Dakour-Aridi Hanaa, Arora Manasi, Nejim Besma, Locham Satinderjit, Malas Mahmoud B
Department of Surgery, Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD; Department of Surgery, University of California San Diego, La Jolla, CA.
Department of Surgery, Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD.
Ann Vasc Surg. 2019 Jul;58:122-133.e4. doi: 10.1016/j.avsg.2018.12.070. Epub 2019 Feb 13.
Drug abuse may affect lower extremity vessels due to ischemia following intra-arterial injections, vasospasm, arterial and venous pseudoaneurysms, arteriovenous fistulae, vasculitis, and complicated abscesses. Little is known about the outcomes of lower extremity bypass (LEB) for peripheral arterial disease (PAD) in patients with a history of drug abuse disorder. The aim of this study is to evaluate the outcomes of LEB in this patient population.
A retrospective study of the Premier Healthcare Database 2009-2015 was performed. In-hospital complications, mortality, and hospitalization costs were assessed in patients with a history of drug abuse disorder (opioids, cannabis, cocaine, sedatives/hypnotics/anxiolytics, and hallucinogens/methamphetamine/psychoactive drugs) who underwent LEB for PAD. Multivariable logistic and generalized linear models were utilized to study the association between drug use/misuse and in-hospital outcomes after LEB.
Our cohort included 50,976 patients, of which 967 (2%) had a history of drug abuse disorder on admission. The majority of drugs were cannabis (38.5%), followed by opioids (21.5%) and cocaine (14.5%). Patients with a history of drug use/misuse were significantly at a higher risk of developing complications during their hospital stay (71.9% vs. 64.2%, P < 0.001) including acute renal failure (11.8% vs. 9.1%), stroke (1.6% vs. 0.6%), respiratory complications (pneumonia and respiratory failure) (15.0% vs. 9.6%), hemorrhage/shock (36.2% vs. 31.8%), vascular or graft-related complications (29.8% vs. 26.4%), wound complications (9.1% vs. 6.3%), cellulitis (8.5% vs. 6.8%), and sepsis (2.1% vs. 1.2%, all P < 0.001). In addition, drug users were found to have higher risk of concomitant major amputations compared to nondrug users (2.0% vs. 0.9%, P < 0.001). On multivariable analysis, no difference was noted between the 2 groups in terms of in-hospital mortality and concomitant major amputations. However, drug use/misuse was associated with 57% higher odds of overall in-hospital complications (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.34-1.83, P < 0.001), a prolonged length of hospital stay (median: 7 days vs. 5 days in nonabusers, P < 0.001), and higher hospitalization costs compared to nonusers (adjusted mean difference: OR $3,075, 95% CI $2,096-$4,055, P < 0.001).
Drug use/misuse is significantly associated with increased odds of in-hospital complications, longer hospital stays, and higher hospitalization costs following LEB. Vascular surgeons need to pay special attention to this patient population and explore interventions to decrease the morbidity and economic burden associated with drug use.
药物滥用可能因动脉内注射后的缺血、血管痉挛、动静脉假性动脉瘤、动静脉瘘、血管炎和复杂脓肿而影响下肢血管。对于有药物滥用障碍病史的外周动脉疾病（PAD）患者，下肢旁路移植术（LEB）的预后知之甚少。本研究的目的是评估该患者群体中LEB的预后。
对2009 - 2015年Premier医疗数据库进行回顾性研究。评估有药物滥用障碍病史（阿片类药物、大麻、可卡因、镇静剂/催眠药/抗焦虑药以及致幻剂/甲基苯丙胺/精神活性药物）且因PAD接受LEB的患者的住院并发症、死亡率和住院费用。采用多变量逻辑回归和广义线性模型研究药物使用/滥用与LEB后住院结局之间的关联。
我们的队列包括50976例患者，其中967例（2%）入院时有药物滥用障碍病史。使用最多的药物是大麻（38.5%），其次是阿片类药物（21.5%）和可卡因（14.5%）。有药物使用/滥用病史的患者在住院期间发生并发症的风险显著更高（71.9%对64.2%，P < 0.001），包括急性肾衰竭（11.8%对9.1%）、中风（1.6%对0.6%）、呼吸并发症（肺炎和呼吸衰竭）（15.0%对9.6%）、出血/休克（36.2%对31.8%）、血管或移植物相关并发症（29.8%对26.4%）、伤口并发症（9.1%对6.3%）、蜂窝织炎（8.5%对6.8%）和脓毒症（2.1%对1.2%，所有P < 0.001）。此外，与未使用药物者相比，药物使用者发生同期大截肢的风险更高（2.0%对0.9%，P < 0.001）。多变量分析显示，两组在住院死亡率和同期大截肢方面无差异。然而，药物使用/滥用与总体住院并发症的几率高57%相关（优势比[OR] 1.57，95%置信区间[CI] 1.34 - 1.83，P < 0.001），住院时间延长（中位数：非滥用者为5天，滥用者为7天，P < 0.001），且与未使用者相比住院费用更高（调整后平均差异：OR 3075美元，95% CI 2096 - 4055美元，P < 0.001）。
药物使用/滥用与LEB后住院并发症几率增加、住院时间延长和住院费用更高显著相关。血管外科医生需要特别关注这一患者群体，并探索干预措施以降低与药物使用相关的发病率和经济负担。
