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An analysis of limb-threatening lower extremity wound complications after 1090 consecutive coronary artery bypass
T A Thomas1, S M Taylor, M M Crane
1Department of Surgical Education, Greenville Hospital System, South Carolina 29605, USA.
Insights
Serious leg complications after coronary artery bypass surgery (CABG) affect 5% of patients, often due to non-healing vein incisions and ulcers. Older diabetic women with undetected peripheral vascular disease are at higher risk.
Area of Science:
- Vascular Surgery
- Cardiovascular Surgery
- Wound Care
Background:
- Coronary artery bypass surgery (CABG) can lead to lower extremity complications.
- Limb-threatening wounds, though less common than minor issues, are significant post-CABG complications.
Purpose of the Study:
- To characterize limb-threatening lower extremity wound or soft tissue complications after CABG.
- To identify risk factors associated with these serious complications.
Main Methods:
- Retrospective review of 1090 consecutive CABG procedures.
- Inclusion criteria: complications requiring additional surgery, prolonged hospital stay, or extensive home nursing.
- Exclusion criteria: minor outpatient-treated issues like lymph leaks or swelling.
Main Results:
- 5.0% (54/1090) of patients experienced limb-threatening complications.
- Common complications included non-healing vein harvest incisions (66.7%), decubitus ulcers (20.4%), and forefoot ischemia (18.5%).
- Risk factors identified: older age, female sex, diabetes, and longer cardiopulmonary bypass time.
Conclusions:
- Non-healing vein incisions, decubitus ulcers, and ischemic lesions are major limb-threatening complications post-CABG.
- Older diabetic females with undiagnosed peripheral vascular disease (PVD) are particularly vulnerable.
- Nearly one-third of complications might be preventable by avoiding ankle vein harvest in patients with unappreciated PVD.
Abstract:
The objective of this study was to examine and characterize limb-threatening lower extremity wound or soft tissue complications after coronary artery bypass (CABG) and determine risk factors for their cause. While minor wound problems of the leg after CABG are not uncommon, serious limb-threatening complications, though less frequent, do occur and are often de-emphasized in the surgical literature. A review of 1090 consecutive CABG procedures performed from January 1, 1995 through December 31, 1995 was instituted, which screened for limb-threatening lower extremity wound or soft tissue complications defined as wounds that: required additional surgery for treatment; prolonged the length of stay; or which required lengthy home health nursing for treatment. Minor lymph leaks, leg swelling, infections or wound problems treated as an outpatient were excluded. Of 1090 patients, 54 (5.0%) experienced a limb-threatening lower extremity complication. Complications were categorized as vein harvest incision non-healing (n = 36, 66.7%), decubitus ulceration (n = 11, 20.4%), forefoot ischemia/embolization (n = 10, 18.5%), groin hematoma/abscess (n = 6, 11.1%), severe cellulitis (n = 3, 5.6%), or a combination (n = 12, 22.2%). Statistically significant risk factors by univariate and bivariate analysis for a complication included older age (68 years vs 62 years, p = 0.007), female sex (57% vs 28%, p < 0.001), diabetes (57% vs 33%, p = 0.005) and longer pump time (129 min vs 114 min, p = 0.009). These complications necessitated five major lower extremity amputations and nine revascularization procedures. Chronic lower extremity ischemia from peripheral vascular disease (PVD) was a major contributing factor for the development of wounds in at least 23 (42.6%) of these patients, though suspected in only 10 (43.5%) preoperatively. A non-healing vein harvest incision below the knee of a patient retrospectively found to have inadequate distal circulation for healing occurred in 17 (31.5%) of the total 54 cases. It was concluded that non-healing vein incisions, decubitus ulcers and forefoot ischemic lesions frequently occurring in older diabetic females with undetected pre-existing PVD, comprise the majority of limb-threatening leg complications after CABG. Nearly one-third of the complications may have been avoided had the vein harvest incision not been made at the ankle of a patient with unappreciated PVD.