A Systematic Review and Meta-analysis of the Impact of Obesity on Patients Undergoing Lower Extremity Revascularization.

OBJECTIVE: This review aims to assess the impact of obesity on clinical outcomes for peripheral arterial disease patients undergoing endovascular or open lower extremity revascularization surgery. METHODS: A systematic search strategy of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was conducted. Included studies compared obese and non-obese cohorts with peripheral arterial disease undergoing endovascular or open lower extremity revascularization. The outcomes included mortality, major adverse cardiovascular events, major adverse limb events, surgical site infections, endovascular access site complications, and perioperative complications. RESULTS: 8 studies were included which detailed 171,648 patients. Obese patients (body mass index ≥30) were more likely to be women, diabetic, and have more cardiovascular comorbidities despite being younger. There was no association between obesity and peripheral arterial disease severity. Obesity was associated with an overall 22% decreased mortality risk after lower extremity revascularization (RR 0.78, 95% CI [0.71, 0.85], p<.001, I2=0%, GRADE: very low quality). Subgroup analysis by intervention type showed similar findings (Endovascular RR 0.79, 95% CI [0.71, 0.87], p<.001, I2=0%; Open RR 0.70, 95% CI [0.51, 0.95], p=.024, I2=43%). Obesity was associated with a 14% decreased risk in major adverse cardiovascular events for open surgery only (RR 0.86, 95% CI [0.76, 0.98], p=.021, I2=0%, GRADE: very low quality). Obesity was associated with an increased risk for surgical site infections pooled across intervention types (RR 1.69, 95% CI [1.34, 2.14], p<.001, I2=78%, GRADE: very low quality). There was no association between obesity and major adverse limb events (RR 1.02, 95% CI [0.93, 1.11], p=.73, I2=15%, GRADE: very low quality) or endovascular access site complications (RR 1.11, 95% CI [0.76, 1.63], p=.58, I2=86%, GRADE: very low quality). Pooled perioperative complications did not differ between obese and non-obese cohorts (RR 1.04, 95% CI [0.84, 1.28], p=.73, I2=92%, GRADE: very low quality). CONCLUSIONS: Obesity was associated with reduced mortality risk in both endovascular and open surgery while a reduction in major adverse cardiovascular events was only observed in open surgery. There is additionally an increased risk for surgical site infections in obese individuals. Obesity was not associated with major adverse limb events, endovascular access site complications, or perioperative complications. The GRADE quality of evidence is very low. This review suggests a survival advantage in obese patients with peripheral arterial disease. Future studies may focus on prospectively investigating the impact of obesity on peripheral arterial disease outcomes. A nuanced evaluation of body mass index as a preoperative risk factor is warranted.