# Relationship of intraoperative hypotension with major adverse cardiovascular events and acute kidney injury after pancreaticoduodenectomy

## TL;DR

This study shows that low blood pressure during surgery is linked to heart and kidney problems after pancreatic surgery, with different pressure thresholds affecting each organ.

## Contribution

The study identifies specific blood pressure thresholds and metrics that correlate with cardiovascular and kidney risks after pancreatic surgery.

## Key findings

- Intraoperative hypotension is associated with increased risk of MACE and AKI after pancreaticoduodenectomy.
- The association of MACE follows a J-shaped curve with a turning point at MAP around 65 mmHg.
- AKI risk increases progressively with decreasing MAP, with significant associations at thresholds below 60 mmHg.

## Abstract

Intraoperative hypotension (IOH) is a common concern during major surgery and is associated with end-organ injury. However, its specific impact on major adverse cardiovascular events (MACE) and acute kidney injury (AKI) following pancreaticoduodenectomy (PD) has not been well elucidated.

A retrospective cohort study was conducted, including 1846 patients who underwent PD between January 2018 and December 2023. Intraoperative mean arterial pressure (MAP) was recorded continuously via radial arterial catheterization. Restricted cubic spline models (RCS) were used to assess the associations of IOH with MACE and AKI. IOH was quantified using four exposure metrics: absolute maximum decrease (AMD), time under threshold (TIME), area under the threshold (AUT), and time-weighted average (TWA) to further analyse the association of MACE and AKI risk at the stratified threshold of MAP <60, 65, 70 mmHg.

Among 1,846 patients enrolled, 211 (11.4%) developed MACE and 52 (2.8%) developed postoperative AKI. Multivariable-adjusted RCS analysis revealed that AKI occurrence increased progressively with decreasing MAP, whereas MACE followed a J-shaped curve with the turn-point of MAP around 65 mmHg. Forest plot analysis found that AMD was the sole metric that maintained a statistically significant association with both MACE and AKI across all tested MAP thresholds (<70, 65, 60 mmHg). Regarding specific thresholds, AMD, AUT, and TWA were significantly associated with MACE at MAP <65 mmHg, whereas AMD, TIME, AUT, and TWA all demonstrated statistical significance for AKI at MAP <60 mmHg.

IOH is associated with MACE and AKI following PD. The higher MAP threshold for MACE (<65 mmHg) than for AKI (<60 mmHg) suggests the need for stricter hemodynamic goals to protect organs with differing ischemic thresholds.