Targeting the most important complications in vascular surgery

Abstract Objective This study was conducted to identify the most clinically relevant and costly perioperative complications occurring in vascular surgery patients. Methods The analysis included patients in the 2012 to 2014 National Surgical Quality Improvement Program database undergoing one of four high-risk vascular procedures. The procedures—aortic reconstruction, lower extremity bypass, lower extremity amputation, and carotid endarterectomy (CEA)—were selected because they have been established as high risk in the literature, rendering them natural targets for quality improvement initiatives. Population-attributable fractions (PAFs) were used to estimate the impact of seven prespecified complications on 30-day outcomes in the study population. The PAF predicts the reduction in outcome anticipated if a particular complication were to be prevented across the study population. Unadjusted and adjusted PAFs were reported. CEA was analyzed separately from the other procedures. Results The analysis included 72,805 National Surgical Quality Improvement Program patients. Pneumonia had the largest impact on the incidence of end-organ dysfunction in CEA patients (adjusted PAF, 24.4%; 95% confidence interval, 20.6-28.1), and cerebrovascular accident had the largest impact on mortality in these patients (adjusted PAF, 23.1%; 95% confidence interval, 18.5-27.3). In patients undergoing abdominal or lower extremity vascular surgery, bleeding and pneumonia had the largest impact on clinical outcomes and need for prolonged hospitalization, and surgical site infection had the largest impact on hospital readmission. In contrast, prevention of venous thromboembolism, urinary tract infection, and myocardial infarction do not demonstrate substantial impact on patient outcomes or resource utilization in either group of vascular surgery patients. Conclusions Quality initiatives that can successfully reduce the occurrence of postoperative stroke, bleeding, and pneumonia will have the greatest clinical impact on the outcomes of vascular surgery patients. Initiatives that target complications such as venous thromboembolism, urinary tract infection, or myocardial infarction will have little impact on this patient population.