Predictors of surgical site infection following infrainguinal bypass surgery: An analysis of the Vascular Quality Initiative data.

Abstract

Surgical site infection (SSI) is a common complication after infrainguinal bypass (IIB) in patients with peripheral artery disease, leading to significant morbidity, including prolonged hospital stays, increased readmission rates, graft failure, and mortality. Despite advances in aseptic techniques, SSI continues to impact patient outcomes, driven by a complex interplay of patient-specific and procedural factors. This study aims to identify predictors of postoperative SSI in patients undergoing IIB providing insights into potentially modifiable risk factors. We performed a retrospective analysis of all patients undergoing IIB for peripheral artery disease in the Vascular Quality Initiative database from 2010 to 2024. Patients with concomitant ipsilateral major amputation, suprainguinal bypass, acute limb ischemia, or aneurysmal disease were excluded. Multivariable logistic regression was used to identify risk factors associated with postoperative SSI. Of 59,221 patients undergoing IIB, 1857 (3.1%) developed SSI. Patients with SSI were more likely to be female, obese, and have chronic kidney disease or congestive heart failure (CHF). Urgent procedures, longer operative times, intraoperative blood transfusions, autogenous grafts, and below-knee bypasses were also more common in the SSI group. Multivariable analysis identified several significant predictors of SSI. Among patient factors, non-U.S. insurance (odds ratio [OR]: 2.84; 95% confidence interval [CI]: 1.43-5.65; P = .003) and obesity (body mass index [BMI] 25-29.9: OR: 1.43, 95% CI: 1.09-1.88, P = .01; BMI 30-40: OR: 1.64, 95% CI: 1.21-2.21, P < .001; BMI ≥40: OR: 2.22, 95% CI: 1.57-3.13, P < .001) were associated with an increased risk of SSI. Rest pain (OR: 1.23; 95% CI: 1.01-1.49; P = .04) and tissue loss (OR: 1.67; 95% CI: 1.38-2.03; P<.001) were also associated with increased risks of SSI. Comorbidities, including untreated chronic obstructive pulmonary disease (OR: 1.21; 95% CI: 1.01-1.44; P = .04), severe CHF (OR: 1.89; 95% CI: 1.13-3.14; P = .01), untreated diabetes mellitus (DM) (OR: 1.32; 95% CI: 1.02-1.70; P = .03), and end-stage renal disease (OR: 1.83; 95% CI: 1.01-3.33; P = .046), were significantly associated with SSI. Perioperative factors such as intraoperative blood transfusion (OR: 2.28; 95% CI: 2.00-2.59; P < .001), prolonged operative time ≥150 minutes (OR: 1.51; 95% CI: 1.20-1.89; P < .001), and ≥300 minutes (OR: 1.95; 95% CI: 1.50-2.54; P < .001) increased the risk of SSI. Protective factors included medication-controlled DM (OR: 0.75; 95% CI: 0.58-0.97; P < .03), preoperative antibiotics (OR: 0.74; 95% CI: 0.64-0.85; P < .001), prosthetic grafts (OR: 0.85; 95% CI: 0.74-0.99; P = .03), and using chlorhexidine (CHG) or iodine alone vs CHG-iodine combined for skin preparation (CHG: OR: 0.49, 95% CI: 0.34-0.69, P < .001; iodine: OR: 0.52, 95% CI: 0.33-0.84, P = .007). This study confirms several risk factors for SSI including increased SSI risk with higher BMI, chronic obstructive pulmonary disease, CHF, untreated DM, rest pain or tissue loss presentation, intraoperative blood transfusion, and prolonged operative time. Protective factors, including preoperative antibiotic use, and medication-controlled DM and hypertension underscore the importance of optimizing perioperative care to reduce SSI risk. These findings highlight opportunities for targeted interventions and personalized risk stratification to reduce SSI and improve patient outcomes.