S. S. Adkar1, R. S. Turley1, L. Youngwirth1, E. Benrashid1, C. K. Shortell1, L. Mureebe1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA
Introduction:
The American Heart Association recommends use of an anti-platelet agent (APA) and a statin in patients with symptomatic peripheral arterial disease. The extent of guideline adherence by clinicians and patients is unknown. Given the inherent morbidity of lower extremity bypass (LEB), including limb loss, loss of patency, cardiac risk and bleeding complications, we sought to assess current usage of APA and statins and their effects on LEB outcomes.
Methods:
Data were obtained from the 2011-2013 ACS-NSQIP participant user files with LEB targeted data. Patients with LEB performed for aneurysmal disease and trauma were excluded from this analysis. Patient, procedural characteristics, and 30-day postoperative outcomes were compared using Pearson Χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. The primary outcome measures were graft patency rates, perioperative bleeding, and mean hospital length of stay.
Results:
During the study period, 5500 total LEB were identified. Demographics and major complications are displayed in Table 1. We stratified patients treated with both statin and APA (59.4%), statin only (9.3%), APA only (20.3%), and those receiving neither medication (11%). Smoking was more prevalent in the group receiving neither medication and diabetics were more often treated with either an APA or statin (p<.01). Graft patency rates were higher in patients receiving APA compared to other groups (51.3% vs 44.4%, p < .001). The incidence of bleeding requiring transfusion or a second procedure was higher in patients receiving a statin but not APA alone (13.2% vs 19%, p<.01). Mean hospital length of stay was significantly lower in patients receiving APA alone (8 days vs 9 days, p<.001). No significant difference in post-operative myocardial infarction or stroke was observed between treatment groups (p=.762). No differences in wound infection or mortality was observed between groups.
Conclusion:
Both the American Heart Association and the Society for Vascular Surgery have given their strongest recommendations that patients with atherosclerotic lower extremity arterial disease be treated with APA and statins (literature grade: Level 1A). We fail to accomplish this in 4 out of every 10 patients undergoing LEB nationally. Furthermore, APA, and not statin, treatment is associated with a shorter post-operative length of stay, but statin use (not APA) is associated with an increased risk of bleeding after surgery. This dichotomy between guidelines and our observed data suggests an ambiguous interplay between statins and APA that will require concentrated exploration.
