The Impact of Completion Angiography on Outcomes of Infrainguinal Lower Extremity Bypass for Chronic Limb-Threatening Ischemia.
Academic Article
Overview
abstract
BACKGROUND: Intraoperative technical success of lower extremity bypass (LEB) is essential for all vascular surgeons. Completion angiography (CA) allows real-time assessment of the bypass, enabling revision for technical defects if needed. However, no consensus exists on the use of CA at the time of LEB. Therefore, we aimed to investigate the impact of CA on perioperative outcomes of LEB in real-world practice. METHODS: We queried all patients with chronic limb-threatening ischemia (CLTI) who underwent LEB during 2011 to 2023 in the Vascular Quality Initiative database. The bypasses were stratified by the performance of CA. The primary outcome was postoperative major amputation. Secondary outcomes included postoperative complications, postoperative reintervention, 30-day mortality, in-hospital major adverse cardiovascular events (MACEs), in-hospital major adverse limb events (MALEs), and 6-month overall survival, limb salvage, amputation-free survival, freedom from reintervention, freedom from MALE, and MALE-free survival. Logistic and Cox regressions were used for the multivariate analysis. RESULTS: A total of 35,525 limbs (28,824 patients) were included in this study. Of these, CA was performed for 9,888 bypasses (27.8%). The rate of postoperative major amputation in bypasses without and with CA was 1.7% and 1.8%, respectively (P = 0.503). The rates of postoperative myocardial infarction (3.6% vs. 2.8%; P < 0.001), respiratory complications (2.5% vs. 2.0%; P = 0.019), reintervention (4.4% vs. 3.5%; P < 0.001), MACE (5.0% vs. 4.4%; P = 0.010), and MALE (5.7% vs. 4.7%; P < 0.001) were higher in bypasses performed with CA. However, after adjusting for potential confounders, CA was not associated with major amputation (adjusted odds ratio = 0.95, 95% confidence interval [CI]: 0.74-1.23; P = 0.703), 30-day mortality, or other postoperative outcomes. Additionally, CA was not associated with 6-month outcomes in the multivariate analyses. However, in a subanalysis of outcomes stratified by the level of bypass, CA was associated with decreased hazards of major amputation/death at 6-month in femorotibial bypasses (adjusted hazards ratio = 0.87, 95% CI: 0.76-0.99; P = 0.040). CONCLUSION: We found that postoperative and 6-month outcomes are not influenced by the performance of CA in CLTI patients undergoing LEB. The only beneficial effect observed was for femorotibial bypasses, likely due to the length of the bypass. Based on this study, the routine use of CA for infrainguinal bypasses is not recommended, and the decision should be made at the surgeon's discretion. However, further prospective studies are necessary to validate our findings.
