Journal of Vascular Surgery
Background: First-line treatment of peripheral arterial disease (PAD) involves medical therapy and lifestyle modification. Specifically, the 2016 American Heart Association/American College of Cardiology guidelines for the management of PAD make Class I recommendations for antiplatelet therapy, statin therapy, antihypertensive therapy, and cilostazol therapy, as well as exercise therapy and smoking cessation. Although evidence supports medical and lifestyle management of PAD before surgical intervention, it is currently unclear whether clinical practice reflects this. Moreover, it is also unknown whether variability in medical and lifestyle optimization before revascularization affects short- and long-term outcomes. This study was conducted to determine the proportion of patients actively receiving evidence-based medical and lifestyle therapy at the time of surgery in a regional hospital network and whether receipt of therapy affected outcomes. Methods: We conducted a retrospective study of adult patients undergoing elective open lower extremity bypass for claudication, rest pain, or tissue loss from 2012 to 2021 within a large, statewide, 35 hospital quality registry. The primary exposures were preoperative medical therapy (specifically antiplatelet agents, statins, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and cilostazol) and lifestyle management including supervised exercise therapy and participation in smoking cessation counseling. The primary outcomes were 30-day and 1-year mortality, hospital readmission, amputation, wound complications, myocardial infarction, nonpatent bypass, and nonambulatory functional status. Multivariable logistic regression was performed to estimate the association of receiving some or all recommended therapy on outcomes. Results: There were 10,278 patients who underwent bypass surgery during the study period, with a mean age of 65.8 6 10.4 years; 7036 patients (68.5%) were male. The prevalence of medical and lifestyle management at the time of surgery was variable (Figure). Of the original cohort, 30-day follow-up data were available for 9664 patients (94.0% follow-up rate) and 1-year follow-up data were available for 7341 patients (71.4% 1-year follow-up rate). Among patients on relevant medications at discharge, at 30 days, 96.8% were still taking antiplatelet agents, 96.7% were still taking statins, 86.5% were still taking angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and 24.7% of patients who received smoking cessation therapy had quit smoking. Compared with patients on no therapy, patients on some therapy had significantly lower odds of amputation at 30 days (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI], 0.38-1.00). At 1 year, there was no significant association between being on some or all therapy and any outcomes; however, similar trends were observed for amputation (some therapy: aOR, 0.64 [95% CI, 0.39-1.04]; all therapy: aOR, 0.48 [95% CI, 0.22-1.04]). Conclusions: Although medical and lifestyle management are recommended as first-line treatments for patients with PAD, preoperative adherence to these recommendations was highly variable. Patients actively receiving preoperative treatment seem to have a lower risk of subsequent amputation after surgery. This suggests that not only are there significant opportunities to improve adherence to evidence-based treatment of PAD, but that doing so may benefit patients postoperatively.
Howard R, Albright J, Corriere M, Osborne N, Laveroni E, Henke P. Variability and outcomes of medical and lifestyle management of peripheral arterial disease at the time of lower extremity bypass. J Vasc Surg. 2022 Jan 1;75(1):e19-20.