Abstract
Objectives:
Percutaneous endovascular treatment for arterial vascular diseases has revolutionized vascular care. While these procedures offer improved morbidity, mortality, and length of stay (LOS), their effect on post-discharge complications is unknown. The objectives of the study were to (1) evaluate trends in LOS and post-discharge complications over time, and (2) assess factors associated with post-discharge complications.
Methods:
Patients who underwent surgery for common vascular pathologies (abdominal aortic aneurysm [AAA], aortoiliac occlusive disease, lower extremity disease, and carotid stenosis) were identified from the ACS NSQIP Procedure-Targeted database (2014–2019). Outcomes included LOS, 30-day complications, and proportions of post-discharge complications. Predictors of post-discharge complications were assessed using multivariable logistic regression.
Results:
Of 80,311 patients evaluated, median LOS did not change from 2014 to 2019 (2, IQR 1–5). Overall, 15.7% of patients experienced any 30-day complication, with 31.3% occurring after discharge. The proportion of post-discharge complications increased from 29.1% (2014) to 35.9% (2019), p<0.001. With exception of carotid procedures, endovascular procedures had lower overall complication rates than open procedures, however, there was increased proportion of post-discharge complications for endovascular procedures, (all p<0.001). Factors associated with an increased odds of post-discharge complications included female, Black or other race, dependent functional status, underweight or obesity, increased LOS, and procedural time, all p<0.05.
Conclusion:
Across four representative common vascular pathologies, endovascular treatments had a higher proportion of post-discharge complications compared to open procedures. Early identification and evaluation of post-discharge complications for endovascular patients may be warranted to avoid unplanned readmission.
Keywords: Post discharge complications, length of stay, endovascular, open repair, postoperative complications
INTRODUCTION
The use of percutaneous endovascular treatment has grown in popularity through advancement of technology and improvement in techniques.1 This was fueled by studies that demonstrated equivalent outcomes between endovascular and open approaches for various vascular procedures, including limb salvage rate, and abdominal aortic aneurysm (AAA) repair.2–6 Several randomized controlled trials showed endovascular approach to AAA repair and lower extremity revascularization provided lower perioperative mortality and morbidity, quicker recovery and shorter hospital length of stay (LOS).7–10 However, most surgical quality measures only focus on inpatient complications, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides 30-day events postoperatively which captures both inpatient and outpatient outcomes.
While the benefits of a shortened LOS after procedures, such as endovascular interventions, is recognized by hospitals, payers, and policy makers, it is important to evaluate events that may occur after discharge, such as readmission rate, and post-discharge complications.11 Previous studies that evaluated post-discharge complication rates in lower extremity revascularization demonstrated a significant number of major adverse events occurred after discharge for those who underwent endovascular repair, and Medicare data showed one in seven surgical patients had potentially preventable adverse events that led to readmission.10,12–14 Thus, it is important to recognize that the post-discharge period is a particularly vulnerable time for patients.
A comprehensive, over time analysis evaluating the effects of shorter LOS and operative approach have on post-discharge complication is necessary for major vascular pathologies, including AAA, aortoiliac occlusive disease, lower extremity disease, and carotid stenosis. The objectives of the study were (1) to evaluate trends in LOS and post-discharge complications over time, and (2) to assess factors associated with post-discharge complications.
METHODS
Data Source and Patient Population
Patients who underwent vascular/endovascular procedures between January 1, 2014, and December 31, 2019 for AAA, aortoiliac occlusive disease, lower extremity disease, and carotid stenosis were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) procedure-targeted participant use database.15 ACS NSQIP is a nationally validated, prospectively maintained surgical registry which collects information on patients who undergo surgical procedures at participating hospitals. Over 150 patient variables including demographics, comorbidities, pre-operative risk factors, intraoperative variables, and 30-day postoperative complications are collected by trained nurse abstractors, as previously described.16 Since 2012, hospitals have been able to voluntarily participate in procedure-targeted modules which collect additional variables that are specific to certain procedures. All patients entered in the database have outcomes reported up to 30 days post-operatively or to death, whichever occurs first. High-quality data collection is ensured via audits which have shown reliability.16,17
Patients were excluded from analysis if they underwent American Society of Anesthesiologist (ASA) classification of 6 (n=1314), LOS>30 days (n=687), or those who suffered inpatient death (n=17). These exclusion criteria were chosen to include patients who were considered at risk for a post-discharge complications event.18,19 Based on these exclusion criteria, 2,018 patients were excluded from analysis. CPT codes considered for analysis are listed in the Supplemental Table 2.
Outcome Variables
The primary outcome assessed were LOS, defined as number of days after a procedure that a patient spent in the hospital, and postoperative complications within 30 days after surgery for open and endovascular approaches. Post-discharge complications were defined as events occurring after the day of discharge and within 30-days from the intervention. Six categories of complications were captured in the ACS-NSQIP database including surgical site infection (SSI) (superficial, deep, and organ space SSI, wound dehiscence), infection (pneumonia, urinary tract infection [UTI], sepsis, shock), pulmonary complications (reintubation, prolonged intubation), cardiovascular complications (CV) (myocardial infarction [MI], cardiac arrest, cerebrovascular accident [CVA]), venous thromboembolism (VTE) (deep vein thrombosis [DVT], pulmonary embolism [PE]), and renal insufficiency.
Covariates
Patient variables included age, gender, race/ethnicity, ASA classification, functional health status prior to surgery (independent versus dependent), body mass index (BMI), and patient comorbidities including hypertension, diabetes, bleeding disorder, dyspnea, chronic obstructive pulmonary disease (COPD), current smoker, congestive heart failure (CHF), end-stage renal disease (ESRD), ascites, chronic steroid use, more than 10% weight loss within 6 months of operation, albumin less than 3.0g/dL, and inpatient complications. Procedural factors included wound class, procedural time, and procedural type.
Statistical Analysis
Median length of stay was assessed by Kruskal-Wallis test from 2014 to 2019. Non-parametric tests for trend and Kruskal-Wallis H tests were used to evaluate changes in postoperative complication rates over time, and the proportion of individual complications occurred post-discharge over time. Bivariate analyses of individual patient, and procedural variables were assessed for association with operative approach using separate chi-squared tests for categorical variables and student t tests for continuous variables. Statistically significant predictors on bivariate analysis with a p<0.1 or those with clinical significance were entered into a multivariable logistic regression model. Statistical analyses were performed using Stata v16.1 (StataCorp, College Station, TX). This study utilized de-identified data and thus was determined to be exempt from review by the Northwestern University Institutional Review Board.
RESULTS
Patient Cohort Characteristics
During the study period, 80,311 patients underwent vascular procedures for four common vascular pathologies: AAA (20.3%), aortoiliac (13.4%), lower extremity (35.4%), and carotid stenosis (31.0%). There were open and endovascular approaches for each pathology, and interestingly the majority of procedures were open approach (60.9%) compared to endovascular approach (39.1%) in this study cohort. Distribution of procedures are seen in Supplemental Figure 1. In this study cohort, the median age was 70 (IQR 64–77). Most patients were male gender (65.9%), White (67.7%), had ASA classification>II (95.1%), and independent functional status (94.9%). Unadjusted bivariate analysis demonstrated association between operative approach and patient age, gender, race, ASA classification, functional status, BMI, medical comorbidities, and operation time. No differences in operative approach were found for patients with hypertension, diabetes, and operative type. Full bivariate analysis are shown in Table 1.
Table 1:
Demographic of Patients who Underwent Vascular Procedures from 2014–2019
| Total | Open | Endo | p-value | |
|---|---|---|---|---|
| N (%) | N (%) | N (%) | ||
| Median Age (IQR) | 70 (63 – 77) | 70 (63 – 77) | 71 (63 – 78) | <0.001 |
| Gender | ||||
| Female | 27413 (34.1) | 17481 (35.7) | 9932 (31.7) | <0.001 |
| Male | 52896 (65.9) | 31452 (64.3) | 21444 (68.4) | |
| Race | ||||
| NH White | 54396 (67.7) | 33804 (69.1) | 20592 (65.6) | <0.001 |
| NH Black | 8297 (10.3) | 4343 (8.9) | 3954 (12.6) | |
| Hispanic | 3380 (4.2) | 1756 (3.6) | 1624 (5.2) | |
| Other/Unknown | 14238 (17.7) | 9030 (18.5) | 5208 (16.6) | |
| ASA Classification | ||||
| I/II | 3974 (4.9) | 1983 (4.1) | 1991 (6.4) | <0.001 |
| III/IV/V | 76337 (95.1) | 46950 (95.9) | 29387 (93.7) | |
| Functional Status | ||||
| Independent | 76211 (94.9) | 46924 (95.9) | 29287 (93.3) | <0.001 |
| Dependent | 4100 (5.1) | 2009 (4.1) | 2091 (6.7) | |
| BMI | ||||
| Underweight | 4761 (5.9) | 3057 (6.3) | 1704 (5.4) | <0.001 |
| Normal or Healthy Weight | 20982 (26.1) | 12773 (26.1) | 8209 (26.2) | |
| Overweight | 28393 (35.4) | 17354 (35.5) | 11039 (35.2) | |
| Obesity | 16915 (21.1) | 10264 (21.0) | 6651 (21.2) | |
| Morbid Obesity | 9260 (11.5) | 5485 (11.2) | 3775 (12.0) | |
| Comorbidities | ||||
| Hypertension | 64591 (80.4) | 39335 (80.4) | 25256 (80.5) | 0.08 |
| Diabetes | 27673 (34.5) | 16744 (34.2) | 10929 (34.8) | 0.72 |
| Bleeding disorder | 17201 (21.4) | 9504 (19.4) | 7697 (24.5) | <0.001 |
| Dyspnea (moderate exertion/rest) | 10011 (12.5) | 5675 (11.6) | 4336 (13.8) | <0.001 |
| COPD | 10588 (13.2) | 6100 (12.5) | 4488 (14.3) | <0.001 |
| Current Smoker | 28667 (35.7) | 17928 (36.6) | 10739 (34.2) | <0.001 |
| CHF | 1857 (2.3) | 967 (2.0) | 890 (2.8) | <0.001 |
| ESRD | 2983 (3.7) | 1329 (2.7) | 1654 (5.3) | <0.001 |
| Steroid use | 3357 (4.2) | 1833 (3.8) | 1524 (4.9) | <0.001 |
| Weight loss >10% | 747 (0.9) | 408 (0.8) | 339 (1.1) | <0.001 |
| Ascites | 78 (0.1) | 37 (0.1) | 41 (0.1) | 0.02 |
| Albumin Less than 3.0 g/dL | 46548 (58.7) | 27565 (57.0) | 18983 (61.4) | <0.001 |
| Inpatient Complication | 6636 (8.3) | 4712 (9.6) | 1924 (6.1) | <0.001 |
| Operation time (Hours) | ||||
| Less than 1.5 hours | 21620 (26.9) | 8571 (17.5) | 13049 (41.6) | <0.001 |
| 1.5–3 hours | 36182 (45.1) | 22525 (46.0) | 13657 (43.5) | |
| 3–5 hours | 15918 (19.8) | 12265 (25.1) | 3653 (11.6) | |
| More than 5 hours | 6591 (8.2) | 5572 (11.4) | 1019 (3.3) | |
| Operation type | ||||
| Elective Surgery | 17355 (21.6) | 10575 (21.6) | 6780 (21.6) | 0.99 |
| Emergency Surgery | 62956 (78.4) | 38358 (78.4) | 24598 (78.4) |
Trends in LOS and Postoperative Complications for Open and Endovascular Approaches
Overall, median LOS was 2 days (IQR 1–5) during the study period which did not change from 2014 to 2019. As shown in Supplemental Table 1, median LOS had a statistically significant change for open aortoiliac repair (7 days [IQR 5–10]), open lower extremity repair (5 days [IQR 3–7]), and carotid endarterectomy (1 day [IQR 1–2]) (p<0.05), however this was not clinically significant change in LOS. The overall 30-day complication rate was 15.7%, which did not change significantly during this study period from 15.3% to 16.4%, p=0.2. Table 2 demonstrated that 30-day complication rate varied by procedures, ranging from 7.2% for CEA to 32.8% for open AAA repair. However, when comparing endovascular approach to open approach, endovascular approaches had statistically significant lower overall postoperative complications for AAA, aortoiliac, and lower extremity pathologies, p<0.01 (Figure 1).
Table 2.
Trends in Post-Discharge Complication by Procedure Types by Non-Parametric Test for Trend and Kruskal-Wallis Test by Ranks
| Post-Discharge Complication | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | Patient (N) | Overall Complication Rate (%) | Total PD Complication (%) | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | p-value |
| Open AAA | 3105 | 32.8 | 16.6 | 15.4 | 18.5 | 20.1 | 15.9 | 17.2 | 12.6 | 0.40 |
| EvAR | 13154 | 11.4 | 34.6 | 35.1 | 35.5 | 37.6 | 33.1 | 32.8 | 32.1 | 0.33 |
| Open Aortoiliac | 6782 | 26.1 | 25.3 | 24.6 | 27.1 | 24.9 | 24.7 | 21.1 | 29.4 | 0.44 |
| Endo Aortoiliac | 3986 | 13.2 | 43.3 | 54 | 46.3 | 37 | 37.4 | 43.3 | 42.3 | 0.32 |
| Open LE | 15365 | 26.4 | 25.9 | 25.2 | 25.5 | 27.6 | 20.8 | 23 | 32.7 | 0.01 |
| Endo LE | 13052 | 14.9 | 40.3 | 35.6 | 36.3 | 42.6 | 37 | 41.5 | 44.3 | 0.03 |
| CEA | 23681 | 7.2 | 41.7 | 35.5 | 41.2 | 36.4 | 41.7 | 45.6 | 48.9 | 0.004 |
| CAS | 1186 | 8.3 | 37.8 | 25 | 9.1 | 30 | 63.6 | 41.7 | 31.6 | 0.09 |
| Overall | 80311 | 15.7 | 31.3 | 29.1 | 31.2 | 31.3 | 28.5 | 31.0 | 35.9 | <0.001 |
Figure 1.
Overall Postoperative Complication Rates for Open vs. Endovascular Procedures by Pathology
Post-Discharge Complications for Open and Endovascular Approaches
The overall post-discharge complication rate was 31.3%, which increased from 29.1% in 2014 to 35.9% in 2019, p<0.001. As seen in Table 2, lower extremity endovascular repair and carotid endarterectomy demonstrated a significant increase in proportion of complications after discharge over time, p<0.01. Among the six categories of post-discharge complications, the overall postoperative complication rate was lower for endovascular approach, however, there was a higher proportion of complications occurring in the post-discharge setting including other infection, CV, VTE, and progressive renal insufficiency compared to open approach, p<0.05. As shown in Table 3, compared to open AAA repair, EVAR was associated with higher proportion of post-discharge complication for SSI (84.0% vs. 46.1%, p<0.001), other infection (46.3% vs. 13.3%, p<0.001), respiratory problem (17.8% vs. 9.4%, p=0.001), VTE (61.7% V S. 35.7%, p=0.005), and renal insufficiency (32.1% vs. 2.1%, p<0.001). This pattern was also seen in complications for aortoiliac occlusive disease, and lower extremity disease.
Table 3.
Pre vs. Post-Discharge Complications by Procedure Types
| Total | Open AAA | EVAR | p-value | AIO | AIE | p-value | LEO | LEE | p-value | CEA | CAS | p-value | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | |||||
| Overall Complication | 12627 (15.7) | 1019 (32.8) | 1505 (11.4) | <0.001 | 1770 (26.1) | 527 (13.2) | <0.001 | 4054 (26.4) | 1940 (14.9) | <0.001 | 1714 (7.2) | 98 (8.3) | 0.185 |
| Overall Post-Discharge | |||||||||||||
| Complications | 6664 (8.3) | 279 (9.0) | 745 (5.7) | <0.001 | 895 (13.2) | 308 (7.7) | <0.001 | 2312 (15.1) | 1221 (9.4) | <0.001 | 857 (3.6) | 47 (4.0) | 0.537 |
| Surgical Site | |||||||||||||
| Pre-D/C | 448 (15.7) | 62 (53.9) | 28 (16) | <0.001 | 115 (19.3) | 11 (10.9) | 0.043 | 179 (11.6) | 46 (24.5) | <0.001 | 7 (5.2) | 0 (0.0) | 0.9 |
| Post-D/C | 2407 (84.3) | 53 (46.1) | 147 (84) | 482 (80.7) | 90 (89.1) | 1364 (88.4) | 142 (75.5) | 127 (94.8) | 2 (100.0) | ||||
| Infection | |||||||||||||
| Pre-D/C | 1539 (55.1) | 313 (86.7) | 231 (53.5) | <0.001 | 240 (61.9) | 61 (52.1) | 0.06 | 368 (53.9) | 182 (44.7) | 0.003 | 131 (34.8) | 13 (43.3) | 0.34 |
| Post-D/C | 1256 (44.9) | 48 (13.3) | 201 (46.5) | 148 (38.1) | 56 (47.9) | 315 (46.1) | 225 (55.3) | 246 (65.2) | 17 (56.7) | ||||
| Respiratory problem | |||||||||||||
| Pre-D/C | 1330 (75.9) | 377 (90.6) | 259 (82.2) | 0.001 | 203 (74.6) | 36 (69.2) | 0.42 | 170 (69.1) | 81 (57.0) | 0.017 | 189 (65.0) | 15 (78.9) | 0.213 |
| Post-D/C | 423 (24.1) | 39 (9.4) | 56 (17.8) | 69 (25.4) | 16 (30.8) | 76 (30.9) | 61 (43.0) | 102 (35.0) | 4 (21.1) | ||||
| CV problem | |||||||||||||
| Pre-D/C | 1760 (60.8) | 228 (62.1) | 234 (57.9) | 0.234 | 255 (65.4) | 51 (54.3) | 0.045 | 429 (69.6) | 125 (42.7) | <0.001 | 412 (59.5) | 26 (66.7) | 0.38 |
| Post-D/C | 1135 (39.2) | 139 (37.9) | 170 (42.1) | 135 (34.6) | 43 (45.7) | 187 (30.4) | 168 (57.3) | 280 (40.5) | 13 (33.3) | ||||
| VTE | |||||||||||||
| Pre-D/C | 198 (44.2) | 36 (64.3) | 23 (38.3) | 0.005 | 28 (52.8) | 7 (31.8) | 0.097 | 56 (45.2) | 27 (42.2) | 0.697 | 21 (32.3) | 0 (0.0) | 0.17 |
| Post-D/C | 250 (55.8) | 20 (35.7) | 37 (61.7) | 25 (47.2) | 15 (68.2) | 68 (54.8) | 37 (57.8) | 44 (67.7) | 4 (100.0) | ||||
| Progressive Renal Insufficiency | |||||||||||||
| Pre-D/C | 261 (69.8) | 92 (97.9) | 53 (68.0) | <0.001 | 35 (76.1) | 4 (44.4) | 0.056 | 47 (68.1) | 22 (44.9) | 0.01 | 8 (30.7) | 0 (0.0) | 0.26 |
| Post-D/C | 113 (30.2) | 2 (2.1) | 25 (32.0) | 11 (23.9) | 5 (55.6) | 22 (31.9) | 27 (55.1) | 18 (69.3) | 3 (100.0) |
Factors Associated with Post-Discharge Complications Based on Pathology
As shown in Table 4, for AAA repair, patient factors associated with post-discharge complications included female sex (OR 1.35, 95% CI 1.16–1.57 vs. male), dependent functional status (OR 1.53, 95% CI 1.09–2.19), and BMI (underweight OR 2.35, 95% CI 1.87–2.94 vs. normal BMI). Patient comorbidities were also associated with increased odds of post-discharge complications including bleeding disorder, and ascites, p<0.05. Each additional day in LOS was associated with decreased odds of post-discharge complications (OR 0.94, 95% CI 0.92–0.97), and inpatient complications was associated with increased odds of post-discharge complications (OR 1.70, 95% CI 1.34–2.15). Procedure factors associated with post-discharge complication included open approach (OR 1.59, 95% CI 1.27–1.99), and increased procedural time (3–5h OR 1.33, 95% CI 1.08–1.65; >5h OR 1.66, 95% CI 1.27–2.18; vs. <1.5h).
Table 4.
Multivariable Logistic Regression Analysis for Post-Discharge Complications by Procedures
| Predictors | AAA | Aortoiliac | Lower Extremity | Carotid | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Approach | ||||||||||||
| Endovascular | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| Open | 1.59 | (1.27 – 1.99) | < 0.001 | 1.59 | (1.34 – 1.88) | < 0.001 | 1.54 | (1.39 – 1.70) | < 0.001 | 1.07 | (0.78 – 1.47) | 0.668 |
| Gender | ||||||||||||
| Male | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| Female | 1.35 | (1.16 – 1.58) | < 0.001 | 1.10 | (0.97 – 1.26) | 0.127 | 1.17 | (1.09 – 1.26) | < 0.001 | 1.00 | (0.88 – 1.15) | 0.953 |
| Age (Years) | 1.00 | (0.99 – 1.01) | 0.922 | 1.01 | (1.01 – 1.02) | < 0.001 | 1.00 | (1.00 – 1.01) | 0.180 | 1.01 | (1.00 – 1.02) | 0.160 |
| Race/Ethnicity | ||||||||||||
| NH White | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| NH Black | 0.89 | (0.67 – 1.20) | 0.454 | 1.29 | (1.04 – 1.59) | 0.019 | 0.93 | (0.84 – 1.03) | 0.162 | 1.08 | (0.81 – 1.45) | 0.600 |
| Hispanic | 1.02 | (0.64 – 1.65) | 0.921 | 1.19 | (0.81 – 1.75) | 0.373 | 0.98 | (0.84 – 1.13) | 0.744 | 1.32 | (0.94 – 1.87) | 0.112 |
| Other/Unknown | 0.97 | (0.82 – 1.15) | 0.715 | 1.19 | (1.01 – 1.39) | 0.030 | 1.05 | (0.95 – 1.17) | 0.3331 | 0.87 | (0.68 – 1.10) | 0.247 |
| Gender | ||||||||||||
| ASA I/II | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| ASA III/IV/V | 1.26 | (0.85 – 1.86) | 0.252 | 0.79 | (0.59 – 1.08) | 0.141 | 1.19 | (0.99 – 1.43) | 0.067 | 1.06 | (0.73 – 1.52) | 0.765 |
| Functional Status | ||||||||||||
| Independent | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| Dependent | 1.53 | (1.09 – 2.19) | 0.017 | 1.21 | (0.91 – 1.62) | 0.205 | 1.46 | (1.29 – 1.64) | < 0.001 | 1.37 | (0.98 – 1.92) | 0.066 |
| BMI | ||||||||||||
| Normal | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| Underweight | 2.35 | (1.87 – 2.94) | < 0.001 | 1.22 | (0.98 – 1.52) | 0.080 | 1.16 | (0.98 – 1.36) | 0.083 | 1.07 | (0.74 – 1.56) | 0.711 |
| Overweight | 0.94 | (0.78 – 1.11) | 0.471 | 0.98 | (0.83 – 1.15) | 0.791 | 1.05 | (0.95 – 1.16) | 0.306 | 0.85 | (0.71 – 1.02) | 0.076 |
| Obesity | 0.98 | (0.80 – 1.20) | 0.826 | 1.28 | (1.06 – 1.54) | 0.010 | 1.25 | (1.12 – 1.39) | < 0.001 | 0.93 | (0.76 – 1.14) | 0.481 |
| Morbid Obesity | 1.16 | (0.91 – 1.48) | 0.233 | 1.64 | (1.31 – 2.06) | < 0.001 | 1.44 | (1.27 – 1.63) | < 0.001 | 0.97 | (0.77 – 1.23) | 0.807 |
| Wound Class | ||||||||||||
| Wound class I/II | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| Wound class III/IV | 1.44 | (0.88 – 2.36) | 0.147 | 0.95 | (0.64 – 1.41) | 0.803 | 1.14 | (0.89 – 1.44) | 0.303 | 1.75 | (0.52 – 5.88) | 0.368 |
| Comorbidities | ||||||||||||
| Hypertension | 1.06 | (0.90 – 1.25) | 0.462 | 1.06 | (0.90 – 1.25) | 0.466 | 1.05 | (0.95 – 1.16) | 0.323 | 1.09 | (0.90 – 1.31) | 0.397 |
| Diabetes | 0.91 | (0.74 – 1.10) | 0.323 | 1.32 | (1.16 – 1.52) | < 0.001 | 1.19 | (1.10 – 1.28) | < 0.001 | 1.07 | (0.93 – 1.24) | 0.353 |
| Bleeding Disorder | 1.43 | (1.19 – 1.71) | < 0.001 | 1.32 | (1.13 – 1.53) | < 0.001 | 1.09 | (1.00 – 1.18) | 0.048 | 1.25 | (1.07 – 1.46) | 0.006 |
| Dyspnea | 1.16 | (0.96 – 1.40) | 0.119 | 0.97 | (0.81 – 1.16) | 0.723 | 0.99 | (0.88 – 1.11) | 0.812 | 1.13 | (0.93 – 1.38) | 0.225 |
| Current Smoker | 0.95 | (0.82 – 1.10) | 0.472 | 1.01 | (0.88 – 1.16) | 0.862 | 1.01 | (0.93 – 1.10) | 0.785 | 1.13 | (0.96 – 1.34) | 0.135 |
| COPD | 0.98 | (0.82 – 1.17) | 0.844 | 1.14 | (0.97 – 1.34) | 0.125 | 1.34 | (1.20 – 1.49) | < 0.001 | 1.45 | (1.18 – 1.77) | < 0.001 |
| CHF | 1.28 | (0.84 – 1.95) | 0.260 | 1.27 | (0.89 – 1.79) | 0.177 | 1.11 | (0.91 – 1.35) | 0.307 | 2.60 | (1.83 – 3.70) | < 0.001 |
| ESRD | 1.54 | (0.96 – 2.47) | 0.074 | 1.85 | (1.34 – 2.55) | < 0.001 | 1.68 | (1.49 – 1.91) | < 0.001 | 1.72 | (1.07 – 2.78) | 0.026 |
| Ascites | 5.40 | (1.79 – 16.25) | 0.003 | 2.50 | (0.71 – 8.88) | 0.155 | 2.19 | (1.01 – 4.77) | 0.048 | 2.12 | (0.42 – 10.65) | 0.361 |
| Steroid Use | 1.23 | (0.91 – 1.66) | 0.176 | 1.58 | (1.20 – 2.09) | 0.001 | 1.43 | (1.23 – 1.65) | < 0.001 | 1.37 | (1.00 – 1.88) | 0.053 |
| Weight Loss | 0.91 | (0.53 – 1.56) | 0.731 | 1.20 | (0.75 – 1.91) | 0.447 | 1.54 | (1.11 – 2.15) | 0.01 | 1.08 | (0.43 – 2.71) | 0.868 |
| Albumin<3.0 g/dL | 0.90 | (0.79 – 1.03) | 0.142 | 0.92 | (0.81 – 1.05) | 0.227 | 0.94 | (0.87 – 1.01) | 0.092 | 0.87 | (0.76 – 0.99) | 0.037 |
| LOS (day) | 0.94 | (0.92 – 0.97) | < 0.001 | 0.95 | (0.94 – 0.97) | < 0.001 | 0.98 | (0.97 – 0.99) | < 0.001 | 1.05 | (1.02 – 1.07) | < 0.001 |
| Inpatient Complication | 1.70 | (1.34 – 2.15) | < 0.001 | 1.15 | (0.92 – 1.43) | 0.227 | 0.81 | (0.70 – 0.94) | 0.005 | 1.11 | (0.78 – 1.57) | 0.565 |
| Operation Time | ||||||||||||
| <1.5 hours | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| 1.5–3 hours | 0.98 | (0.82 – 1.16) | 0.790 | 1.57 | (1.28 – 1.93) | < 0.001 | 1.32 | (1.18 – 1.49) | < 0.001 | 1.08 | (0.93 – 1.26) | 0.324 |
| 3–5 hours | 1.33 | (1.08 – 1.65) | 0.009 | 2.35 | (1.87 – 2.95) | < 0.001 | 1.71 | (1.49 – 1.96) | < 0.001 | 0.94 | (0.72 – 1.24) | 0.677 |
| More than 5 hours | 1.66 | (1.27 – 2.18) | < 0.001 | 3.22 | (2.46 – 4.20) | < 0.001 | 2.01 | (1.72 – 2.34) | < 0.001 | 1.12 | (0.43 – 2.89) | 0.820 |
| Operation Year | ||||||||||||
| 2014 | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | ||||||||
| 2015 | 1.07 | (0.86 – 1.32) | 0.561 | 0.91 | (0.73 – 1.14) | 0.420 | 1.00 | (0.87 – 1.14) | 0.991 | 1.42 | (1.11 – 1.81) | 0.006 |
| 2016 | 1.07 | (0.86 – 1.33) | 0.526 | 0.81 | (0.64 – 1.01) | 0.056 | 1.14 | (0.98 – 1.27) | 0.106 | 1.09 | (0.84 – 1.42) | 0.500 |
| 2017 | 0.81 | (0.65 – 1.01) | 0.066 | 0.87 | (0.69 – 1.08) | 0.199 | 1.07 | (0.94 – 1.22) | 0.325 | 1.44 | (1.13 – 1.84) | 0.003 |
| 2018 | 0.85 | (0.67 – 1.07) | 0.168 | 0.92 | (0.74 – 1.14) | 0.454 | 1.10 | (0.96 – 1.25) | 0.171 | 1.40 | (1.−0 – 1.79) | 0.008 |
| 2019 | 0.95 | (0.75 – 1.20) | 0.679 | 1.04 | (0.84 – 1.28) | 0.731 | 1.31 | (1.16 – 1.49) | <0.001 | 1.41 | (1.10 – 1.80) | 0.007 |
For aortoiliac occlusive disease, patient factors associated with post-discharge complications included age (OR 1.01, 95% CI 1.01–1.02), Black race (OR 1.29, 95% CI 1.04–1.59 vs. White), and other/unknown race/ethnicity (OR 1.19, 95% CI 1.01–1.39 vs. White), BMI (obesity OR 1.28, 95% CI 1.06–1.54; morbid obesity OR 1.64, 95% CI 1.31–2.06 vs. normal BMI). Patient comorbidities associated with post-discharge complications for this cohort included diabetes, bleeding disorder, ESRD, and steroid use, p<0.05. LOS was associated with decreased odds for post-discharge complications (OR 0.95, 95% CI 0.94–0.97). Procedure factors associated with post-discharge complications included operative approach (open OR 1.59, 95% CI 1.34–1.88 vs. open), and operative time (1.5–3 hours OR 1.57, 95% CI 1.28–1.93; 3–5 hours OR 2.35, 95% CI 1.87–2.95; >5 hours OR 3.22, 95% CI 2.46–4.20 vs. <1.5 hours).
For lower extremity repairs, patient factors associated with post-discharge complications included female gender (OR 1.17, 95% CI 1.09–1.26 vs. male), dependent functional status (OR 1.46, 95% CI 1.29–1.64), and BMI (obesity OR 1.25, 95% CI 1.12–1.39; morbid obesity OR 1.44, 95% CI 1.27–1.63 vs. normal BMI). Patient comorbidities included diabetes, bleeding disorder, COPD, ESRD, steroid use, and weight loss, p<0.05. Each additional day in LOS (OR 0.98, 95% CI 0.97–0.99) and inpatient complications (OR 0.81, 95% CI 0.70–0.94) were associated with decreased odds for post-discharge complications in this cohort. Procedure factors associated with post-discharge complication included operative approach (open OR 1.54, 95% CI 1.39–1.70), and operative time (1.5–3 hours OR 1.32, 95% CI 1.18–1.49; 3–5 hours OR 1.71, 95% CI 1.49–1.96; >5 hours OR 2.01 95% CI 1.72–2.34 vs. <1.5 hours).
For carotid stenosis, patient factors associated with post-discharge complications included bleeding disorder, COPD, CHF, ESRD, and albumin <3.0 g/dL, all p<0.05. LOS was associated with increased odds for post-discharge complications (OR 1.05, 95% CI 1.02–1.07). Operative approach was not associated with post-discharge complication among these patients.
DISCUSSION
Advancement in endovascular techniques has enabled certain vascular procedures to be performed for higher risk patients, and even on an outpatient basis without general anesthesia or a typical skin incision.20,21 Prior studies demonstrated the benefits of endovascular approach where it decreased LOS, short-term morbidity and mortality compared to open techniques, however fewer studies have evaluated the impact it has on post-discharge complications.1,4,10 The ACS-NSQIP procedure-targeted database allowed us to examine the trend in LOS between open and endovascular techniques for common vascular pathologies, and their impacts on post-discharge complications for these pathologies at a multi-institutional level. In this retrospective cohort study for patients who underwent eight different surgical procedures for four common vascular pathologies, we found that LOS did not change over time, and endovascular was associated with fewer postoperative complications compared to open procedures, however, there was a higher proportion of post-discharge complications. Factors associated with post-discharge complications among vascular patients were evaluated to help identify targets for interventions in an effort to decrease post-discharge complications.
Trends in LOS and Post-Discharge Complications for Open and Endovascular Approaches
We first evaluated the trends in LOS, which has been used as a potential quality improvement measure after surgery as it may indicated more efficient care. In this study, we demonstrated that between 2014 and 2019, there was no clinical significant decrease in LOS for all procedures over time, however endovascular procedures had significantly shorter LOS compared to their respective open procedures with the exception of carotid interventions. It is important to note that majority of procedures were open versus endovascular in this study cohort. To our knowledge, this is the first study to evaluate trends in LOS over time for vascular surgery. While we did not find a clinically significant trend in LOS, our findings did confirm previous studies that demonstrated endovascular approaches are associated with shorter LOS compared to its respective open approach.22,23
Although LOS was shorter for endovascular procedures, it is unclear whether there were any unintended effects on post-discharge complications. To understand this, we first sought to understand the trends in overall postoperative complication. Other than carotid interventions, it was observed that an open surgical approach for AAA repair, aortoiliac occlusive disease, and lower extremity repair all had more than a 10% of postoperative complication rate compared to its respective endovascular approach between 2014 and 2019. This is similar to prior findings that endovascular techniques are associated with less 30-day postoperative complications compared to its respective open technique.10
Next, we sought to determine how LOS of different approaches affected the change in proportion of post-discharge complications. Overall, we found an increase in the proportion of post-discharge complications by 6.8% between 2014 and 2019. With the exception of carotid procedures, there was an increased proportion of post-discharge complications for endovascular approaches. Carotid stenosis procedures including endarterectomy and stenting in this study cohort generally had one day LOS, similar to previously reported LOS.24,25 This LOS is likely the reason behind no different in post-discharge complications between the two carotid procedures. This was different compared to more extensive procedures such as open surgery for AAA and aortoiliac occlusive disease, which had significantly longer LOS compared to the endovascular technique.
Among the six categories of complications evaluated, endovascular procedures had higher proportion of post-discharge complications compared to its respective open procedures, despite the lower rate of postoperative complications for endovascular procedures. This was especially notable for AAA repair: EVAR had a higher proportion of post-discharge complications in SSI, other infection, respiratory, VTE, and progressive renal failure compared to open AAA repair. Postoperative complications such as SSI and VTE are considered as important measures of surgical quality.26 In our study, among the AAA cohort, 84% of SSI occurred in the post-discharge setting for EVAR patients, compared to the 46.1% for open repair. This is concerning that despite the shorter LOS in hospital, EVAR patients may be increasingly developing complications at home. While certain postoperative complications such as superficial SSI, or UTI, can be treated with oral antibiotics and/or outpatient wound care, patients may not be able to identify the early signs and symptoms to notify their doctors in a timely manner, and delaying treatment can lead to serious sequelae, including wound dehiscence or sepsis. Several studies have identified significant economic burden associated with readmission, including cost of SSI can up to $5000 in healthcare costs per infection.27–29 This pattern was seen among for other complications among the four pathologies evaluated in our study. While this finding may argue that longer LOS may be beneficial for patients to be able to address their postoperative complications, however prior studies have shown that prolonged LOS does not benefit the patients or payers. Thus, it is vital to develop a structured outpatient monitoring system during the recovery period that can provide early recognition and intervention to prevent the development or worsening of complications.
Factors associated with Post-Discharge Complications Based on Pathology
In our study, we identified patient characteristics and potential targets for future interventions that can affect outcomes for vascular patients in the post-discharge period based on different pathology. For AAA and lower extremity pathologies, we found that female patients had higher odds for post-discharge complications than male patients, a finding that is consistent with prior studies which have shown female patients have increased risk for postoperative complications.10,32,33 However, this may be due to the effect of LOS on post-discharge complications which was also shown in the study finding. If male patients experienced higher postoperative complication, this likely prolonged their hospital LOS, hence there was a shorter post-discharge period to be followed in order to demonstrate a complete post-discharge picture due to the limitation of ACS NSQIP dataset in which follow-up period after surgery is limited to 30 days. Other patient factors that were associated with post-discharge complications included dependent functional status, increased BMI, and certain comorbidities, which are consistent with previous studies. Weight loss, and optimal glucose control are potential targets for intervention in the preoperative phase to optimize patients in order to decrease their post-discharge complication rate.
Procedural factor associated with post-discharge complications included operative approach, and increased procedural time. Prior studies have found that prolonged operative time was associated with post-discharge complications.30–32 Similarly in our study, we found prolonged procedural time was associated with post-discharge complications for AAA, aortoiliac occlusive disease, and lower extremity diseases. LOS was associated with decreased odds for post-discharge complications for all except carotid procedures. However, this was likely due to an inherent limitation in the ACS-NSQIP dataset which follows patient for 30-days after index procedure, which may not capture the full picture of post-discharge setting if patient had prolonged LOS. To our knowledge, this is the first study that comprehensively evaluated the trends in LOS and the risk factors for post-discharge complications for four common vascular pathologies, and we found that in order to improve post-discharge outcomes, patient selection, co-morbidities optimization, and operative techniques are all important factors to consider. In addition, our study highlighted the potential utility for early outpatient follow-up for patients to assess for early post-discharge complications that can be addressed in the outpatient setting instead of referral to the emergency department for evaluation. Clear, verbal, and written instructions and early education to patients and family members outlining common post-discharge complications to be aware of, and utilization of telehealth or documented photos of wounds may mitigate significant early post-discharge complications.
Limitations
This study has several limitations. First, the follow-up period for ACS NSQIP is limited to 30-days after index procedure, and therefore complications occurring outside of this timeframe are not captured. Second, patients with longer LOS will inherently have fewer captured post-discharge days. While this may be true, it is unlikely to change the overall findings of increased proportion of post-discharge complications among endovascular approach cohort compared to open approach for multiple pathologies. Third, we were unable to account for surveillance bias in this study, where we would not be able to account for patients who did not follow up at the hospital where the index surgery took place for postoperative complication. Finally, we may not be able to capture all patients who suffered postoperative complications, if he/she were admitted to a different hospital that may not participate in NSQIP.
Conclusion:
Our study demonstrated LOS has not changed over time, an endovascular approach was associated with lower postoperative complications compared to its respective open approach; however, endovascular interventions had a higher proportion of post-discharge complications. Despite the advancements in endovascular techniques, surgeons should be attentive to the post-discharge period for ongoing complication concerns. A comprehensive, and proactive post-discharge outpatient monitoring system should be developed to allow early identification and assessment for patients to avoid unnecessary readmission.
Supplementary Material
Conflicts of Interest and Source of Funding:
Stipend for “Ruojia Debbie Li and Matthew C. Chia is partially supported by National Institutes of Health Grant #T32HL094293.
The authors report no conflicts of interest or disclosures related to the content of this study. MKE has received honoraria from Silk Road Medical, Inc. for service on the Roadster Clinical Events Committee; and from W. L. Gore & Associates as a TEVAR course director and Data Safety Monitoring Board member.
Footnotes
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Presentation Information: This study was presented in poster session at 2021 Midwestern Vascular Surgical Society, Chicago, IL 9/9–9/11, 2021
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