Correlation between ankle-brachial index, symptoms, and health-related quality of life in patients with peripheral vascular disease

AbstractObjectiveImproving health-related quality of life (HRQL) is the main goal of surgery to treat peripheral vascular disease (PVD); however, HRQL is rarely measured directly. Rather, most surgeons use other measures, such as patient symptoms and ankle-brachial index (ABI) to determine the need for intervention in PVD. The accuracy of these surrogates in representing HRQL has been untested. The purpose of this study was to determine the correlation of these measures with HRQL in patients undergoing evaluation for intervention in symptomatic PVD.MethodsPatients (n = 108) referred to the vascular surgery service with symptoms of PVD were enrolled in a prospective study of HRQL. Patients completed two validated HRQL questionnaires: the short form-36 (SF-36) and the Walking Impairment Questionnaire (WIQ). All patients had symptoms consistent with PVD, including claudication (n = 69; 63.9%), ischemic rest pain (n = 17; 15.7%), or tissue loss (n = 22; 20.4%). ABI was measured at presentation.ResultsThe mean ABI was 0.53 (range, 0.00-0.98). The maximal correlation between SF-36 score and ABI was reflected in the Physical Component Summary score (r = 0.25). WIQ score also exhibited modest correlation with ABI, with maximal correlation noted for stair climbing (r = 0.26). Both SF-36 and WIQ scores exhibited a highly significant association with symptoms. Patients with more severe symptoms, such as lifestyle-limiting claudication or limb-threatening ischemia, had lower HRQL scores compared with patients with non-lifestyle-limiting claudication. Multivariate analysis demonstrated that SF-36 and WIQ physical summary scores are better predicted by symptoms than by ABI (P < .01).ConclusionsHRQL in patients with PVD correlates weakly with ABI, but exhibits a closer association with vascular symptoms. However, neither variable fully expresses patient HRQL. These data suggest that sole reliance on these surrogates may not accurately reflect the effect of PVD on HRQL, or the potential benefit of vascular surgery in improving HRQL

Transient advanced mental impairment: An underappreciated morbidity after aortic surgery

AbstractObjectives: To determine the incidence, risk factors, and associated morbidity of transient advanced mental impairment (TAMI) after aortic surgery. Methods: We retrospectively studied the charts of 188 consecutive patients undergoing elective aortic reconstruction during a recent 6-year period at a university hospital. All patients were lucid on admission and nonintubated at the time of evaluation at least 2 days after operation. TAMI was defined as disorientation or confusion on 2 or more postoperative days. Preoperative, intraoperative, and postoperative clinical variables were examined statistically for associations with TAMI. Results: Fifty-three patients (28%) had development of TAMI 3.9 ± 2.8 days after operation. Stepwise logistic regression analysis selected the following independent predictors for TAMI: age >65 years (odds ratio [OR], 7.9; 95% confidence interval [CI], 2.7 to 23.7), American Society of Anesthesiology physical status classification >3 (OR, 2.8; 95% CI, 1.3 to 5.9), diabetes mellitus (OR, 3.4; 95% CI, 1.2 to 9.8), old myocardial infarction (OR, 2.4; 95% CI, 1.1 to 5.3), and hypertension (OR, 2.3; 95% CI, 1.0 to 5.3). Alcohol consumption was not significantly associated with TAMI. In the postoperative period, patients with TAMI were more likely to have hypoxia (P <.001), a need for reintubation (P <.001), pneumonia (P <.001), congestive heart failure (P =.003), and kidney failure (P =.05). In addition, patients with TAMI had a longer duration of endotracheal intubation (3.7 ± 7.8 vs 0.6 ± 1.2 days, P <.001), stay in the intensive care unit (8.9 ± 9 vs 3.9 ± 2 days, P <.001), and postoperative hospital stay (14.8 ± 11 vs 9.2 ± 5 days, P <.001) than patients without TAMI. Twenty (38%) patients with TAMI were discharged to intermediate-care facilities, compared with 11 (8%) patients without TAMI (P <.001). Postoperative variables conferring the largest relative risks for development of TAMI included oxygen saturation less than 92% (5.4), the need for reintubation (3.3), congestive heart failure (3.3), and pneumonia (3.2). TAMI, conversely, conferred the largest relative risks for development of postoperative congestive heart failure (15.3), the need for reintubation (9.3), pneumonia (7.1), and the need for ICU readmission (3.8). Conclusions: These data show that TAMI is prevalent among patients undergoing aortic reconstruction and is associated with dramatically increased morbidity and postoperative hospitalization rates. (J Vasc Surg 2002;35:376-81.

Do preoperative finger pressures predict early arterial steal in hemodialysis access patients? A prospective analysis

AbstractBackground: Hand ischemia resulting from arterial steal is a serious complication in patients undergoing hemodialysis access, but specific risk factors for steal remain in dispute. The purpose of this study was to determine whether plethysmographically derived finger pressures (FPs) or digital-brachial indices (DBIs) are predictive of symptomatic arterial steal. Methods: We prospectively studied 72 patients (37 men, 35 women; mean age, 57 ± 10 years) who were undergoing brachial artery-based hemodialysis access. All patients had complete pre- and postoperative hand examinations and FP determinations. Surgeons were blinded to preoperative FP results. Results: Prosthetic graft was used in 60 patients (6-mm polytetrafluoroethylene [PTFE] in 50, tapered PTFE in 10), and brachial-based arteriovenous fistulas were created in 12. Fourteen (19%) patients developed arterial steal symptoms. The mean preoperative FP was significantly lower in steal patients than in those without steal (131 ± 27 vs 151 ± 31 mm Hg, P < .03). Nine (64%) of the patients with steal had DBIs <1.0, compared to 18 (31%) of the patients without steal (P = .02). However, there was no absolute FP or DBI threshold below which steal was inevitable. The occurrence of steal was attributed to proximal arterial stenoses in seven, to distal arterial disease in five, and was unknown in two. When comparing the 14 patients who developed steal to the 58 who did not, we noted that a higher proportion of steal patients had coronary artery disease (57% vs 17%, P = .005). Steal was more likely to develop in patients with arteriovenous fistulas than in patients with prosthetic grafts (43% vs 14%, P = .009). There were no significant differences in demographic factors, atherosclerotic risks (diabetes, smoking, hypertension, dyslipidemia), prevalence of peripheral vascular disease, cerebrovascular disease, shunt location, tapered vs straight graft, or number of prior grafts placed. Conclusions: These data indicate that preoperative FPs are lower in patients who develop steal syndrome after hemodialysis access. Patients with preoperative DBIs <1.0 are more likely to develop steal, but there is no DBI threshold below which steal is inevitable. Steal is more likely in patients undergoing brachial-based arteriovenous fistulas than in those receiving prosthetic grafts. (J Vasc Surg 2002;36:351-6.