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

Background 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. Methods 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. Results 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. Conclusion 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.