Gender Disparities in Presentation, Operative Characteristics, and Clinical Outcomes After Lower Extremity Bypass for Peripheral Artery Disease

Abstract

Despite data suggesting greater rates of functional decline and worse clinical outcomes for women compared with men after invasive treatment of peripheral artery disease (PAD), women are underrepresented in contemporary PAD studies. We used Vascular Quality Initiative (VQI) data to evaluate gender differences in presentation, treatment, and clinical outcomes after lower extremity bypass (LEB) for PAD. Patients with data in the VQI database who had undergone LEB for claudication or chronic limb-threating ischemia (CLTI) from 2010 to 2019 were included. Descriptive statistics and competing risks survival analyses were performed. A total of 36,289 patients (33% female) had undergone LEB during the study period. Compared with men, the women were more likely to be older (mean age, 68 ± 12 years vs 66 ± 11 years), black (21% vs 15%), and diabetic (53% vs 51%; P < .001 for all). Women were also more likely to have a preoperative ankle brachial index of <0.40 (38% vs 30%; P < .001) and CLTI (75% vs 71%; P < .001) compared with men (Table I). The women were less likely to have undergone LEB to the tibial/peroneal arteries (35% vs 44%; P < .001) or a single segment vein graft (47% vs 54%; P < .001). Despite the shorter operative times and less blood loss, the women had longer hospital stays (mean, 6.4 ± 11.3 days vs 5.8 ± 8.2 days; P < .001) and greater rates of major adverse cardiovascular events (4.2% vs 3.7%; P < .001) compared with the men (Table II). At discharge, the women were less likely to be independently ambulatory (35% vs 42%; P < .001) and less likely to be prescribed a statin (78% vs 82%; P < .001; Table II). The overall 2-year cumulative incidence of major adverse limb events (MALE; major amputation, graft revision/thrombectomy, occlusion) was 47.7% (95% confidence interval, 46.6%-48.7%). In a hierarchical multivariable model that included age, diabetes, race, renal failure, previous bypass, CLTI, and tibial/peroneal distal target, female gender was significantly and independently associated with MALE (hazard ratio, 1.17; 95% confidence interval, 1.11-1.24; Figs 1 and 2). Women undergoing LEB for PAD have more advanced disease at surgery, worse cardiovascular outcomes, and a greater risk of MALE compared with men, despite having more proximal graft targets and shorter operative times. A better understanding of gender differences is critical for improving outcomes and providing optimal care for women with PAD.Table IBaseline patient characteristicsCharacteristicMale (n = 24,301)Female (n = 11,988)P valueAge, years66.3 ± 10.667.7 ± 11.7<.001Black race3729 (15)2539 (21)<.001Current smoker10,219 (42)4445 (37)<.001Diabetes12,325 (51)6349 (53)<.001Hypertension21,427 (88)10,736 (90)<.001Coronary artery disease11,101 (46)4553 (38)<.001Preoperative statin18,087 (75)8545 (72)<.001Preoperative ABI <0.45362 (30)3395 (38)<.001Critical limb ischemia17,014 (71)8932 (75)<.001ABI, Ankle brachial index.Data presented as mean ± standard deviation or number (%). Open table in a new tab Table IIOperative characteristics and short-term outcomesVariableMale (n = 24,301)Female (n = 11,988)P valueOperative characteristics<.001 Tibial/peroneal graft recipient10,610 (44)4202 (35) Single segment vein graft13,202 (54)5668 (47) Operative time, minutes241 ± 113233 ± 111Short-term outcomes<.001 Postoperative LOS, days5.8 ± 8.26.4 ± 11.3 Death, MI, or stroke before DC894 (3.7)507 (4.2) Major adverse limb event before DC1371 (5.7)826 (6.9) Independently ambulatory at DC10,070 (42)4153 (35) Statin on DC19,858 (82)9307 (78)LOS, Length of stay; MI, myocardial infarction.Data presented as number (%) or mean ± standard deviation. Open table in a new tab Fig 2Competing risks regression for major adverse limb events (MALE) stratified by gender.View Large Image Figure ViewerDownload Hi-res image Download (PPT)