Lower extremity ischemia, an ominous complication after elective EVAR
Kalsi R, Oates CP, Olson S, Drucker CB, Harris DG, Shepard AD, Crawford RS, and Toursavadkohi SS. Lower extremity ischemia, an ominous complication after elective EVAR. J Vasc Surg 2017; 66(2):E22.
J Vasc Surg
Objectives: Elective endovascular repair (EVAR) is considered to be a safe and effective intervention for abdominal aortic dissection. Although rare, ischemic complications after EVAR are highly feared. In particular, data on lower extremity ischemia (LEI) after EVAR are sparse. Our objective was to determine the impact of LEI on outcomes after elective EVAR in a national database.
Methods: We queried the American College of Surgeons National Safety Quality Improvement Project participant and corresponding procedure targeted data files for EVAR from 2011 to 2015 to identify and compare clinical features, operative details, and 30-day outcomes of elective EVAR. Patients with incomplete data sets with regards to evaluated factors were excluded from analysis. Bivariate and multivariate analyses were performed using SAS software (SAS Institute, Inc, Cary, SC).
Results: Of 8981 patients who underwent elective EVAR, 137 patients (1.52%) developed LEI. The Table shows that patients who developed LEI were significantly more likely to also develop pneumonia (3.3% vs 0.5%; P = .014), renal failure requiring dialysis (4.4 vs 0.4%; P < .001), skin and soft tissue infection (4.4 vs 1.2; P = .024), deep venous thrombosis (4.4% vs 0.2%; P < .0001), and required return to the operating room (80% vs 2.74%; P < .0001). Inpatient mortality was also significantly higher in this group (6.7 vs 0.5%; P < .0001; Table). On multivariate regression controlling for patient characteristics, perioperative characteristics and postoperative complications known to be associated with LEI, odds of inpatient mortality remained higher among patients with LEI than those without (odds ratio, 7.032; 91% confidence interval, 2.362-20.939; Table). Additionally, LEI was associated with higher odds of an extended hospital length of stay, defined as length of stay >75 percentile (odds ratio, 1.652; 95% confidence interval, 1.029-2.652; Table). Other significant predictors of inpatient mortality in these elective EVAR patients include operative time and postoperative renal failure requiring dialysis, whereas male sex was associated with lower odds of inpatient mortality.
Conclusions: LEI after elective EVAR increases the risk of inpatient mortality after EVAR by almost tenfold. As such, careful intraoperative assessment of the access site and bilateral lower extremity circulation is critical for early recognition and management of this morbid and often deadly postoperative complication.