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PVSS21. Improved Outcomes in Mildly Obese Vascular Surgery Patients: The Obesity Paradox

Eleftherios S. Xenos, Daniel L. Davenport, Nick Abedi, David J. Minion, Patrick Hosakawa, Jacob Radford, Eric D. Endean.
University of Kentucky, Lexington, Ky.

OBJECTIVES: Mild obesity may have a protective effect against some diseases, termed an “obesity paradox”. This study examined the effect of body mass index (BMI) on surgical 30-day morbidity and mortality in patients undergoing vascular surgical procedures.

METHODS: As part of the National Surgical Quality Improvement Program (NSQIP), demographic and clinical risk variables, mortality, and 22 defined complications (morbidity) were obtained over 3 years from vascular services at 14 medical centers. At each medical center, patients from the operative schedule were systematically enrolled according to NSQIP protocols. Outcomes and risk variables were compared across NIH-defined obesity classes using analysis of variance and means comparisons. Logistic regression was used to control for other risk factors.

RESULTS: Vascular procedures in 7,543 patients included lower extremity revascularization (24.5%), aneurysm repair (17.4%), cerebrovascular procedures (17.3%), amputations (9.4%), and “other” procedures (31.3%). In the entire cohort, there were 1,659 (22.0%) patients with complications and 295 (3.9%) deaths. Risk factors of hypertension and diabetes increased with BMI (p<0.05) as expected; smoking, disseminated cancer and stroke decreased (p<0.01). Twenty other risk factors, as well as mortality and morbidity [Figure 1], had “U”-shaped distributions with the highest incidence in underweight and/or morbidly obese extremes but reduced minimums in overweight or obese I classes. After controlling for age, gender and operation type, mortality risk remained lowest in obese-I patients (Odds ratio 0.63, p=0.023) while morbidity risk was highest in morbidly obese patients (Odds ratio 1.70, p=0.0003), primarily due to wound infection.

CONCLUSIONS: Underweight patients have poorer outcomes and morbid obesity is associated with increased morbidity. Mildly obese patients have reduced co-morbid illness, surprisingly even less than normal-class patients, with correspondingly reduced mortality. Mild obesity is not a risk factor for vascular surgery and confers an outcome advantage.

Figure 1. The Influence of Obesity Class on Morbidity and Mortality