Brianna M Krafcik1, Alik Farber1, Mohammad H Eslami1, Jeffrey A Kalish1, Denis Rybin2, Gheorghe Doros2, Nishant K Shah1, Jeffrey J Siracuse3. 1. Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, Mass. 2. Department of Biostatistics, Boston University, Boston, Mass. 3. Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, Mass. Electronic address: jeffrey.siracuse@bmc.org.
Abstract
OBJECTIVE: The Model for End-Stage Liver Disease (MELD) score has traditionally been used to prioritize liver transplantation. However, its use has been extended to predict overall and postoperative outcomes in patients with hepatic and renal dysfunction. Our objective was to use the MELD score to predict outcomes in patients undergoing lower extremity bypass. METHODS: Patients undergoing infrainguinal bypass were identified in the American College of Surgeons National Surgical Quality Improvement Program data sets from 2005 to 2012. The MELD score was calculated using serum bilirubin and creatinine values and the international normalized ratio. Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The associations of the MELD score on postoperative morbidity and mortality were assessed by multivariable logistic and gamma regressions and by propensity matching. RESULTS: There were 5967 patients who underwent infrainguinal bypass with the following MELD score distribution: <9, 3795 (64%); 9 to 14, 1819 (30%); and 15+, 353 (6%). Matched analysis in comparing low, moderate, and high MELD scores showed a higher risk for cardiac complications (2.8% vs 3.2% vs 5.4%; P < .001), bleeding complications (9.3% vs 11.1% vs 13.9%; P = .048), and increased postoperative length of stay (median [range], 5 [0-93] vs 6 [0-73] vs 6 [0-86]; P < .001). The MELD score had no association with early bypass failure, wound complications, or operative time. Moderate and high MELD scores were independent predictors of postoperative myocardial infarction/cardiac arrest (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001; and OR, 4.1; 95% CI, 2.3-7.3; P < .01), bleeding complications (OR, 1.3; 95% CI, 1.1-1.6; P < .01; and OR, 1.8; 95% CI, 1.3-2.5; P < .01), return to the operating room (OR, 1.3; 95% CI, 1.1-1.5; P < .01; and OR, 1.4; 95% CI, 1.03-1.8; P = .03), extended postoperative length of stay (means ratio, 1.2; 95% CI, 1.1-1.2; P < .01; and means ratio, 1.2; 95% CI, 1.2-1.3; P < .01), and perioperative mortality (OR, 1.6; 95% CI, 1.02-2.5; P = .04; and OR, 2.9; 95% CI, 1.6-5.4; P = .01), respectively. Propensity matching between low, moderate, and high MELD score groups confirmed an increased risk of postoperative myocardial infarction/cardiac arrest (P < .01), bleeding complications (P = .05), and extended postoperative length of stay (P < .01) with a trend toward increased mortality and return to operating room. CONCLUSIONS: An elevated MELD score places patients undergoing infrainguinal bypass at higher risk of perioperative morbidity and mortality. This provides an evidence base for risk stratification and informed consent for these patients. Alternative treatment may be considered in these patients; however, the overall morbidity and mortality rates may still be acceptable, even in high-risk patients.
OBJECTIVE: The Model for End-Stage Liver Disease (MELD) score has traditionally been used to prioritize liver transplantation. However, its use has been extended to predict overall and postoperative outcomes in patients with hepatic and renal dysfunction. Our objective was to use the MELD score to predict outcomes in patients undergoing lower extremity bypass. METHODS:Patients undergoing infrainguinal bypass were identified in the American College of Surgeons National Surgical Quality Improvement Program data sets from 2005 to 2012. The MELD score was calculated using serum bilirubin and creatinine values and the international normalized ratio. Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The associations of the MELD score on postoperative morbidity and mortality were assessed by multivariable logistic and gamma regressions and by propensity matching. RESULTS: There were 5967 patients who underwent infrainguinal bypass with the following MELD score distribution: <9, 3795 (64%); 9 to 14, 1819 (30%); and 15+, 353 (6%). Matched analysis in comparing low, moderate, and high MELD scores showed a higher risk for cardiac complications (2.8% vs 3.2% vs 5.4%; P < .001), bleeding complications (9.3% vs 11.1% vs 13.9%; P = .048), and increased postoperative length of stay (median [range], 5 [0-93] vs 6 [0-73] vs 6 [0-86]; P < .001). The MELD score had no association with early bypass failure, wound complications, or operative time. Moderate and high MELD scores were independent predictors of postoperative myocardial infarction/cardiac arrest (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001; and OR, 4.1; 95% CI, 2.3-7.3; P < .01), bleeding complications (OR, 1.3; 95% CI, 1.1-1.6; P < .01; and OR, 1.8; 95% CI, 1.3-2.5; P < .01), return to the operating room (OR, 1.3; 95% CI, 1.1-1.5; P < .01; and OR, 1.4; 95% CI, 1.03-1.8; P = .03), extended postoperative length of stay (means ratio, 1.2; 95% CI, 1.1-1.2; P < .01; and means ratio, 1.2; 95% CI, 1.2-1.3; P < .01), and perioperative mortality (OR, 1.6; 95% CI, 1.02-2.5; P = .04; and OR, 2.9; 95% CI, 1.6-5.4; P = .01), respectively. Propensity matching between low, moderate, and high MELD score groups confirmed an increased risk of postoperative myocardial infarction/cardiac arrest (P < .01), bleeding complications (P = .05), and extended postoperative length of stay (P < .01) with a trend toward increased mortality and return to operating room. CONCLUSIONS: An elevated MELD score places patients undergoing infrainguinal bypass at higher risk of perioperative morbidity and mortality. This provides an evidence base for risk stratification and informed consent for these patients. Alternative treatment may be considered in these patients; however, the overall morbidity and mortality rates may still be acceptable, even in high-risk patients.
Authors: Robert B Hawkins; Bree Ann C Young; J Hunter Mehaffey; Alan M Speir; Mohammed A Quader; Jeffrey B Rich; Gorav Ailawadi Journal: Ann Thorac Surg Date: 2019-01-09 Impact factor: 4.330