Positive Preoperative Stress Test is Associated with Increased Risk of Postoperative Myocardial Infarction in Patients Undergoing Aortoiliac Reconstruction for Chronic Limb-Threatening Ischemia.

BACKGROUND

Aortofemoral or aortoiliac bypasses (AFBs/AIBs) are considered the gold standard treatment for patients with aortoiliac occlusive disease. Myocardial infarction (MI) is a postoperative risk in AFB/AIB surgeries and preoperative stress test (PST) is frequently utilized to inform operative planning and preoperative risk discussions. The aim of this study is to assess the utility of PST in determining outcomes following AFB/AIB in patients with chronic limb-threatening ischemia (CLTI).

METHODS

This is a retrospective study from Vascular Quality Initiative database. Patients undergoing AFB/AIB for chronic limb-threatening ischemia during 2009-2023 were stratified by PST result. Primary outcomes included postoperative MI and 30-day mortality. Secondary outcomes included in-hospital death, in-hospital death/MI, postoperative respiratory complications, postoperative congestive heart failure, intensive care unit stay > 3 days, and 1-year mortality. Logistic and Cox regressions were used for multivariate analyses.

RESULTS

The study included 2 cohorts of patients: negative (N = 1,809, 81.2%) and positive PST (N = 420, 18.8%). The patients with positive PST had increased rate of postoperative MI compared to the patients with negative PST (6.7% vs. 2.9%, P < 0.001). The rate of 30-day mortality was greater for patients with positive PST but the difference was not significant (3.8% vs. 2.9%, P = 0.315). After adjusting for potential confounders, positive PST was associated with increased risk of postoperative MI (adjusted odds ratio = 1.89 [95% confidence interval: 1.04-3.43], P = 0.038). However, positive PST was not associated with 30-day mortality. Pulmonary complications, congestive heart failure, and intensive care unit stay >3 days were also not associated with PST result. The overall survival rate at 1-year was 93.3% and 92.0% for patients with negative and positive PSTs (P = 0.343), respectively. After adjusting for potential confounders, postoperative MI was associated with increased hazards of death at 1 year (adjusted hazard ratio = 3.62 [95% confidence interval: 2.21-5.92], P < 0.001).

CONCLUSION

This study emphasizes the important of appropriate preoperative planning. A positive stress test before open aortic reconstruction for aortoiliac occlusive disease is associated with increased risk of postoperative MI. Although this was neither associated with increased risk of 30-day nor 1-year mortality, the negative impact of MI on patient functionality, quality of life, and 1-year death cannot be ignored.