Symptomatic human immunodeficiency virus infection is associated with advanced presentation and perioperative mortality in patients undergoing surgery for peripheral arterial disease.
Symptomatic human immunodeficiency virus infection is associated with advanced presentation and perioperative mortality in patients undergoing surgery for peripheral arterial disease.
复制标题
DOI：
10.1016/j.jvs.2021.09.034
复制
发表时间：
2022-04
影响因子：
4.3
通讯作者：
Sachdev-Ost U
中科院分区：
文献类型：
--
作者：
Tran LM;Cong G;Eslami MH;Mailliard RB;Sachdev-Ost U
先前的研究表明，人类免疫缺陷病毒（HIV）患者发生心血管和外周动脉疾病（PAD）的风险增加。然而，慢性HIV感染对既存PAD患者和需要血管介入治疗的患者的影响尚不清楚。在本研究中，我们评估了接受血运重建或截肢的PAD患者（有或无HIV感染）在临床表现和围手术期结局方面的差异。使用国际疾病分类第9版和第10版临床修改代码识别国家住院患者样本（2003-2017年）中既往诊断为PAD并接受下肢血运重建或截肢的患者。从这一组中，患者被分为有和没有艾滋病毒感染者进行分析。在HIV感染（PWH）患者中，我们确定了额外的患者亚群：既往或当前诊断为HIV相关疾病（包括获得性免疫缺陷综合征）的患者（指定为症状性HIV）和未诊断为无症状性HIV感染的患者。进行倾向评分匹配以创建匹配的队列。对HIV感染者和未感染者的临床特征进行基于人群的比较分析。对匹配的队列进行了围手术期住院结局的单变量和多变量logistic回归分析。共确定了224，912名年龄在18至85岁之间的患者，他们被确诊为PAD并接受了下肢手术。在这些患者中，1264人（0.56%）也被诊断为艾滋病毒感染。有症状的PWH比未感染HIV的患者或无症状的PWH更容易出现严重肢体缺血（66.2%比46.3%和43.6%; P <0.01）。然而，无症状和有症状的PWH比匹配的未感染HIV的对照组更可能需要小截肢（7.5%和6.7%对2.6%; P <0.01）和大截肢（12.9%和27.4%对7.0%; P <0.01）。虽然调整后的多变量logistic回归分析表明，有症状的HIV感染是院内死亡率的一个重要的、独立的预测因子（比值比，2.46; 95%置信区间，1.37-4.40; P = .003），无症状PWH的围手术期死亡率与匹配的HIV未感染对照组相当。症状性PWH，包括患有获得性免疫缺陷综合征的患者，需要PAD相关手术的患者表现为更晚期的血管疾病，并且最有早期围手术期死亡的风险。然而，疾病控制良好的无症状PWH患者和未感染HIV的患者之间的表现和死亡率具有可比性。与未感染HIV的对照组相比，所有患有PAD的PWH患者更有可能接受下肢截肢。无症状、控制良好的HIV感染不应成为择期PAD相关手术的禁忌症，因为其死亡率与未感染HIV的对照组相似。然而，无论HIV疾病的严重程度如何，所有伴有PAD的PWH的保肢率可能较低。总之，这些发现可以改善这一高危人群中PAD的围手术期风险分层和手术管理。
Prior studies have demonstrated an increased risk of developing cardiovascular and peripheral arterial disease (PAD) in patients with human immunodeficiency virus (HIV). However, the effect of chronic HIV infection in patients with preexisting PAD and requiring vascular intervention is unclear. In the present study, we assessed the differences in clinical presentation and perioperative outcomes for patients with PAD who had undergone revascularization or amputation with and without HIV infection. International Classification of Diseases, 9th and 10th Revisions, Clinical Modification, codes were used to identify patients with a prior diagnosis of PAD who had undergone lower extremity revascularization or amputation in the National Inpatient Sample (2003–2017). From this group, the patients were divided for analysis into those with and without HIV infection. Of the patients with HIV infection (PWHs), we identified additional subsets of patients: those with any prior or current diagnosis of an HIV-related illness, including acquired immunodeficiency syndrome, designated as symptomatic HIV, and those without such a diagnosis, designated as asymptomatic HIV infection. Propensity score matching was performed to create matched cohorts. Population-based comparative analyses were performed of the clinical characteristics of the HIV-infected and HIV-uninfected groups. Univariate and multivariate logistic regression analyses of the perioperative in-hospital outcomes were performed on the matched cohorts. A total of 224,912 patients aged 18 to 85 years were identified who had been admitted with an established diagnosis of PAD and had undergone a lower extremity procedure. Of these patients, 1264 (0.56%) also had a diagnosis of HIV infection. Symptomatic PWHs were more likely to present with critical limb ischemia than were the HIV-uninfected patients or asymptomatic PWHs (66.2% vs 46.3% and 43.6%; P < .01). However, both asymptomatic and symptomatic PWHs were more likely to have required minor (7.5% and 6.7% vs 2.6%; P < .01) and major (12.9% and 27.4% vs 7.0%; P < .01) amputations than were matched HIV-uninfected controls. Although adjusted multivariate logistic regression analysis demonstrated symptomatic HIV infection to be a significant, independent predictor of in-hospital mortality (odds ratio, 2.46; 95% confidence interval, 1.37–4.40; P = .003), the perioperative mortality for the asymptomatic PWH was comparable to that of matched HIV-uninfected controls. Symptomatic PWHs, including patients living with acquired immunodeficiency syndrome, who had required a PAD-related procedure had presented with more advanced vascular disease and were most at risk of early perioperative mortality. However, the presentation and mortality between asymptomatic PWHs with well-controlled disease and HIV-uninfected patients were comparable. All PWHs with PAD were more likely to undergo lower extremity amputations than were HIV-uninfected matched controls. Asymptomatic, well-controlled HIV infection should not be a contraindication to elective PAD-related procedures because the mortality was similar to that of HIV-uninfected controls. However, the limb salvage rates might be lower for all PWHs with PAD, regardless of HIV disease severity. Taken together, these findings can improve perioperative risk stratification and surgical management of PAD in this high-risk population.
登录
查看更多内容
影响因子：
5.4
作者：
Alonso, Alvaro;Barnes, A. Elise;Marconi, Vincent
通讯作者：
Marconi, Vincent
DOI：
10.1001/jama.2017.17653
发表时间：
2017-11-28
期刊：
JAMA
影响因子：
--
作者：
Khera R;Angraal S;Couch T;Welsh JW;Nallamothu BK;Girotra S;Chan PS;Krumholz HM
通讯作者：
Krumholz HM
影响因子：
4.6
作者：
Hooker, Craig M.;Meguid, Robert A.;Brock, Malcolm V.
通讯作者：
Brock, Malcolm V.
影响因子：
3.5
作者：
Kim, Tanner, I;Brahmandam, Anand;Orion, Kristine C.
通讯作者：
Orion, Kristine C.
影响因子：
3.7
作者：
Kwiatkowska W;Knysz B;Arczyńska K;Drelichowska J;Czarnecki M;Gąsiorowski J;Karczewski M;Witkiewicz W
通讯作者：
Witkiewicz W