INTRODUCTION: Aortofemoral or aortoiliac bypasses (AFB/AIB) are considered the gold standard treatment for patients with aortoiliac occlusive disease. Myocardial infarction (MI) is a postoperative risk in AFB/AIB surgeries and preoperative stress testing (PST) is frequently utilized to inform operative planning and pre-operative risk discussions. The aim of this study is to assess the utility of PST in determining outcomes following AFB/AIB in patients with chronic limb threatening ischemia (CLTI). METHODS: This is a retrospective study from Vascular Quality Initiative (VQI) database. Patients undergoing AFB/AIB for CLTI during 2009-2023 were stratified by PST result. Primary outcomes included postoperative MI and 30-day mortality. Secondary outcomes included in-hospital death, in-hospital death/MI, postoperative respiratory complications, postoperative congestive heart failure (CHF), intensive care unit (ICU) stay >
three days, and one-year mortality. Logistic and Cox regressions were used for multivariate analyses. RESULTS: The study included two cohorts of patients: negative (N=1,809, 81.2%) and positive PST (N=420, 18.8%). The patients with positive PST had increased rate of postoperative MI compared to the patients with negative PST (6.7% vs. 2.9%, P<
.001). The rate of 30-day mortality was greater for patients with positive PST but the difference was not significant (3.8% vs. 2.9%, P=0.315). After adjusting for potential confounders, positive PST was associated with increased risk of postoperative MI (adjusted Odds Ratio=1.89 [95% Confidence Interval: 1.04-3.43], P=0.038). However, positive PST was not associated with 30-day mortality. Pulmonary complications, CHF and ICU stay >
three days were also not associated with preoperative stress test result. The overall survival rate at one-year was 93.3% and 92.0% for patients with negative and positive PSTs (P=0.343), respectively. After adjusting for potential confounders, postoperative MI was associated with increased hazards of death at one year (adjusted Hazard Ratio=3.62 [95% Confidence Interval: 2.21-5.92], P<
.001). CONCLUSION: This study emphasizes the important of appropriate preoperative planning. A positive stress test before open aortic reconstruction for aortoiliac occlusive disease is associated with increased risk of postoperative MI. Although this was not associated with increased risk of 30-day nor one-year mortality, the negative impact of MI on patient functionality, quality of life, and one-year death cannot be ignored.