Impact of increasing comorbidity on infrainguinal reconstruction: a 20-year perspective

Abstract

Objective: To examine trends in patient and procedural variables and outcomes associated with autogenous lower extremity arterial reconstruction (LER) in a single center during a period of two decades.

Summary background data: Surgical arterial reconstruction is of proven value in the therapy of patients with critical ischemia of the lower extremities. Changing demographics and increasing comorbidity are resulting in an increasing prevalence and associated complexity of peripheral vascular disease. The effect of these variables on the types and outcomes of surgical reconstructions is not known.

Methods: The authors performed a retrospective analysis of all autogenous LER procedures performed at their institution from 1978 to 1997. Procedures were divided into 5-year intervals: group 1, 1978 to 1982; group 2, 1983 to 1987; group 3, 1988 to 1992; group 4, 1993 to 1997. Categorical parameters were compared using chi-square analysis; rates were computed by the life-table method and compared using Mantel-Cox log-rank analysis.

Results: A total of 1,642 autogenous LER procedures were performed in 1,274 patients. A significant increase in age, female gender, diabetes mellitus, renal failure, and prior coronary artery bypass grafting was noted in group 4. Increased technical complexity in this group was reflected by a greater incidence of tissue necrosis as the indication for LER, the use of ectopic or composite vein, and more distal levels of outflow. The surgical death rate remained unchanged (2%) throughout. Patient survival, primary and secondary graft patency, and limb salvage at 5 years for the entire cohort were 70 +/- 2%, 63 +/- 2%, 73 +/- 1%, and 85 +/- 1%, respectively. Hospital length of stay was reduced 25% from a mean of 15.7 +/- 0.8 days in group 3 to 11.7 +/- 0.4 days in group 4.

Conclusion: In a tertiary practice setting, patients requiring LER present an increasingly complex medical and surgical challenge compared with the previous decade. Excellent outcomes may still be achieved by an aggressive approach relying on autogenous vein conduit.

Figure 1. Total numbers of lower extremity arterial reconstruction (LER) procedures performed in each of the four 5-year intervals. Minor amputations shown were performed in patients who had also undergone LER.

Figure 2. Changing patterns of autogenous lower extremity arterial reconstruction during a 20-year period. Types of conduit used are shown in pie charts on the left; the unshaded area indicates the total of all ectopic (arm, lesser saphenous vein, composite) grafts. Breakdown of distal anastomotic sites is illustrated in the pie charts on right, with the unshaded area representing total infrageniculate outflow sites (tibial plus pedal). GSV-rev, reversed greater saphenous vein, GSV-IS, in-situ greater saphenous vein, GSV-NR, nonreversed greater saphenous vein, ARM/LSV, either arm vein or lesser saphenous vein; composite, composite vein, Pop-AK, above-knee popliteal artery; Pop-BK, below-knee popliteal artery.

Figure 3. Life-table plots of patient survival (A), patency (primary [B] and secondary [C]), and limb salvage (D) for all autogenous lower extremity arterial reconstructions during each of the four 5-year intervals and overall (1978–1997).

Figure 4. Cumulative secondary patency (A) and limb salvage (B) rates for tibial bypass grafts performed for limb salvage indications during a 20-year period.

Figure 5. Mean hospital length of stay for patients undergoing autogenous lower extremity arterial reconstruction during the last two consecutive 5-year intervals. The tissue necrosis subgroup is composed of patients with ulceration, gangrene, or both.