Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 356-360

Postoperative complications in geriatric patients in vascular surgery: A tertiary care center experience


Department of Vascular Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India

Date of Submission05-Jun-2020
Date of Acceptance23-Jun-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Prabhu Premkumar
Department of Vascular Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_80_20

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  Abstract 


Introduction: The frequency of operations in geriatric population has been on a rise due to longevity and better medical care. Developing countries such as India have a significant proportion of geriatric patients who require various surgical interventions. There is limited data on various postoperative complications that are seen in geriatric vascular surgery patients. Methodology: A retrospective study was conducted in patients aged 65 and above who were operated under the department of vascular surgery, between 2013 and 2018. The patients' inpatient and outpatient records were analyzed to obtain the required data. Results: The study included 437 patients. The most common postoperative complication was surgery related (24.5%), followed by cardiac complications (13.5%). The overall mortality rate was 2% (n = 9). The 30-day readmission rate was 15.7%, of which peripheral arterial occlusive disease was seen in 92.7% of the patients. The patients who underwent endovascular procedures had fewer postoperative complications compared to those who underwent open procedures (14.3% vs. 23.3%). The incidence of intensive care unit transfers was 19.9%. The primary amputation rate was 21.5% and the secondary amputation rate was 21.6%, with a limb salvage rate of 78.4%. Conclusion: Postoperative complications are significant in geriatric patients. Recognizing the increasing and complex nature of geriatric patients, special measures must be taken to minimize the in-hospital complications.

Keywords: Endovascular procedures in the elderly, mortality in the elderly after vascular surgical procedures, outcomes in the elderly after vascular surgical procedures, postoperative complications in the elderly, vascular surgery in the elderly


How to cite this article:
Dsouza RJ, Premkumar P, Samuel V, Kota A, Selvaraj D. Postoperative complications in geriatric patients in vascular surgery: A tertiary care center experience. Indian J Vasc Endovasc Surg 2020;7:356-60

How to cite this URL:
Dsouza RJ, Premkumar P, Samuel V, Kota A, Selvaraj D. Postoperative complications in geriatric patients in vascular surgery: A tertiary care center experience. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 20];7:356-60. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/356/304643




  Introduction Top


The frequency of surgery involving the geriatric population has been increasing due to the aging population and better medical care.[1],[2] Although this is more prevalent in Western countries, developing nations such as India also have a significant number of geriatric patients requiring operative interventions. Postoperative complications are directly related to poor surgical outcomes in these patients, and studies demonstrate that morbidity and mortality are increased following surgery in geriatric patients compared to the younger ones.[3],[4]

Vascular surgery comprises a major portion of the operations performed in geriatric patients.[5] The rates of complications after an emergency surgery increase exponentially in the geriatric patients due to inadequate preoperative optimization of comorbid conditions.[6] In India, there are no studies available to date to describe the postoperative complications in the geriatric age group in vascular surgery.


  Methodology Top


After approval from the institutional review board, a retrospective study was conducted on all patients aged 65 or above, admitted from June 1, 2013, to May 31, 2018, who underwent any elective or emergency vascular procedure under general or regional anesthesia. The data were accessed from the prospectively maintained electronic inpatient and outpatient records. The database sheet contained the following information: patient's demographics, comorbidities, elective or an emergency procedure, minor and major postoperative complications, shift to surgical intensive care unit (ICU), wound outcomes, reoperations, number of specialty unit consults sought, duration of hospital stay, 30-day readmission, and mortality.

The postoperative events and complications were recorded by the treating doctors in their daily progress notes. These were classified into the following types: neurological complications, cardiovascular complications, renal complications, pulmonary complications, and surgery-related complications.

Analysis

All data were entered into a Microsoft Excel spreadsheet and statistically analyzed using IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. (Armonk, NY: IBM Corp.). Preoperative and postoperative variables were analyzed using descriptive statistics for mean and standard deviation of continuous variables. Frequency tables were used for categorical variables.


  Results Top


The study included 437 patients aged 65 and above, which is 19.4% of the total vascular surgical admissions. The demographic data of the study patients are shown in [Table 1]. The mean age of the patients was 71 years (range 65–95 years). There were 358 male patients (81.9%) and 79 female patients (18.1%). Most patients had elective surgeries (72.5%) and the remaining had emergency surgeries (27.5%). Type 2 diabetes mellitus (58.8%) and systemic hypertension (56.8) were the most common comorbid illnesses, followed by coronary artery disease (23.8%) and chronic kidney disease (5.9%). The 30-day readmission rate was 15.7% (n = 69). The most common diagnosis at readmission was persistent limb ischemia (n = 40) followed by necrotizing soft-tissue infections (n = 15).
Table 1: Demographic details of the patients

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The spectrum of diagnosis and various procedures that were offered is shown in [Table 2] and [Table 3], respectively. The majority of the surgical admissions were for peripheral arterial occlusive disease (64.5%), followed by chronic venous insufficiency (20.1%). Of the various surgical procedures that were performed, angioplasty was the most common (33.9%), followed by debridement and amputations (24.2%).
Table 2: Diagnosis

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Table 3: Operative procedures performed (n=437)

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The various postoperative complications are shown in [Table 4]. Complications related to surgery were the most common and were seen in 24.5% of the patients followed by cardiac (13.5%) and renal complications (11.4%). Persistent limb ischemia (44.3%) ranked first among the surgery-related complications, followed by surgical-site infections (35.8%) as shown in [Table 5]. The reoperation rate was 21.5% [Table 6], and 19.9% of the patients needed a transfer to the surgical ICU or high-dependency unit during the hospital stay. Of the reoperations, the majority comprised amputations (56.8%) and debridement (16.8%). The others were repeat angioplasty (12.6%), re-exploration for hemorrhage (7.3%), and embolectomy (5.2%).
Table 4: Postoperative complications

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Table 5: Surgery-related complications

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Table 6: Reoperations

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The study also looked at the number of specialty consultations that were obtained during the hospital stay. Of the patients admitted, 48.6% required at least one or more specialty consultations and 12% needed three or more consultations. The specialty units involved were cardiology, nephrology, endocrinology, and pulmonary medicine.

The follow-up rates at 30 days following discharge were analyzed. A total of 115 of the 437 patients (26.4%) did not come for any follow-up after discharge.

Mortality

There were nine postoperative mortalities during the study period, of which seven were elective admissions. Seven patients were admitted with peripheral arterial occlusive disease and two with abdominal aortic aneurysm. Myocardial infarction was the most common cause of death (n = 7) followed by ventilator-associated pneumonia (n = 2). The overall mortality was 2.0% [Table 7].
Table 7: Mortality

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Endovascular procedures in geriatric patients

The postoperative complications were fewer in the patients who underwent endovascular procedures in comparison to those who underwent open operations [Table 8]. The incidence of reoperations was lesser (25% vs. 34.6%) after endovascular procedures. Similarly, more patients had to be transferred to the surgical ICU or high-dependency unit following open bypass operations compared to those who underwent endovascular procedures (36.5% vs. 12.9%). However, persistent limb ischemia following surgery was more commonly seen after percutaneous transluminal angioplasty (17.7% vs. 9.6%) [Table 9] and [Table 10].
Table 8: Comparison of complications between endovascular and open bypass procedures

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Table 9: Surgery-related complications between endovascular and open bypass procedures

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Table 10: Comparison of reoperations between endovascular and open bypass procedures

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  Discussion Top


An aging population results in an increase in the number of operations.[2] Developing countries such as India have a significantly high number of geriatric patients accessing surgical care for various conditions. Vascular surgery comprises a major proportion of operations performed in geriatric patients.[5] The postoperative complications are directly related to poor outcomes as shown in literature.[3],[4] Through this study, we aimed to assess the various postoperative outcomes in geriatric patients following vascular surgical procedures. The postoperative mortality rate in our hospital after vascular surgical procedures in geriatric patients was 2.05% as compared to other studies where postoperative outcomes of geriatric patients showed a mortality rate of 5% and 6%.[7],[8] A review of the American College of Surgeons National Surgical Quality Improvement Program data showed that patients over the age of 80 years had a mortality rate of 7% in the postoperative period.[9] In geriatric patients, there is conflicting evidence for increased mortalities after emergency operations.[8],[7],[10] In our study, seven of the nine mortalities occurred after elective procedures.

The most common preoperative comorbid illnesses in our study were diabetes mellitus and hypertension, which was prevalent in more than 50% of the patients. Hypertension is the most prevalent comorbidity according to other studies.[8] In a study assessing the risk factors in elderly vascular surgery patients, age, coronary artery disease, heart failure, cerebrovascular disease, renal failure, and diabetes were significantly associated with increased hospital and long-term mortality.[11]

Postoperative cardiac events were the most frequently developed complications that were seen in 59 patients, and these included myocardial infarction, unstable angina, and congestive cardiac failure. Renal, neurological, and respiratory complications had incidences of 11.4% (n = 50), 8.9% (n = 39), and 7.6% (n = 33), respectively. Similar results were published by Brosi et al. in patients with critical limb ischemia.[12] Neurologic events were the most common postoperative complications as reported by Liu and Leung in geriatric patients after surgery.[8] Polanczyk et al. in their study divided the postoperative complications into cardiac and noncardiac complications and death. In the noncardiac group, the most frequent complications were related to the respiratory system.[13] Similar results were seen in patients above 80 years in Taiwan as reported by Chung et al.[14]

Our study also looked at the surgical ICU or high-dependency unit admission rates in geriatric patients. Eighty-seven (19.9%) patients had to be transferred to the intensive care or high-dependency units at some point during their hospital stay. The majority of the ICU transfers occurred in patients who underwent abdominal aortic or peripheral arterial aneurysmal repairs (69%), followed by carotid endarterectomies (40%) and bypass procedures (36.5%). Similarly, the number of specialty consultations obtained during the hospital stay for geriatric patients is higher due to the need for optimization for various comorbid conditions.

The vulnerability of geriatric patients also reflected in terms of a high 1-month readmission rate which was 15.7%. A study done by Gupta et al. reported unplanned readmission rate in vascular surgery of 0.04%.[15] Of the readmissions, 92.7% of the patients had complications related to peripheral arterial occlusive disease. Although regular follow-up in the outpatient department was emphasized at discharge, 26.4% of the patients failed to do so within 30 days of discharge. This reflects the demography of the population our institution caters to. A significant number of patients belong to the states far away, making regular follow-up not feasible.

The choice of a procedure in the geriatric patients depends on many factors such as surgical risk and associated cardiovascular disease. The recent guidelines suggest an “endovascular first” approach where re-vascularization is indicated.[16] In our study, the complications after PTA and stenting were fewer compared to those after the bypass procedures. The reoperation rates and the rate of transfer to surgical ICU were also significantly lower. Studies by Brosi et al. and Adam et al. have shown that short-term survival is better in patients with angioplasty than those with bypass surgery.[12],[17] However, the limb salvage rate was lower in patients who underwent endovascular procedures. The secondary amputation rates were 19.5% (n = 29) compared to 15.3% (n = 8) after open bypass procedures. This is reflective of the delayed presentation especially in geriatric patients in the current socioeconomic milieu of our country where scarce resources are kept for possibly more economically productive members of the family. Endovenous ablations for varicose veins when performed even in the elderly, proved to be safe procedures. Similar results have been obtained in studies done by Tamura et al., Shaĭdakov et al., and Lam and Chao.[18],[19],[20]

Our study had certain limitations. It was a retrospective study based on the inpatient and outpatient records. We hope to conduct a prospective study to compare the complications and various outcomes after vascular surgical and endovascular procedures in geriatric patients.


  Conclusion Top


In our patient profile, we often witness patients presenting late and limb salvage is crucial. Geriatric patients require special attention with regard to preoperative optimization of comorbid conditions, careful intraoperative monitoring, and watchful postoperative management. Postoperative complications are directly related to increased mortality in these patients and hence, all measures must be taken to minimize the in-hospital complications, especially surgery related. Endovascular procedures have proven to be safe with minimal complications. Preoperative optimization and individualized management remain critical in the management of elderly patients undergoing vascular surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vaupel JW. Biodemography of human ageing. Nature 2010;464:536-42.  Back to cited text no. 1
    
2.
Yang R, Wolfson M, Lewis MC. Unique aspects of the elderly surgical population: An Anesthesiologist's perspective. Geriatr Orthop Surg Rehabil 2011;2:56-64.  Back to cited text no. 2
    
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Bentrem DJ, Cohen ME, Hynes DM, Ko CY, Bilimoria KY. Identification of specific quality improvement opportunities for the elderly undergoing gastrointestinal surgery. Arch Surg 2009;144:1013-20.  Back to cited text no. 3
    
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Sieber FE, Barnett SR. Preventing postoperative complications in the elderly. Anesthesiol Clin 2011;29:83-97.  Back to cited text no. 4
    
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Jim J, Owens PL, Sanchez LA, Rubin BG. Population-based analysis of inpatient vascular procedures and predicting future workload and implications for training. J Vasc Surg 2012;55:1394-9.  Back to cited text no. 5
    
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Khan-Kheil AM, Khan HN. Surgical mortality in patients more than 80 years of age. Ann R Coll Surg Engl 2016;98:177-80.  Back to cited text no. 6
    
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Kojima Y, Narita M. Postoperative outcome among elderly patients after general anesthesia. Acta Anaesthesiol Scand 2006;50:19-25.  Back to cited text no. 7
    
8.
Liu LL, Leung JM. Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc 2000;48:405-12.  Back to cited text no. 8
    
9.
Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006;203:865-77.  Back to cited text no. 9
    
10.
Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: Retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424.  Back to cited text no. 10
    
11.
Feringa HH, Bax JJ, Karagiannis SE, Noordzij P, van Domburg R, Klein J, et al. Elderly patients undergoing major vascular surgery: Risk factors and medication associated with risk reduction. Arch Gerontol Geriatr 2009;48:116-20.  Back to cited text no. 11
    
12.
Brosi P, Dick F, Do DD, Schmidli J, Baumgartner I, Diehm N. Revascularization for chronic critical lower limb ischemia in octogenarians is worthwhile. J Vasc Surg 2007;46:1198-207.  Back to cited text no. 12
    
13.
Polanczyk CA, Marcantonio E, Goldman L, Rohde LE, Orav J, Mangione CM, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 2001;134:637-43.  Back to cited text no. 13
    
14.
Chung JY, Chang WY, Lin TW, Lu JR, Yang MW, Lin CC, et al. An analysis of surgical outcomes in patients aged 80 years and older. Acta Anaesthesiol Taiwan 2014;52:153-8.  Back to cited text no. 14
    
15.
Gupta PK, Fernandes-Taylor S, Ramanan B, Engelbert TL, Kent KC. Unplanned readmissions after vascular surgery. J Vasc Surg 2014;59:473-82.  Back to cited text no. 15
    
16.
Olin JW, White CJ, Armstrong EJ, Kadian-Dodov D, Hiatt WR. Peripheral artery disease: evolving role of exercise, medical therapy, and endovascular options. J Am Coll Cardiol 2016;67:1338-57.  Back to cited text no. 16
    
17.
Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet 2005;366:1925-34.  Back to cited text no. 17
    
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Tamura K, Maruyama T, Sakurai S. Effectiveness of endovenous radiofrequency ablation for elderly patients with varicose veins of lower extremities. Ann Vasc Dis 2019;12:200-4.  Back to cited text no. 18
    
19.
Shaĭdakov EV, Khavinson VKh, Bulatov VL, Son'kin IN, Rosukhovskiĭ DA, Iliukhin EA, et al. Endovenous laser obliteration and combined phlebectomy for treatment of varicose veins in elderly and senile patients. Adv Gerontol 2013;26:721-7.  Back to cited text no. 19
    
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Lam HB, Chao LF. Endovascular ablation therapies for varicose veins in elderly patients. Int J Gerontol 2014;8:219-22.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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