Journal of Vascular Surgery
Volume 50, Issue 2 , Pages 341-348.e1, August 2009

Mesenteric revascularization: management and outcomes in the United States, 1988-2006

Beth Israel Deaconess Medical Center, Boston, Mass

Received 5 November 2008; accepted 2 March 2009. published online 17 April 2009.

Article Outline

Background

Recent reports have suggested that angioplasty, with and without stenting (PTA/S), may have a lower perioperative mortality rate than open surgery for revascularization of acute (AMI) and chronic mesenteric ischemia (CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is actually a mortality benefit.

Methods

We identified all patients undergoing surgical (bypass, endarterectomy, or embolectomy) or PTA/S mesenteric revascularization from the Nationwide Inpatient Sample from 1988 to 2006. A diagnosis by International Classification of Diseases, 9th Revisioncoding of AMI or CMI was required for inclusion. We evaluated trends in management during this period and compared in-hospital death and complications between surgical bypass and PTA/S for the years 2000 to 2006.

Results

From 1988 to 2006, there were 6342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily, surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. The mortality rate was lower after PTA/S than after bypass for CMI (3.7% vs 13%, P < .01) and AMI (16% vs 28%, P < .01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P < .01). This subgroup showed an increased in-hospital mortality rate for both repair types (54% and 25%, respectively).

Conclusion

PTA/S is being used with increasing frequency for revascularization of CMI and AMI. The lower in-hospital mortality rate for patients, as they are currently being selected, shows that PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group, making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

 

Mesenteric ischemia requiring revascularization is associated with high mortality in both chronic and acute forms. Open surgical treatment with bypass, endarterectomy, or embolectomy has been the standard for many years. Revascularization for chronic mesenteric ischemia (CMI) is typically performed in elderly patients with extensive atherosclerotic disease and malnutrition. Given the rarity of the disease, there are few reported series with large numbers of patients undergoing surgery for CMI. Results from these relatively high-volume centers of excellence have operative mortality rates of up to 12%.1, 2, 3, 4, 5, 6, 7 Derrow et al8 reported national outcomes for surgical revascularization of CMI from the Nationwide Inpatient Sample (NIS), revealing an in-hospital mortality rate of 15%. A few articles have reported large numbers of patients with acute mesenteric ischemia (AMI) undergoing revascularization. Revascularization for AMI is typically associated with mortality rates >50%.1, 9, 10, 11

An increasing number of small cohorts have been reported in whom angioplasty, with or without stenting (PTA/S), has been used for treatment of CMI, with mortality rates similar to surgery in some reports and lower than surgery in others.12, 13, 14, 15, 16, 17 Several small case series have described using PTA/S for treatment of AMI.18, 19, 20, 21, 22 The national adoption of PTA/S for CMI and AMI is largely unknown. It is also unclear if PTA/S has a short-term mortality benefit compared with surgery. To address this, we evaluated trends in management of CMI and AMI using surgery or PTA/S between 1988 and 2006 and used a national hospital administrative database to compare in-hospital outcomes in the most recent years.

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Methods 

Data sample 

The Nationwide Inpatient Sample (NIS) was used for this study. The NIS is maintained by the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality. The database is a 20% all-payer sample of hospital stays and contains sampling weights to allow for stratified calculation of total population estimates. The years 1988 to 2006 were used for trend analysis, whereas comparisons between PTA/S and surgery were limited to the years 2000 to 2006 when PTA/S became commonplace. Study approval was obtained from the Institutional Review Board at Beth Israel Deaconess Medical Center. Data use agreements for use of the NIS data were made with HCUP.

Queries were performed with SAS 9.1 statistical software (SAS Institute, Cary, NC) using the International Classification of Diseases, 9th Revision (ICD-9) diagnosis and procedure codes. Initial case selection required a primary admission diagnosis of acute (557.0) or chronic mesenteric ischemia (557.1) combined with a procedure code of mesenteric angioplasty, with and without stent placement (39.50, 39.90), or open mesenteric surgical procedures including mesenteric bypass (39.26, 38.36, 38.46), mesenteric embolectomy (38.06), or mesenteric endarterectomy (38.16). The analysis excluded patients undergoing aortic reconstruction and those <18 years.

Total population estimates were calculated per year of hospitalization. The primary outcome was in-hospital death. Secondary outcomes included need for bowel resection and complications including acute renal failure, acute myocardial infarction, and others as defined by ICD-9 coding for complications Appendix (online only).

Statistical analysis 

Statistical analysis was performed using survey analysis programs with Stata 8 software (StataCorp LP, College Station, Tex). Population estimates are reported by applying the sampling weight for each observation within Stata calculations. Means and standard deviations are reported for parametric data and median values and ranges for nonparametric data. Statistical significance was assigned at P < .01. Comparisons between cohorts were done using the Wilcoxon ranked sum test for nonparametric continuous data, the t test for parametric continuous data, and the χ2 test for categoric and numeric data. Groups were stratified by diagnosis (AMI vs CMI) and by revascularization method.

Univariate and multivariate logistic regression was performed using all demographic and comorbidity data as potential risk factors. Procedure complications were not included in multivariate analyses. The need for a bowel resection was included as an independent predictor variable in analysis of AMI (but not CMI) because this was considered more likely to be a reflection of the pre-existing extent of ischemia at the time of revascularization rather than a complication of the revascularization procedure. Multivariate analysis was performed by backwards selection of risk factors meeting statistical significance at the P < .10 level on univariate analysis.

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Results 

Overall 

From 1988 to 2006, there were 6342 PTA/S and 16,071 open surgical repairs. Between 2000 and 2006, 64.5% of patients diagnosed with AMI underwent open surgery vs 35.5% for PTA/S, whereas patients with CMI more often were treated with PTA/S (61.9% vs 38.1%). Overall revascularization for CMI has increased over time (Fig 1), but there has been relatively little change for AMI (Fig 2). PTA/S increased over time for both diagnoses and by 2002 had surpassed surgery for CMI and more than doubled it by 2005. For AMI, PTA/S has surpassed bypass and embolectomy individually, but surgical revascularization in general remains the predominant treatment. Of note, the proportion of patients with atrial fibrillation or atrial flutter decreased over time from a maximum of 38% in 1994 to 24% in 2006.

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  • Fig 1. 

    Procedure volume for revascularization of chronic mesenteric ischemia (CMI) by percutaneous transluminal angioplasty, with or without stenting (PTA/S), compared with open repairs from 1988 to 2006.

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  • Fig 2. 

    Procedure volume for revascularization of acute mesenteric ischemia (AMI) by percutaneous transluminal angioplasty, with or without stenting (PTA/S), compared with open repairs from 1988 to 2006.

Over time, the overall mortality rate for CMI and AMI decreased (test of trend, P <.001; Fig 3, Fig 4). After the year 2000, when endovascular therapy was more commonly used, the mortality rate after repair for either indication was significantly lower than before this time period (CMI, 8% vs 15%, P < .001; AMI, 30% vs 49%, P < .001).

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  • Fig 3. 

    Mortality rate after percutaneous transluminal angioplasty, with or without stenting (PTA/S), compared with surgical repair for chronic mesenteric ischemia (CMI) from 1988 to 2006.

  • View full-size image.
  • Fig 4. 

    Mortality rate after percutaneous transluminal angioplasty, with or without stenting (PTA/S), compared with surgical repair for acute mesenteric ischemia (AMI) from 1988 to 2006.

CMI from 2000 to 2006 

Patients undergoing revascularization for CMI from 2000 to 20006 were generally older women with multiple comorbidities. Those undergoing PTA/S were older, more likely men, and had higher rates of comorbidities (Table I). The surgical procedure performed for CMI was overwhelmingly bypass (93%) compared with endarterectomy (4%) or embolectomy (3%). Mortality was 3.7% after PTA/S and 15% after open surgical repair (P < .001). Mortality after PTA/S was significantly lower when the comparison was limited to bypass (13% P < .001) and the higher mortality seen in those undergoing endarterectomy (31%) or embolectomy (69%) was excluded. The mortality differences for male vs female for PTA/S (4% vs 4%, P = .72) or open repairs (14% vs 16%, P = .66) were not significant (Table II).

Table I. Baseline characteristics of patients undergoing angioplasty, with or without stenting, compared with surgical repair for chronic and acute mesenteric ischemia from 2000 to 2006
VariableChronic mesenteric ischemiaAcute mesenteric ischemia
PTSA/SSurgeryaPbPTSA/SSurgeryaPb
Patients, No. (%)3455(61.9)2128(38.1). . .1857(35.5)3380(64.5). . .
Age, median (range), y74(24-97)68(29-99)<.00172(26-96)72(21-99).53
<60, %1532<.0012426.34
60-69, %2328<.052522.36
70-79, %3730<.013133.62
≥80, %2511<.0012119.52
Female, %7479<.057066.14
Comorbidities, %
Hypertension6651<.0015646<.01
PVD4032<.013313<.001
CAD3926<.0013419<.001
AFib/flutter16.514.9.4923.638.7<.001
Prior MI8.36.0.176.44.7.23
CHF17.510.5<.0122.122.6.85
Diabetes mellitus1912<.011817.73
COPD2527.402923.06
Chronic renal disease6.31.2<.0019.83.5<.001
CVD6.97.7.614.75.9.41
Charlson, mean ± SD1.3±1.11.0±1.0<.0011.4±1.30.9±1.1<.001
Bowel resection, %. . .. . .. . .28.147.8<.001

AFib, Atrial fibrillation; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; MI, myocardial infarction; PTA/S, percutaneous transluminal angioplasty, with or without stenting; PVD, peripheral vascular disease; SD, standard deviation.

aSurgery includes bypass, endarterectomy, or embolectomy.

bStatistical significance set at P < .01.

Table II. Mortality after angioplasty, with or without stenting, compared with surgical repair for chronic and acute mesenteric ischemia from 2000-2006
VariableChronic mesenteric ischemia, %Acute mesenteric ischemia, %
PTA/SSurgeryaPbPTA/SSurgeryaPb
All patients3.715.4<.00115.638.6<.001
With bypass. . .13.1<.001 27.6<.001
Mortality within subgroups
Age, years
<600.78.8<.0114.422.3.13
60-702.414.8<.00112.928.2<.01
70-803.814.1<.00112.546.1<.001
≥806.839.2<.00124.859.9<.001
Sex
Female3.615.8<.00115.441.0<.001
Malec4.213.9<.0116.234.0<.001
Comorbidity
Hypertension2.99.2<.00113.141.3<.001
PVD1.813.7<.00110.239.7<.001
CAD2.216.4<.00110.245.0<.001
AFib/flutter11.535.9<.00128.949.2<.001
Prior MI1.83.7.5912.539.1<.05
CHF9.938.8<.00128.244.6<.05
Diabetes mellitus4.112.6<.0511.638.0<.001
COPD5.017.8<.00116.341.3<.001
Chronic renal disease4.917.9.2619.449.0<.05
CVD2.323.9<.0111.632.2.11
Bowel resection24.655.3<.0528.846.5<.01
With bypass. . .53.9<.05 45.4<.05

AFib, Atrial fibrillation; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; MI, myocardial infarction; PTA/S, percutaneous transluminal angioplasty, with or without stenting; PVD, peripheral vascular disease; SD, standard deviation.

aSurgery includes bypass, endarterectomy, or embolectomy.

bStatistical significance set at P < .01.

cP = NS for mortality of males vs females for each repair type.

Overall morbidity was also lower after PTA/S (20%) compared with bypass (38%, P < .001), with significant differences in cardiac and respiratory complications (Table III). PTA/S had approximately half the rate of acute renal failure and need for bowel resection. Mortality in those undergoing bowel resection was significantly increased for all patients regardless of the revascularization method compared with those without a bowel operation (PTA/S, 25% vs 3.1%, P < .001; bypass, 54% vs 10%, P < .001). Length of stay was shorter after PTA/S than bypass, with a median of 5 days (range, 0-94 days) vs 11 days (range, 1-135 days; P < .001). Discharge to home was more common after PTA/S (87%) vs bypass (79%, P < .01).

Table III. Perioperative complications and length of stay after angioplasty, with or without stenting, compared with surgical repair for chronic and acute mesenteric ischemia from 2000 to 2006
ComplicationChronic mesenteric ischemiaAcute mesenteric ischemia
PTA/SSurgery aPbBypass onlyPbPTA/SSurgery aPbBypass onlyPb
Any complication, %20.239.7<.00138.4<00136.748.2<.00149.9<.001
Bowel resection, %3.08.0<.0016.6<.05. . .. . .. . .. . .. . .
Acute renal failure, %6.010.5<.019.7<.0511.418.4<.0116.8<.05
Acute MI, %3.04.8.133.6.615.07.6.104.4.73
Cardiac, %0.75.9<.0015.6<.0012.17.2<.0019.3<.001
Stroke, %00.7<.050.8<.051.00.3.110.3.24
PVD, %0.80.2.25.280.3 0.50.3.580.7.79
Respiratory, %0.35.3<.0015.7<.0011.15.7<.0018.8<.001
Hemorrhage, %1.33.4<.053.4<.052.42.7.743.1.59
LOS, median (range), d5(0-94)11(1-135)<.00111(1-135)<.0019(0-104)13(0-198)<.00114(1-127)<.001

LOS, Length of stay; MI, myocardial infarction; PTA/S, percutaneous transluminal angioplasty, with or without stenting; PVD, peripheral vascular disease.

aSurgery includes bypass, endarterectomy, or embolectomy.

bStatistical significance set at P < .01.

On multivariate analysis, mortality was still fivefold to sixfold higher with bypass compared with PTA/S (Table IV). Increasing age was also a predictor of death, with a 50% increased risk per decade of life. Comorbidities that were predictive of death included congestive heart failure and atrial fibrillation/flutter, with a greater than twofold increased risk for both. Hypertension was protective.

Table IV. Multivariate predictors of death after angioplasty, with or without stenting, compared with mesenteric bypass for chronic and acute mesenteric ischemia from 2000 to 2006
PredictorOR95% CIPa
Without comorbidities
Chronic mesenteric ischemia
Bypass (vs PTA/S)5.13.1-8.4<.001
Age (per decade)1.61.2-2.0<.001
Acute mesenteric ischemia
Bypass (vs PTA/S)2.21.5-3.3<.001
Age (per decade)1.31.1-1.6<.001
With comorbidities
Chronic mesenteric ischemia
Bypass (vs PTA/S)5.73.3-9.8<.001
Age (per decade)1.51.1-2.0<.01
Hypertension0.40.2-0.7<.001
Atrial fibrillation/flutter2.51.4-4.5<.01
Congestive heart failure2.81.5-5.3<.01
Acute mesenteric ischemia
Bypass (vs PTA/S)2.21.5-3.4<.001
Age (per decade)1.31.02-1.5<.05
Bowel resection3.62.4-5.4<.001
Atrial fibrillation/flutter2.21.3-3.4<.001

CI, Confidence interval; OR, odds ratio; PTA/S, percutaneous transluminal angioplasty, with or without stenting.

aStatistical significance set at P < .01.

AMI from 2000 to 2006 

Surgical revascularization for AMI consisted of 49% embolectomy, 44% bypass, and 7% endarterectomy. Patients undergoing revascularization for AMI tended to be older women with multiple comorbidities. Those undergoing PTA/S for AMI also had higher rates of comorbidities than those undergoing open surgical repair, including hypertension, peripheral vascular disease, coronary artery disease, atrial fibrillation/flutter, and chronic renal failure (Table I). Atrial fibrillation and flutter were more common for AMI than CMI, as expected (33% vs 16%, P < .001). Bowel resection occurred in 28% of patients undergoing PTA/S and 37% of those undergoing bypass (P < .05). In-hospital mortality was 16% after PTA/S and 39% after surgical repair for AMI (P < .001). Mortality was 49% for embolectomy, 28% for bypass, and 35% for endarterectomy. When comparison with PTA/S was limited to bypass, mortality was still significantly lower with PTA/S (P < .001). There was a trend for men to have a lower mortality than women after open repair (34% vs 41%, P = .07); however, mortality by gender was similar after PTA/S (16% vs 15%, P = .85). Mortality was again increased for both groups when bowel resection was performed during the same admission (bypass, 45% vs 17%, P < .001; PTA/S, 29% vs 11%, P < .001).

Overall morbidity for AMI was higher after bypass compared with PTA/S (Table III). Specifically, cardiac and respiratory complications were again significantly higher. Length of stay was shorter after PTA/S than bypass, with a mean of 9 days (range, 0-104 days) vs 14 days (range, 1-127; P < .001). Discharge disposition to home was similar, at 72% for PTA/S and 68% for bypass (P = .37).

Multivariate predictors of mortality for AMI included bypass vs PTA/S and age (Table IV). With comorbidities included, the need for a bowel resection and atrial fibrillation/flutter were also significant predictors. Bypass was associated with a greater than twofold increased risk of death, and the need for a bowel resection carried a greater than 3.5-fold increased risk. Bowel resection was included in the multivariate analysis for AMI (but not CMI) as a coexisting condition. Gender was not a significant predictor of mortality.

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Discussion 

Revascularization for CMI and AMI is increasingly being performed with PTA/S. PTA/S for CMI is associated with a lower in-hospital mortality rate, shorter length of stay, and fewer bowel resections. For AMI, bypass was typically done in more advanced cases requiring bowel resection, making comparison with PTA/S difficult. After controlling for the need for bowel resection, however, there was a lower mortality rate with PTA/S. Revascularization procedures for CMI are increasing overall, with a dramatic rise in PTA/S and a constant rate of surgical procedures, whereas revascularization for AMI is relatively constant, with PTA/S apparently replacing surgery in some cases.

The increase in revascularization procedures for CMI may be due to many reasons. There may be increasing awareness of the disease, particularly now that a minimally invasive treatment is available and being more widely used. The advancing age of the population may be contributing, although this would also be expected to demonstrate a rise in AMI as well unless the increase in elective procedures is preventing AMI. With the less invasive approach, treatment indications may be expanding to include patients previously considered to be at prohibitive risk for surgery. PTA/S patients in this series were older with greater comorbidity. In addition, indications may have expanded to include treatment of those with symptoms that are less severe or those in whom the diagnosis is in question. If this is the case, this may bias the results in favor of PTA/S, whereas treatment of those at prohibitive risk for surgery would potentially bias in favor of surgery. Finally, it is well documented that PTA/S is associated with a greater risk of restenosis and recurrent symptoms,15 which is certainly having some effect in the increase in overall CMI interventions. In addition, patients undergoing repeat intervention for restenosis may have a different risk for in-hospital mortality and could again influence the comparison of PTA/S with surgery.

Longitudinal follow-up is needed to determine whether PTA/S has any long-term benefit compared with surgery. Some have suggested that a strategy of initial PTA/S would allow for correction of the malnourished state so that the patient may more safely undergo surgical revascularization after the early onset of recurrent stenosis and symptoms before a severe deterioration in nutritional status.12, 23

The decline in surgical procedures for AMI appears to be primarily in those undergoing embolectomy, which is likely due to an increasing use of anticoagulation for dysrhythmias such as atrial fibrillation. A recent study from Mayo Clinic found an increase in rates of anticoagulation and a decrease in embolic strokes in patients with atrial fibrillation between 1980 and 2000.24

A recent review by Kougias et al15 summarized the largest series of PTA/S for CMI. They found a 30-day mortality rate of 3% and a restenosis rate of 28% at a mean follow-up of 2 years, with 27% undergoing repeat PTA/S. The mortality rate from large series of open revascularization for CMI ranged from 0% to 12%.1, 2, 3, 4, 5, 6, 7, 13, 14 The broad range reflects the small number of patients undergoing revascularization for CMI, even at large referral centers. Derrow et al8 reviewed the NIS database for surgical revascularization of CMI from 1993 to 1997 and found a mortality rate of 14.7%, which corresponds to our findings from a broader period using the same database.8 Therefore, the numbers from the current study better reflect the true risk of open surgical revascularization and demonstrate the potential benefit of PTA/S.

Mortality with revascularization for AMI is typically >50%.1, 5, 9, 10 We found that the surgical revascularization mortality rate was highest with embolectomy and lowest with bypass. This is likely due to the lack of an established collateral circulation with embolization. Because most believe PTA/S is inappropriate treatment for most cases of embolism, we focused on a comparison of PTA/S with bypass.

We found that the need for bowel resection was the primary predictor of death with AMI more so than the use of PTA/S vs bypass. Unlike CMI, the need for bowel resection with AMI likely reflects the severity of ischemia at the time of the vascular consultation rather than a complication of revascularization.9, 10 Given that resection was required in a much larger proportion of those undergoing bypass, the two cohorts are likely dissimilar, which biases the comparison in favor of PTA/S.

There is general agreement that in most cases of AMI, bowel viability needs to be inspected and resection performed as needed. The diagnosis of AMI is often made at laparotomy in an operating room setting that may not be amenable for angiography and intervention that may limit the broader application of this technology. Retrograde stenting of the superior mesenteric artery through an arteriotomy has been advocated as a means to provide rapid revascularization through the open abdomen at the time of laparotomy.18, 21, 22 We do not have the ability to determine whether percutaneous antegrade or open retrograde PTA/S was used in patients undergoing laparotomy in the NIS database and cannot comment on the potential merits of this approach.

With the expansion of operating room endovascular suites and the increasing use of rapid multiple row detector computed tomographic angiography for diagnosis, PTA/S may be used with greater frequency when the diagnosis is entertained before laparotomy. However, PTA/S would not be expected to obviate the need to inspect bowel viability.

Our study has several limitations. This is a retrospective study with clear selection bias in the choice of therapy. This is most evident in AMI, where more patients with advanced ischemia underwent bypass than PTA/S. Other factors that were unmeasured in addition to the need for bowel resection may have affected the decision to choose bypass rather than PTA/S. We do not have anatomic details about the number of vessels treated, lesion length, or stenosis vs occlusion, which are likely to impact revascularization strategy and could affect outcome.

The large numbers in this study (20% sample of nonfederal hospitals) obtained from hospital discharge data are the strength of the study. This is evidenced by a comparison with the recent review of the literature of mesenteric PTA/S by Kougias et al15 with a total of 292 patients that would represent a <5% sample of patients undergoing this procedure. Discharge databases such as NIS are subject to coding errors, however, which are highlighted by the 3% of patients who were coded as undergoing embolectomy for CMI. A nearly threefold higher percentage of CMI patients undergoing embolectomy had atrial fibrillation/flutter compared with those undergoing another method of repair. In addition, the diagnosis of CMI is often a difficult one and may be made without a complete workup, particularly when percutaneous therapy is attempted. We also cannot identify patients undergoing repeat mesenteric procedures.

The increasing number of endovascular procedures may be reflective of either of these and bias mortality in favor of PTA/S. The inability to definitively state whether a bowel resection is done at the time of mesenteric operation, during a “second look” procedure, before revascularization, or as a complication of the mesenteric operation is one more limitation of the NIS database. There is a variable for day of operation, but this was infrequently recorded and thus was an unreliable method to further clarify this.

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Conclusion 

There is a clear trend toward increasing use of PTA/S for CMI and AMI. PTA/S appears to be reasonable first-line therapy in selected patients, particularly in CMI, based on significantly lower in-hospital mortality and complications. Longitudinal data are needed to determine if this benefit is maintained over time. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

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Author contributions 


Conception and design: MS

Analysis and interpretation: MS, KG, AH, MW, FP

Data collection: KG

Writing the article: MS, KG

Critical revision of the article: MS, KG, AH, MW, FP

Final approval of the article: MS, KG, AH, MW, FP

Statistical analysis: MS, KG

Obtained funding: MS, KG

Overall responsibility: MS

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Appendix, (online only) 

Appendix, (online only). Table of International Classification of Diseases, 9th Revision (ICD-9) codes used for comorbidities and complications
ICD-9 Codes
Comorbidities
Hypertension401-405
Peripheral vascular disease440, 443
Coronary artery disease412-414
Cardiac dysrhythmias427
Atrial fibrillation/flutter427.3
Prior myocardial infarction412
Congestive heart failure428
Diabetes mellitus250
Chronic obstructive pulmonary disease491, 491, 492, 496
Chronic renal disease585, 586, V45.1, V56
Cerebrovascular disease433-438
Bowel resection45.5, 45.6, 45.7, 45.8, 45.9, 46.1, 46.2, 48.5
Complications
Acute renal failure584
Acute myocardial infarction410
Not elsewhere classified996-999
Stroke997.02
Cardiac997.1
Peripheral vascular997.2
Respiratory997.3
Hemorrhage998.11

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 This study was supported by a National Institutes of Health (NIH) T-32 grant #5T32HL007734 Harvard-Longwood Research Training in Vascular Surgery.

 Competition of interest: none.

 Additional material for this article may be found online at www.jvascsurg.org.

PII: S0741-5214(09)00611-9

doi:10.1016/j.jvs.2009.03.004

Journal of Vascular Surgery
Volume 50, Issue 2 , Pages 341-348.e1, August 2009

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