ABSTRACT
INTRODUCTION: The pain associated with lower extremity arterial disease is difficult to treat, even with lower extremity revascularization. We sought to evaluate in-hospital and post-operative opioid usage in patients with different disease severities and treatments for lower extremity vascular disease. METHODS: A retrospective review was performed for all hospital encounters for patients with an International Classification of Diseases (ICD) code consistent with lower extremity arterial disease admitted to a single center between January 2018 and March 2023. Cases included patients admitted to the hospital with a primary diagnosis of lower extremity arterial disease. These patients were subdivided based on disease severity, treatment type, and comorbid diagnosis of diabetes mellitus. The analysis focused on in-hospital opioid use frequency and dosage among these patients. The control group (CON) included encounters for patients admitted with a secondary diagnosis of lower extremity atherosclerotic disease. A total of 438 patients represented by all the analyzed encounters were then reviewed for the number and type of vascular procedures performed as well as opioid use in the outpatient setting for one year. RESULTS: Critical limb ischemia (CLI) encounters were more likely to use opioids as compared to the CON and peripheral arterial disease (PAD) without rest pain, ulcer or gangrene groups (CLI 67.9% (95% CI: 63.6%-71.6%) versus CON 52.1% (95% CI: 48.5%-55.7%), p < 0.001 and CLI 67.9% (95% CI: 63.6%-71.6%) versus PAD 50.2% (95% CI: 42.6%-57.4%), p < 0.001). Opioid use was also more common in encounters for gangrene and groups treated with revascularization (REVASC) and amputation (AMP) as compared to CON (gangrene 74.5% (95% CI: 68.5%-82.1%) versus CON 52.1% (95% CI: 48.5%-55.7%), p < 0.01; REVASC 58.3% (95% CI: 57.3%-66.4%) versus CON 52.1% (95% CI: 48.5%-55.7%), p =0.01; and AMP 72.3% (95% CI: 62.1%-74.0%) versus CON 52.1% (95% CI: 48.5%-55.7%), p < 0.01). Significantly increased oral opioid doses per day (MME/day) were not noted for any of the investigated groups as compared to the CON. In the outpatient setting, 186 (42.5% (95% CI: 37.2%-46.4%)) patients were using opioids one month after the most recent vascular intervention. By one year, 31 (7.1% (95% CI: 1.30%-7.70%)) patients were still using opioids. No differences in opioid usage were noted for patients undergoing single versus multiple vascular interventions at one year. Patients undergoing certain vascular surgery procedures were more likely to be using opioids at one year. CONCLUSION: Patients with CLI and gangrene as well as those undergoing vascular treatment have a greater frequency of opioid use during hospital encounters as compared to those patients with less severe disease and undergoing conservative management, respectively. However, these findings do not equate to higher doses of opioids used during hospitalization. Patients undergoing multiple vascular procedures are not more likely to be using opioids long-term (at one year) as compared to those patients treated with single vascular procedures.
ABSTRACT
BACKGROUND: Controversy exists about technique of repair for ruptured abdominal aortic aneurysms (rAAA). We studied rAAA treated at a single tertiary center from 2005 to 2015 to determine operative morbidity and mortality in open and endovascular aortic aneurysm repair (EVAR) of rAAA. METHODS: All rAAA (n = 144) treated from 2005 to 2015 were reviewed using an IRB-approved database. "EVAR first" strategy was used after 2010. rAAA treatment was open (rAAA began with open surgery); EVAR (rAAA began with EVAR and included EVARs converted to open); and EVAR only (successful EVAR). Preoperative, intraoperative and outcome variables were analyzed with t-test, chi-square and logistic and multivariate regression using SAS. RESULTS: One hundred forty-four rAAAs were treated from 2005 to 2015. Seventy-five percent (108/144) began with open surgery. Twenty-five percent (36/144) began with EVAR. After 2010, 54.5% began with EVAR. Eleven percent of EVARs (4/36) converted to open and 89% (32/36) had EVAR only. Fifty-nine percent (83/144) had preoperative systolic blood pressure (SBP) <90 mm Hg. Eighty-four percent of these (70/83) had open surgery and 16% (13/83) had EVAR. Hospital mortality for all rAAAs was 23.6% (34/144). Operative mortality was 25% (27/108) in open and 19.4% (7/36) in EVAR (P = 0.486). Mortality was 75% (3/4) in EVARs that converted to open and 12.5% (4/32) in EVAR only patients. In univariate analysis age, ASA 5, preoperative SBP <90 mm Hg, intraoperative complications, dialysis, MI/CHF, respiratory failure, stroke and reintervention were significant for mortality. In multivariate modeling preoperative SBP <90 mm Hg (P = 0.0018), ASA 5 (P = 0.0175), intraoperative complications (P = 0.0017), MI/CHF (P = 0.0045), respiratory failure (P = 0.0159) and new renal failure (P = 0.0073) were significant for mortality. There was no difference in mortality between open and EVAR (P = 0.9554) and no difference in cardiac or respiratory failure. Open had more renal failure and EVAR more endoleaks. Fifty-eight percent (21/36) of EVARs started with local anesthesia (LA) and 52.8% (19/36) finished with LA. Nineteen percent (4/21) of EVARs with LA versus 60% (9/15) with general anesthesia (GA) had preoperative SBP <90 mm Hg. In EVAR only there was no difference in mortality between LA (4/18, 22.2%) and GA (3/14, 21.4%) (P = 0.94). CONCLUSIONS: Operative mortality in ruptured AAA was associated with hypotension, ASA status 5, uncontrolled hemorrhage, cardiac events, and respiratory failure but not with type of repair. EVAR and open surgery also had comparable cardiac and respiratory morbidity. Selection was critical in EVAR for rAAA because mortality of unsuccessful EVAR was very high. There was no difference in mortality between LA and GA for EVAR.
