Does the Mode of Anaesthesia (General or Regional) Affect Survival and Complications Following Femoropopliteal and Femorodistal Bypass?

introductionFemoropopliteal and femorodistal bypasses are indicated in the management of severe claudication or critical limb ischaemia. The choice of type of anaesthesia between general anaesthesia (GA) and regional anaesthesia (RA; epidural/spinal) has remained controversial. The study aimed to compare the rates of graft failure, perioperative mortality, and other major complications (including graft failure) associated with GA versus RA for lower limb bypass revascularisation in patients presenting with significant peripheral arterial disease.

methodsAll patients who had femoropopliteal and femorodistal bypass at the vascular unit of Colchester Hospital between January 2016 and September 2018 were included. The primary outcome measure was survival, and secondary outcome measures were respiratory, wound, cardiac, and graft failure complications. Technical success was defined as a successful operation with demonstrated graft patency at discharge and up to 30 days of follow-up. Secondary outcome measures included respiratory, wound, and cardiac complications. Statistical analysis included descriptive statistics and tests of association using chi-square for graft failure outcomes and the Mann-Whitney U test for the length of stay. All analyses were done at a 5% level of significance.

resultsThere were 139 patients identified during the study period who fulfilled the inclusion criteria, of which 127 had complete records. The overall mortality and morbidity in this study were 1.6% and 14.229%, respectively. The proportion of patients who had ischaemic heart disease is almost threefold amongst those who had failed bypass compared to the successful bypass group (33.3% versus 11.9%, p = 0.018). A total of 65 patients received GA and 62 patients underwent RA; there were no significant differences in baseline preoperative comorbidities, postoperative mortality and complications, and length of stay. The majority (84%) of the patients who had RA had combined spinal and epidural (CSE) anaesthesia. The overall mortality and morbidity in this study were 1.6% and 14.2%, respectively. The proportion of patients with graft failure was 14.5% for GA versus 13.8% for RA (p = 0.914); there was no significant difference for conduit type, quality of vein conduit, the prevalence of heart failure and postoperative hypotensive episodes, redo-surgery, and major amputation, and length of stay (GA: 5.0, RA: 6.0, p = 0.854) did not differ significantly between the two groups. The proportion of patients who had ischaemic heart disease is almost threefold amongst those who had failed bypass compared to the successful bypass group (33.3% versus 11.9%, p = 0.018).

conclusionThe mode of anaesthesia, GA or the use of CSE RA in approximately half of the patients, did not influence survival, respiratory, cardiac, wound, graft failure, or length of stay in this study. There was a relationship between the presence of cardiac comorbidity and bypass failure, indicating a need for a standard care protocol to further optimise cardiac perioperative care to improve outcomes.