Kirkham Aidan M, Candeliere Jasmine, Nagpal Sudhir K, Stelfox Henry T, Kubelik Dalibor, Hajjar George, MacFadden Derek R, McIsaac Daniel I, Roberts Derek J
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.
Vascular. 2024 Oct 3:17085381241290039. doi: 10.1177/17085381241290039.
Although surgical site infection (SSI) is a commonly used quality metric after lower-limb revascularization surgery, outcomes associated with development of this complication are poorly characterized. We conducted a systematic review and meta-analysis of studies reporting associations between development of an SSI after these procedures and clinical outcomes and healthcare resource use.
We searched MEDLINE, Embase, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies examining adjusted associations between development of an SSI after lower-limb revascularization surgery and clinical outcomes and healthcare resource use. Two investigators independently screened abstracts and full-text citations, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Heterogeneity was assessed using I statistics. GRADE was used to assess estimate certainty.
Among 6671 citations identified, we included 11 studies (n = 61,628 total patients) that reported adjusted-associations between development of an SSI and 13 different outcomes. Developing an SSI was associated with an increased adjusted-risk of hospital readmission (pooled adjusted-risk ratio (aRR) = 3.55; 95% CI (confidence interval) = 1.40-8.97; n = 4 studies; n = 13,532 patients; I = 99.0%; moderate certainty), bypass graft thrombosis within 30-days (pooled aRR = 2.09; 95% CI = 1.41-3.09; n = 2 studies; n = 23,240 patients; I = 51.1%; low certainty), reoperation (pooled aRR = 2.69; 95% CI = 2.67-2.72; n = 2 studies; n = 23,240 patients; I = 0.0%; moderate certainty), bleeding requiring a transfusion or secondary procedure (aRR = 1.40; 95% CI = 1.26-1.55; n = 1 study; n = 10,910 patients; low certainty), myocardial infarction or stroke (aRR = 1.21; 95% CI = 1.02-1.43; n = 1 study; n = 10,910 patients; low certainty), and major (i.e., above-ankle) amputation (pooled aRR = 1.93; 95% CI = 1.26-2.95; n = 4 studies; n = 32,859 patients; I = 83.0; low certainty). Development of an SSI >30-days after the index operation (aRR = 2.20; 95% CI = 1.16-4.17; n = 3 studies; n = 21,949 patients; low certainty) and prosthetic graft infection (aRR = 6.72; 95% CI = 3.21-12.70; n = 1 study; n = 272 patients; low certainty) were both associated with an increased adjusted-risk of major amputation. Prosthetic graft infection was also associated with an increased adjusted-risk of mortality >30-days after the index procedure (aRR = 6.40; 95% CI = 3.32-12.36; n = 1 study; n = 272 patients; low certainty).
This systematic review and meta-analysis suggests that development of an SSI after lower-limb revascularization surgery significantly increases patient morbidity and healthcare resource use. SSI is therefore a valuable quality metric after these surgeries. However, current estimates are based on heterogenous, low-to-moderate certainty evidence and should be confirmed by large, multicenter, cohort studies.
虽然手术部位感染（SSI）是下肢血管重建手术后常用的质量指标，但这种并发症发生后的相关结局特征尚不明确。我们对报告这些手术后发生SSI与临床结局及医疗资源使用之间关联的研究进行了系统评价和荟萃分析。
我们检索了MEDLINE、Embase、CENTRAL和循证医学综述（从创刊至2023年4月4日），以查找研究下肢血管重建手术后发生SSI与临床结局及医疗资源使用之间校正关联的研究。两名研究人员独立筛选摘要和全文引用文献，提取数据，并评估偏倚风险。使用随机效应模型汇总数据。使用I统计量评估异质性。采用GRADE评估估计的确定性。
在识别出的6671篇文献中，我们纳入了11项研究（共61628例患者），这些研究报告了SSI发生与13种不同结局之间的校正关联。发生SSI与住院再入院的校正风险增加相关（汇总校正风险比（aRR）=3.55；95%置信区间（CI）=1.40-8.97；4项研究；13532例患者；I=99.0%；中等确定性）、30天内旁路移植血管血栓形成（汇总aRR=2.09；95%CI=1.41-3.09；2项研究；23240例患者；I=51.1%；低确定性）、再次手术（汇总aRR=2.69；95%CI=2.67-2.72；2项研究；23240例患者；I=0.0%；中等确定性）、需要输血或二次手术的出血（aRR=1.40；95%CI=1.26-1.55；1项研究；10910例患者；低确定性）、心肌梗死或中风（aRR=1.21；95%CI=1.02-1.43；1项研究；10910例患者；低确定性）以及大截肢（即踝关节以上截肢）（汇总aRR=1.93；95%CI=1.26-2.95；4项研究；32859例患者；I=83.0；低确定性）。首次手术后>30天发生SSI（aRR=2.20；95%CI=1.16-4.17；3项研究；21949例患者；低确定性）和人工血管感染（aRR=6.72；95%CI=3.21-12.70；1项研究；272例患者；低确定性）均与大截肢的校正风险增加相关。人工血管感染还与首次手术后>30天的死亡校正风险增加相关（aRR=6.40；95%CI=3.32-12.36；1项研究；272例患者；低确定性）。
这项系统评价和荟萃分析表明，下肢血管重建手术后发生SSI会显著增加患者发病率和医疗资源使用。因此，SSI是这些手术后一个有价值的质量指标。然而，目前的估计基于异质性、低至中等确定性的证据，应由大型多中心队列研究予以证实。
