D. S. Kauvar1,2, C. L. Osborne3, D. S. Kauvar1,2 1Dwight D. Eisenhower Army Medical Center,Vascular Surgery,Ft. Gordon, GA, USA 2Uniformed Services University Of The Health Sciences,Surgery,Bethesda, MD, USA 3University Of Texas Medical Branch,Rehabilitation Sciences,Galveston, TX, USA
Introduction: Femoropopliteal bypass (FPB) remains a widely accepted treatment option for symptomatic leg ischemia, even in patients without features of critical limb ischemia (CLI). These patients are revascularized to improve symptoms of exertional limb pain and the goal of such treatment is to increase their ability to ambulate within the community. Therefore, the ideal initial discharge disposition for a patient without CLI undergoing FPB is back to their home. This study examined the disposition at initial discharge of such patients.
Methods: Data from the 2012 National Surgical Quality Improvement Program (NSQIP) registry was queried for all elective FPB performed in patients without CLI. Analysis was limited to patients surviving to initial discharge who were living independently at home prior to surgery. Initial disposition was defined as to HOME or to a FACILITY (either rehabilitation or skilled nursing); these constituting the study groups. Univariate analysis and multivariable logistic regression were performed to identify patient risk factors for failure to discharge to home. In-hospital and postoperative events were also recorded and compared. Significance was defined at P≤0.05.
Results: 1060 cases of elective FPB in patients without CLI were found in NSQIP 2012. The mean±SD age of the population was 65±9y; 359 (34%) of patients were female; 198 (19%) had a reported race other than white, and most (893, 84%) had hypertension. 60 (6%) patients failed to discharge to home (26 to rehabilitation, 34 to skilled nursing). On univariate analysis, age (FACILITY 68±11y vs HOME 65±9y, P=0.009), female gender (55% vs 37%, P<0.001), nonwhite race (30% vs 18%, P=0.007), and a history of diabetes (48% vs 33%, P=0.01), dialysis (5% vs 1.3%, P=0.02) congestive heart failure (CHF, 5% vs 1.1%, P=0.01), or a stroke (CVA, 5% vs 2.6%, P=0.01) were found to predict failure to discharge to home. On multivariate analysis, female gender (OR 2.4, 95% CI 1.4-4.1, P=0.002), and a history of CHF (OR 4.7, 1.2-18, 0.03) or CVA (OR 3.4, 1.9-9.4, 0.02) independently predicted failure to discharge to home. FACILITY patients had higher rates of infectious complications (8.3% vs 1.4%, P<0.001), myocardial infarction (3.3% vs 0.8%, P=0.05), operative transfusion (22% vs 5.8%, P<0.001), and unplanned reoperation (17% vs 2.4%, P<0.001) during their initial hospitalization.
Conclusion: Elective FPB results in a high rate of initial return to the community in patients without CLI. Female gender and serious comorbidities predict failure to discharge to home, which is associated with a complicated hospital course. The prediction of initial disposition by gender requires further study to improve FPBPG outcomes among female patients.