The comprehensive risk assessment for bypass (CRAB) facilitates efficient perioperative risk assessment for patients with critical limb ischemia

Andrew J. Meltzer, Ashley Graham, Peter H. Connolly, Ellen C. Meltzer, John K Karwowski, Harry L. Bush, Darren B. Schneider

Research output: Contribution to journalArticle

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Abstract

Objective: Specific perioperative risk assessment models have been developed for bariatric, pancreatic, and colorectal surgery. A similar instrument, specific for patients with critical limb ischemia (CLI), could improve patient-centered clinical decision making. We describe a novel tool to predict 30-day major morbidity and mortality (M&M) after bypass surgery for CLI. Methods: Data for 4985 individuals from the 2007 to 2009 National Surgical Quality Improvement Program were used to develop and internally validate the model. Outcome measures included mortality, major morbidity, and a composite end point (M&M). M&M included mortality and the most severe postoperative morbidities that were highly associated with death (eg, sepsis and major cardiopulmonary complications). More than 30 preoperative factors were tested for association with 30-day mortality, major morbidity, and M&M. Significant predictors in multivariate models were assigned integer values (points), which were added to calculate a patient's Comprehensive Risk Assessment For Bypass (CRAB) score. Performance was assessed (C-index) across all outcome measures and compared with other general tools (American Society of Anesthesiologists class, Surgical Risk Scale) and existing CLI-specific survival prediction models (Finnvasc score, Edifoligide for the Prevention of Infrainguinal Vein Graft Failure [PREVENT III] score) on a distinct validation sample (n = 1620). Results: In the derivation data set (n = 3275), the 30-day mortality rate was 2.9%. The rate of any major morbidity was 19.1%. The composite end point M&M occurred in 10.1%. Significant predictors of M&M by multivariate analysis included age >75 years, prior amputation or revascularization, tissue loss, dialysis dependence, severe cardiac disease, emergency operation, and functional dependence. Applied to a distinct validation sample of 1620 patients, higher CRAB scores were significantly associated with higher rates of mortality, all major morbidities, and M&M (P <.0001). Comparison with other models by assessment of area under the receiver-operating characteristic curve revealed the CRAB was a more accurate predictor of mortality, all major morbidity, and M&M. Conclusions: The CRAB is a CLI-specific, risk assessment instrument derived from multi-institutional American College of Surgeons-National Surgical Quality Improvement Program surgical outcomes data that out-performs existing prognostic risk indices in the prediction of clinically significant adverse events after bypass surgery. Use of the CRAB as a risk assessment tool provides an evidence basis for patient-centered clinical decision making and may have a role in identifying patients at higher risk for surgical revascularization in whom an endovascular approach is preferable.

Original languageEnglish (US)
Pages (from-to)1186-1195
Number of pages10
JournalJournal of Vascular Surgery
Volume57
Issue number5
DOIs
StatePublished - May 2013
Externally publishedYes

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Ischemia
Extremities
Morbidity
Mortality
Quality Improvement
Outcome Assessment (Health Care)
Colorectal Surgery
Bariatric Surgery
Amputation
ROC Curve
Dialysis
Veins
Heart Diseases
Sepsis
Emergencies
Multivariate Analysis
Transplants
Survival

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

The comprehensive risk assessment for bypass (CRAB) facilitates efficient perioperative risk assessment for patients with critical limb ischemia. / Meltzer, Andrew J.; Graham, Ashley; Connolly, Peter H.; Meltzer, Ellen C.; Karwowski, John K; Bush, Harry L.; Schneider, Darren B.

In: Journal of Vascular Surgery, Vol. 57, No. 5, 05.2013, p. 1186-1195.

Research output: Contribution to journalArticle

Meltzer, Andrew J. ; Graham, Ashley ; Connolly, Peter H. ; Meltzer, Ellen C. ; Karwowski, John K ; Bush, Harry L. ; Schneider, Darren B. / The comprehensive risk assessment for bypass (CRAB) facilitates efficient perioperative risk assessment for patients with critical limb ischemia. In: Journal of Vascular Surgery. 2013 ; Vol. 57, No. 5. pp. 1186-1195.
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AU - Karwowski, John K

AU - Bush, Harry L.

AU - Schneider, Darren B.

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N2 - Objective: Specific perioperative risk assessment models have been developed for bariatric, pancreatic, and colorectal surgery. A similar instrument, specific for patients with critical limb ischemia (CLI), could improve patient-centered clinical decision making. We describe a novel tool to predict 30-day major morbidity and mortality (M&M) after bypass surgery for CLI. Methods: Data for 4985 individuals from the 2007 to 2009 National Surgical Quality Improvement Program were used to develop and internally validate the model. Outcome measures included mortality, major morbidity, and a composite end point (M&M). M&M included mortality and the most severe postoperative morbidities that were highly associated with death (eg, sepsis and major cardiopulmonary complications). More than 30 preoperative factors were tested for association with 30-day mortality, major morbidity, and M&M. Significant predictors in multivariate models were assigned integer values (points), which were added to calculate a patient's Comprehensive Risk Assessment For Bypass (CRAB) score. Performance was assessed (C-index) across all outcome measures and compared with other general tools (American Society of Anesthesiologists class, Surgical Risk Scale) and existing CLI-specific survival prediction models (Finnvasc score, Edifoligide for the Prevention of Infrainguinal Vein Graft Failure [PREVENT III] score) on a distinct validation sample (n = 1620). Results: In the derivation data set (n = 3275), the 30-day mortality rate was 2.9%. The rate of any major morbidity was 19.1%. The composite end point M&M occurred in 10.1%. Significant predictors of M&M by multivariate analysis included age >75 years, prior amputation or revascularization, tissue loss, dialysis dependence, severe cardiac disease, emergency operation, and functional dependence. Applied to a distinct validation sample of 1620 patients, higher CRAB scores were significantly associated with higher rates of mortality, all major morbidities, and M&M (P <.0001). Comparison with other models by assessment of area under the receiver-operating characteristic curve revealed the CRAB was a more accurate predictor of mortality, all major morbidity, and M&M. Conclusions: The CRAB is a CLI-specific, risk assessment instrument derived from multi-institutional American College of Surgeons-National Surgical Quality Improvement Program surgical outcomes data that out-performs existing prognostic risk indices in the prediction of clinically significant adverse events after bypass surgery. Use of the CRAB as a risk assessment tool provides an evidence basis for patient-centered clinical decision making and may have a role in identifying patients at higher risk for surgical revascularization in whom an endovascular approach is preferable.

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