Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database

Abstract

Background Use of pedicled flaps in vascular procedures is associated with decreased infection and wound breakdown. We evaluated the risk profile and postoperative complications associated with lower extremity open vascular procedures with and without pedicled flaps.

Methods The American College of Surgeons National Surgical Quality Improvement Program database (2010–2020) was queried for Current Procedural Terminology codes representing lower extremity open vascular procedures, including trunk and lower extremity pedicled flaps. Flap patients were compared with a randomized control group without flaps (1:3 cases to controls). Univariate and multivariate analyses were performed.

Results We identified 132,934 adults who underwent lower extremity open vascular procedures. Concurrent pedicled flaps were rare (0.7%), and patients undergoing bypass procedures were more likely to receive a flap than nonbypass patients (69 vs. 64%, p < 0.0001). Flap patients had greater comorbidities. On univariate analysis, flap patients were more likely to experience wound (p = 0.0026), mild systemic (p < 0.0001), severe systemic (p = 0.0452), and all-cause complications (p < 0.0001). After adjusting for factors clinically suspected to be associated with increased risk (gender, body mass index, procedure type, American Society of Anesthesiologists classification, functional status, diabetes, smoking, and albumin < 3.5 mg/dL), wound (p = 0.096) and severe systemic complications (p = 0.0719) were no longer significantly associated with flap patients.

Conclusion Lower extremity vascular procedures are associated with a high risk of complications. Use of pedicled flaps remains uncommon and more often performed in patients with greater comorbid disease. However, after risk adjustment, use of a pedicled flap in high-risk patients may be associated with lower than expected wound and severe systemic complications.

Keywords

prophylactic plastic surgery - prophylactic muscle flap - high-risk vascular surgery

• References

• 1 Feinglass J, Sohn MW, Rodriguez H, Martin GJ, Pearce WH. Perioperative outcomes and amputation-free survival after lower extremity bypass surgery in California hospitals, 1996-1999, with follow-up through 2004. J Vasc Surg 2009; 50 (04) 776-783.e1
• 2 Fischer JP, Nelson JA, Mirzabeigi MN. et al. Prophylactic muscle flaps in vascular surgery. J Vasc Surg 2012; 55 (04) 1081-1086
• 3 Wallace AB, Piper ML, Holland M. et al. Prophylactic muscle flaps in primary vascular procedures of the groin. Ann Vasc Surg 2022; 78: 77-83
• 4 Price MJ, Tillis R, Howell EP. et al. Muscle flap closures in spine surgery: predictors of usage patterns and factors associated with postoperative complications from the NSQIP database. Clin Spine Surg 2022; 35 (01) E248-E258
• 5 ACS NSQIP participant use data file. ACS. Accessed July 27, 2022 at: https://www.facs.org/quality-programs/data-and-registries/acs-nsqip/participant-use-data-file/
• 6 Birkmeyer JD, Shahian DM, Dimick JB. et al. Blueprint for a new American College of Surgeons: national surgical quality improvement program. J Am Coll Surg 2008; 207 (05) 777-782
• 7 Haug V, Kadakia N, Panayi AC. et al. Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-a propensity score matching analysis in 5386 ACS-NSQIP patients. J Plast Reconstr Aesthet Surg 2021; 74 (05) 1031-1040
• 8 Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-factor modified frailty index using American College of Surgeons NSQIP data. J Am Coll Surg 2018; 226 (02) 173-181.e8
• 9 Rege RM, Runner RP, Staley CA, Vu CCL, Arora SS, Schenker ML. Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries. Injury 2018; 49 (12) 2234-2238
• 10 Tracy BM, Wilson JM, Smith RN, Schenker ML, Gelbard RB. The 5-item modified frailty index predicts adverse outcomes in trauma. J Surg Res 2020; 253: 167-172
• 11 Cuccolo NG, Sparenberg S, Ibrahim AMS, Crystal DT, Blankensteijn LL, Lin SJ. Does age or frailty have more predictive effect on outcomes following pedicled flap reconstruction? An analysis of 44,986 cases^† . J Plast Surg Hand Surg 2020; 54 (02) 67-76
• 12 Fischer JP, Nelson JA, Rohrbach JI. et al. Prophylactic muscle flaps in vascular surgery: the Penn Groin Assessment scale. Plast Reconstr Surg 2012; 129 (06) 940e-949e
• 13 Price A, Contractor U, White R, Williams I. The use of vascularised muscle flaps for treatment or prevention of wound complications following arterial surgery in the groin. Int Wound J 2020; 17 (06) 1669-1677
• 14 Inui T, Bandyk DF. Vascular surgical site infection: risk factors and preventive measures. Semin Vasc Surg 2015; 28 (3-4): 201-207
• 15 Kim Y, Feldman ZM, Majumdar M. et al. Factors influencing hospital readmission after lower extremity bypass for chronic limb-threatening ischemia. Vasc Endovascular Surg 2023; 57 (03) 230-235
• 16 Zhang JQ, Curran T, McCallum JC. et al. Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program. J Vasc Surg 2014; 59 (05) 1331-1339
• 17 Latz CA, Wang LJ, Boitano L. et al. Unplanned readmissions after endovascular intervention or surgical bypass for critical limb ischemia. J Vasc Surg 2021; 73 (03) 942-949.e1
• 18 Fischer JP, Mirzabeigi MN, Sieber BA. et al. Outcome analysis of 244 consecutive flaps for managing complex groin wounds. J Plast Reconstr Aesthet Surg 2013; 66 (10) 1396-1404
• 19 Calligaro KD, Veith FJ, Sales CM, Dougherty MJ, Savarese RP, DeLaurentis DA. Comparison of muscle flaps and delayed secondary intention wound healing for infected lower extremity arterial grafts. Ann Vasc Surg 1994; 8 (01) 31-37
• 20 Evans GR, Francel TJ, Manson PN. Vascular prosthetic complications: success of salvage with muscle-flap reconstruction. Plast Reconstr Surg 1993; 91 (07) 1294-1302
• 21 Kimmel RM, Murphy Jr RX, Chowdary RP. Optimal management of inguinal vascular graft infections. Ann Plast Surg 1994; 32 (06) 623-629
• 22 Menzin J, Marton JP, Meyers JL, Carson RT, Rothermel CD, Friedman M. Inpatient treatment patterns, outcomes, and costs of skin and skin structure infections because of Staphylococcus aureus . Am J Infect Control 2010; 38 (01) 44-49