在全国退伍军人事务部（VA）医疗中心接受择期开放性下肢旁路手术之前，有多少跛行患者接受了最佳的医学管理（OMM），以及术前 OMM 是否与改善手术结果相关。
我们回顾了 2005 年至 2015 年期间，在全国退伍军人事务部医疗中心接受择期开放性下肢旁路手术治疗跛行的退伍军人的 VA 手术质量改进计划数据库中的所有患者。我们将 OMM 定义为跛行患者在手术前 12 个月内接受了以下所有治疗：抗血小板、他汀类药物和戒烟治疗的处方（如果患者为吸烟者）以及血红蛋白 A 的监测（如果患有糖尿病）。结果测量包括任何 30 天 VA 手术质量改进计划并发症、无截肢生存率、30 天和 1 年死亡率。我们使用多变量回归和 Cox 比例风险模型结合逆概率治疗加权来分析 OMM 对调整患者水平混杂因素后的结果测量的影响。
在 10271 例下肢旁路手术中，有 2265 例（22%）是在跛行患者中进行的，中位年龄为 63 岁（四分位间距，58-68 岁）。在跛行患者中，839 例（37%）患有糖尿病，1333 例（59%）患者在手术前 12 个月内吸烟。尽管每个组成部分的依从性各不相同（抗血小板，55%；他汀类药物，63%；戒烟，58%；血红蛋白 A 监测，92%），但只有 581 例（26%）跛行患者在手术前实现了 OMM。在风险调整分析中，与非 OMM 患者相比，接受 OMM 的患者在并发症发生率、无截肢生存率或死亡率方面没有统计学上的显著差异。
在全国退伍军人事务部医疗中心，只有四分之一的跛行患者在接受开放性下肢旁路手术前一年内被记录为接受 OMM，这突显了需要制定策略来确保在进行血管外科学再血管化之前加强医学治疗。然而，我们的数据表明，术前 OMM 的记录并不能改善这些患者的短期或长期术后结果，这表明需要更客观的医疗管理措施来确保实现外周动脉疾病的目标。
