Failure to Normalize Risk Profile of Spine Fusion Patients With Coronary Artery Disease Previously Treated With Percutaneous Stent Revascularization

Waleed Ahmad; Joshua Bell; Oscar Krol; Lara Passfall; Pramod Kamalapathy; Bailey Imbo; Peter Tretiakov; Tyler Williamson; Rachel Joujon-Roche; Kevin Moattari; Nicholas Kummer; Shaleen Vira; Virginie Lafage; Carl Paulino; Andrew J. Schoenfeld; Bassel Diebo; Hamid Hassanzadeh; Peter Passias

doi:10.14444/8392

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Table 1

Patient demographics.

Demographic	1–2 Stents n = 17,087	3–4 Stents n = 1578	Control (No Stents) n = 707,396	P Value
Age, y
<65	3087 (18.1%)	263 (16.7%)	198,451 (28.1%)	<0.001
65–69	3464 (20.3%)	322 (20.4%)	204,913 (29.0%)
70–74	4809 (28.1%)	452 (28.6%)	149,913 (21.2%)
75–79	3796 (22.2%)	360 (22.8%)	103,084 (14.6%)
80–84	1931 (11.3%)	181 (11.5%)	51,035 (7.2%)
Sex
Male	10,365 (60.7%)	1031 (65.3%)	297,591 (42.1%)	<0.001
Female	6722 (39.3%)	547 (34.7%)	409,805 (57.9%)	<0.001
Home discharge	4524 (26.5%)	408 (25.9%)	172,938 (24.4%)	<0.001
Comorbidities
Morbid obesity (BMI >30)	3876 (22.7%)	322 (20.4%)	72,924 (10.3%)	<0.001
PVD	4877 (28.5%)	459 (29.1%)	44,211 (6.2%)	<0.001
Chronic kidney disease	3604 (21.1%)	315 (20.0%)	42,801 (6.1%)	<0.001
CHF	4989 (29.2%)	413 (26.2%)	50,449 (7.1%)	<0.001
COPD	7476 (43.8%)	597 (37.8%)	164,959 (23.3%)	<0.001
Diabetes mellitus	8641 (50.6%)	783 (49.6%)	184,501 (26.1%)	<0.001
Hypertension	16,381 (95.9%)	1512 (95.8%)	439,450 (62.1%)	<0.001
Hyperlipidemia	16,019 (93.7%)	1483 (94.0%)	359,138 (50.8%)	<0.001
Substance Use
Alcohol	755 (4.4%)	65 (4.1%)	22,456 (3.2%)	<0.001
Smoking	8718 (51.0%)	790 (50.1%)	171,370 (24.2%)	<0.001
Surgical variables
1–2 Levels fusion	13,143 (76.9%)	1195 (75.7%)	550,669 (77.8%)	0.002
3–7 Levels fusion	3312 (19.4%)	316 (20.0%)	126,737 (17.9%)	<0.001
8+ Levels fusion	84 (0.5%)	10 (0.6%)	5262 (0.7%)	0.001
Decompression	2078 (12.2%)	220 (13.9%)	87,318 (12.3%)	0.120
Osteotomy	10 (0.1%)	0 (0.0%)	320 (0.0%)	0.505
Anterior cervical	5069 (29.7%)	459 (29.1%)	213,455 (30.2%)	0.233
Posterior cervical	1134 (6.6%)	107 (6.8%)	41,787 (5.9%)	<0.001
Combined cervical	236 (1.4%)	27 (1.7%)	9031 (1.3%)	0.152
Anterior thoracolumbar	30 (0.2%)	3 (0.2%)	2196 (0.3%)	0.005
Posterior thoracolumbar	458 (2.7%)	52 (3.3%)	22,169 (3.1%)	0.003
Combined thoracolumbar	18 (0.1%)	3 (0.2%)	1588 (0.2%)	0.005
Anterior lumbosacral	512 (3.0%)	42 (2.7%)	24,080 (3.4%)	0.004
Posterior lumbosacral	9208 (53.9%)	845 (53.5%)	374,636 (53.0%)	0.050
Combined lumbosacral	537 (3.1%)	56 (3.5%)	27,110 (3.8%)	<0.001

Abbreviations: BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; PVD, peripheral vascular disease.

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Table 2

Length of stay, reimbursement, and hospital cost between patients with 1 to 2 stents and controls.

Variable	1–2 Stents (n = 17,087)	Control (n = 707,396)	P Value	1–2 Stents vs Control, Adjusted β (95% CI)	P Value
LOS, d	4.19 ± 5.01	3.63 ± 4.30	<0.001	−0.16 (−0.22 ≤ β ≤ −0.10)	<0.001
Total reimbursement	$23,346.41 ± $15,645.75	$21,534.89 ± $15,880.22	<0.001	−$723.34 (−959.22 ≤ β ≤ −487.46)	<0.001
Total hospital cost	$93,496.48 ± $81,354.38	$87,427.30 ± $77,287.80	<0.001	$178.9 (−968.08 ≤ β ≤ 1325.88)	0.760

Abbreviations: LOS, length of stay; β, standardized beta coefficient.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 4

The 90-d postoperative outcomes between patients with 1 to 2 stents and controls.

90-d Medical Complications	1–2 Stents (n = 17,087)	Control (n = 707,396)	P Value	1–2 Stents vs Control, Adjusted OR (95% CI)	P Value
Major
Pulmonary embolus	124 (0.7%)	4599 (0.7%)	0.244	0.77 (0.63–0.91)	0.004
Pneumonia	469 (2.7%)	10,617 (1.5%)	<0.001	0.95 (0.86–1.04)	0.267
CVA	136 (0.8%)	3160 (0.4%)	<0.001	0.87 (0.73–1.04)	0.125
MI	232 (1.4%)	2518 (0.4%)	<0.001	1.87 (1.62–2.15)	<0.001
Sepsis	297 (1.7%)	6664 (0.9%)	<0.001	0.96 (0.85–1.09)	0.564
Death	105 (0.6%)	2112 (0.3%)	<0.001	1.00 (0.81–1.22)	0.984
Minor
AKI	528 (3.1%)	10,036 (1.4%)	<0.001	0.97 (0.88–1.06)	0.533
UTI	1095 (6.4%)	32,952 (4.7%)	<0.001	0.90 (0.84–0.96)	0.001
Wound complications	667 (3.9%)	20,181 (2.9%)	<0.001	0.99 (0.91–1.07)	0.826
Transfusion	482 (2.8%)	10,904 (1.5%)	<0.001	1.08 (0.98–1.19)	0.098
DVT	210 (1.2%)	7484 (1.1%)	0.034	0.76 (0.66–0.88)	<0.001
90-d Readmission	2605 (15.2%)	67,366 (9.5%)	<0.001	1.11 (1.06–1.16)	<0.001

Abbreviations: AKI, acute kidney injury; CVA, cerebrovascular accident; DVT, deep vein thrombosis; MI, myocardial infarction; UTI, urinary tract infection.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 3

The 30-d postoperative outcomes between patients with 1 to 2 stents and controls.

30-d Medical Complications	1–2 Stents (n = 17,087)	Control (n = 707,396)	P Value	1–2 Stents vs Control, Adjusted OR (95% CI)	P Value
Major
Pulmonary embolus	64 (0.4%)	1968 (0.3%)	0.023	0.84 (0.65–1.08)	0.189
Pneumonia	190 (1.1%)	3775 (0.5%)	<0.001	0.97 (0.83–1.12)	0.671
CVA	38 (0.2%)	874 (0.1%)	<0.001	0.76 (0.54–1.04)	0.105
MI	93 (0.5%)	776 (0.1%)	<0.001	2.15 (1.70–2.69)	<0.001
Sepsis	128 (0.7%)	2760 (0.4%)	<0.001	0.91 (0.75–1.09)	0.299
Death	33 (0.2%)	601 (0.1%)	<0.001	0.94 (0.64–1.33)	0.752
Minor
AKI	235 (1.4%)	4192 (0.6%)	<0.001	0.95 (0.83–1.09)	0.495
UTI	446 (2.6%)	11,275 (1.6%)	<0.001	0.94 (0.85–1.03)	0.194
Wound complications	383 (2.2%)	11,031 (1.6%)	<0.001	0.95 (0.86–1.06)	0.381
Transfusion	221 (1.3%)	3776 (0.5%)	<0.001	1.25 (1.08–1.44)	0.002
DVT	83 (0.5%)	2962 (0.4%)	0.201	0.74 (0.58–0.91)	0.007
30-d Readmission	1279 (7.5%)	29,761 (4.2%)	<0.001	1.09 (1.02–1.16)	0.006

Abbreviations: AKI, acute kidney injury; CVA, cerebrovascular accident; DVT, deep vein thrombosis; MI, myocardial infarction; UTI, urinary tract infection.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 5

The 30-d postoperative outcomes between patients with 3 to 4 stents and controls.

30-d Medical Complications	3–4 Stents (n = 1578)	Control (n = 707,396)	P Value	3-4 Stents vs Control, Adjusted OR (95% CI)	P Value
Major
Pulmonary embolus	5 (0.3%)	1968 (0.3%)	0.959	0.71 (0.25–1.53)	0.439
Pneumonia	16 (1.0%)	3775 (0.5%)	0.015	0.90 (0.52–1.43)	0.680
CVA	3 (0.2%)	874 (0.1%)	0.694	0.66 (0.16–1.72)	0.472
MI	9 (0.6%)	776 (0.1%)	<0.001	2.26 (1.08–4.14)	0.016
Sepsis	17 (1.1%)	2760 (0.4%)	<0.001	1.33 (0.79–2.09)	0.242
Death	2 (0.1%)	601 (0.1%)	0.891	0.62 (0.10–1.93)	0.497
Minor
AKI	15 (1.0%)	4192 (0.6%)	0.092	0.67 (0.38–1.07)	0.123
UTI	42 (2.7%)	11,275 (1.6%)	0.001	1.00 (0.72–1.34)	0.979
Wound complications	36 (2.3%)	11,031 (1.6%)	0.027	0.99 (0.70–1.37)	0.975
Transfusion	23 (1.5%)	3776 (0.5%)	<0.001	1.46 (0.94–2.16)	0.075
DVT	7 (0.4%)	2962 (0.4%)	1	0.67 (0.29–1.31)	0.300
30-d Readmission	108 (6.8%)	29,761 (4.2%)	<0.001	1.00 (0.82–1.22)	0.985

Abbreviations: AKI, acute kidney injury; CVA, cerebrovascular accident; DVT, deep vein thrombosis; MI, myocardial infarction; UTI, urinary tract infection.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 6

The 90-d postoperative outcomes between patients with 3 to 4 stents and controls.

90-d Medical Complications	3–4 Stents (n = 1578)	Control (n = 707,396)	P Value	3–4 Stents vs Control, Adjusted OR (95% CI)	P Value
Major
Pulmonary embolus	12 (0.8%)	4599 (0.7%)	0.698	0.81 (0.43–1.36)	0.460
Pneumonia	44 (2.8%)	10,617 (1.5%)	<0.001	0.99 (0.72–1.33)	0.953
CVA	11 (0.7%)	3160 (0.4%)	0.194	0.77 (0.40–1.33)	0.392
MI	26 (1.6%)	2518 (0.4%)	<0.001	2.26 (1.49–3.28)	<0.001
Sepsis	35 (2.2%)	6664 (0.9%)	<0.001	1.25 (0.87–1.73)	0.195
Death	18 (1.1%)	2112 (0.3%)	<0.001	1.88 (1.13–2.93)	0.009
Minor
AKI	50 (3.2%)	10,036 (1.4%)	<0.001	1.02 (0.76–1.35)	0.868
UTI	107 (6.8%)	32,952 (4.7%)	<0.001	1.00 (0.81–1.22)	0.997
Wound complications	55 (3.5%)	20,181 (2.9%)	0.152	0.90 (0.68–1.17)	0.456
Transfusion	48 (3.0%)	10,904 (1.5%)	<0.001	1.20 (0.89–1.59)	0.215
DVT	18 (1.1%)	7484 (1.1%)	0.843	0.71 (0.43–1.10)	0.151
90-d Readmission	220 (13.9%)	67,366 (9.5%)	<0.001	1.01 (0.87–1.17)	0.889

Abbreviations: AKI, acute kidney injury; CVA, cerebrovascular accident; DVT, deep vein thrombosis; MI, myocardial infarction; UTI, urinary tract infection.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 7

Length of stay, reimbursement, and hospital cost between patients with 3 to 4 stents and controls.

Variable	3–4 Stents (n = 1578)	Control (n = 707,396)	P Value	3–4 Stents vs Control, Adjusted β (95% CI)	P Value
LOS, d	4.41 ± 4.80	3.63 ± 4.30	<0.001	0.09 (−0.12 ≤ β ≤ 0.29)	0.404
Total reimbursement	$24,482.56 ± $16,592.60	$21,534.89 ± $15,880.22	<0.001	$449.88 (−301.56 ≤ β ≤ 1201.32)	0.241
Total hospital cost	$93,435.13 ± $79,140.99	$87,427.30 ± $77,287.80	0.003	$18.82 (−3629.25 ≤ β ≤ 3666.89)	0.992

Abbreviations: LOS, length of stay; β, standardized beta coefficient.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 8

The 30-d postoperative outcomes between patients with 3 to 4 stents and 1 to 2 stents.

30-d Medical Complications	3–4 Stent (n = 1578)	1–2 Stent (n = 17,087)	P Value	3–4 Stents vs 1–2 Stents, Adjusted OR (95% CI)	P Value
Major
Pulmonary embolus	5 (0.3%)	64 (0.4%)	0.885	0.81 (0.28–1.84)	0.662
Pneumonia	16 (1.0%)	190 (1.1%)	0.818	0.93 (0.53–1.51)	0.787
CVA	3 (0.2%)	38 (0.2%)	1	0.86 (0.21–2.39)	0.803
MI	9 (0.6%)	93 (0.5%)	1	1.06 (0.50–2.00)	0.863
Sepsis	17 (1.1%)	128 (0.7%)	0.204	1.48 (0.86–2.40)	0.131
Death	2 (0.1%)	33 (0.2%)	0.780	0.68 (0.11–2.23)	0.592
Minor
AKI	15 (1.0%)	235 (1.4%)	0.197	0.71 (0.40–1.15)	0.194
UTI	42 (2.7%)	446 (2.6%)	0.968	1.07 (0.77–1.46)	0.672
Wound complications	36 (2.3%)	383 (2.2%)	0.989	1.05 (0.72–1.45)	0.816
Transfusion	23 (1.5%)	221 (1.3%)	0.665	1.16 (0.73–1.76)	0.500
DVT	7 (0.4%)	83 (0.5%)	0.967	0.90 (0.38–1.81)	0.784
30-d Readmission	108 (6.8%)	1279 (7.5%)	0.379	0.93 (0.75–1.14)	0.496

Abbreviations: AKI, acute kidney injury; CVA, cerebrovascular accident; DVT, deep vein thrombosis; MI, myocardial infarction; UTI, urinary tract infection.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 9

The 90-d postoperative outcomes between patients with 3 to 4 stents and 1 to 2 stents.

90-d Medical Complications	3–4 Stents (n = 1578)	1–2 Stents (n = 17,087)	P Value	3–4 Stents vs 1–2 Stents, Adjusted OR (95% CI)	P Value
Major
Pulmonary embolus	12 (0.8%)	4599 (0.7%)	1	1.06 (0.55–1.85)	0.843
Pneumonia	44 (2.8%)	10,617 (1.5%)	0.983	1.05 (0.76–1.43)	0.752
CVA	11 (0.7%)	3160 (0.4%)	0.782	0.89 (0.45–1.58)	0.717
MI	26 (1.6%)	2518 (0.4%)	0.406	1.23 (0.80–1.82)	0.324
Sepsis	35 (2.2%)	6664 (0.9%)	0.201	1.31 (0.90–1.85)	0.137
Death	18 (1.1%)	2112 (0.3%)	0.021	1.94 (1.13–3.13)	0.010
Minor
AKI	50 (3.2%)	10,036 (1.4%)	0.923	1.07 (0.79–1.43)	0.650
UTI	107 (6.8%)	32,952 (4.7%)	0.601	1.13 (0.91–1.38)	0.266
Wound complications	55 (3.5%)	20,181 (2.9%)	0.450	0.91 (0.68–1.20)	0.518
Transfusion	48 (3.0%)	10,904 (1.5%)	0.670	1.12 (0.82–1.50)	0.467
DVT	18 (1.1%)	7484 (1.1%)	0.853	0.93 (0.55–1.47)	0.768
90-d Readmission	220 (13.9%)	67,366 (9.5%)	0.178	0.92 (0.79–1.07)	0.289

Abbreviations: AKI, acute kidney injury; CVA, cerebrovascular accident; DVT, deep vein thrombosis; MI, myocardial infarction; UTI, urinary tract infection.
Note: Values in bold denote statistical significance determined by P < 0.05.

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Table 10

Length of stay, reimbursement, and hospital cost between patients with 3 to 4 stents and 1 to 2 stents.

Variable	3–4 Stents n = 1578	1–2 Stents n = 17,087	P Value	3–4 Stents vs 1–2 Stents, Adjusted β (95% CI)	P Value
LOS, d	4.41 ± 4.80	4.19 ± 5.01	0.081	0.27 (0.03 ≤ β ≤ 0.52)	0.031
Total reimbursement	$24,482.56 ± $16,592.60	$23,346.41 ± $15,645.75	0.009	$1182.80 (405.47 ≤ β ≤ 1960.13)	0.003
Total hospital cost	$93,435.13 ± $79,140.99	$93,496.48 ± $81,354.38	0.977	−$211.60 (−4218.99 ≤ β ≤ 3795.79)	0.918

Abbreviations: LOS, length of stay; β, standardized beta coefficient.
Note: Values in bold denote statistical significance determined by P < 0.05.