Interfacility Transfer is Associated with Higher Postoperative Amputation in Patients Undergoing Lower Extremity Bypass for Acute Limb Ischemia: A Multi-institutional Study from Vascular Quality Initiative.

BACKGROUND

Patients with acute limb ischemia (ALI) should undergo an urgent/emergent revascularization procedure without delay to prevent limb loss. However, interfacility transfer (IFT) is inevitable in certain circumstances, particularly when optimal surgical service is unavailable. IFT can delay surgical care and compromise outcomes. We aimed to investigate the impact of IFT on postoperative outcomes and 1-year mortality of lower extremity bypass (LEB) in patients presenting with ALI.

METHODS

The Vascular Quality Initiative database was queried for patients presenting with ALI and undergoing LEB between 2003 and 2023. The patients were stratified by IFT status. The primary outcome was postoperative major amputation. The secondary outcomes were postoperative complications, 30-day mortality, prolonged length of stay (PLOS, ≥7 days), return to the operating room for thrombosis or revision, major adverse cardiovascular events, major adverse limb events (MALE), and 1-year mortality. Logistic and Cox regressions were used for multivariate analyses.

RESULTS

There were 9,302 bypasses performed for ALI during the study period, of which 1,952 (21.0%) were performed after transfer from an index hospital. These bypasses were performed on 9,302 limbs from 8,493 patients. After adjusting for potential confounders, IFT was associated with increased risks of major amputation (adjusted odds ratio [aOR] = 1.45, 95% confidence interval [CI]: 1.14-1.84; P = 0.002), PLOS (aOR = 1.36, 95% CI: 1.18-1.56; P < 0.001), and MALE (aOR = 1.28, 95% CI: 1.07-1.53; P = 0.008). However, IFT was not associated with the risk of death at 1 year (adjusted hazards ratio = 1.03, 95% CI: 0.84-1.25; P = 0.772). The logistic regression model for IFT revealed that being a current smoker, obesity, moderate-to-severe anemia, having aneurysmal disease, undergoing urgent and emergent bypasses, and having the bypass performed over the weekend were associated with being transferred.

CONCLUSION

Patients presenting with ALI requiring transfer for LEB are more likely to experience limb loss, PLOS, and MALE. Although transfer of patients with ALI is inevitable in certain situations, every effort should be made to manage these patients at the initial institution and transfer should be limited to conditions where an appropriate team to manage ALI is not available.