Gender Disparities in Presentation, Treatment, and Outcomes of Critical Limb Ischemia

Abstract

Women with peripheral artery disease (PAD) experience higher rates of functional decline and may have worse clinical outcomes after invasive treatment for PAD compared to men. Despite this, women remain under-represented in contemporary PAD studies. We aim to use National Surgical Quality Improvement Program data to better understand differences in presentation, treatment, and short-term outcomes for women compared to men undergoing lower extremity (LE) revascularization for critical limb ischemia (CLI). We included 2018 patients. The National Surgical Quality Improvement Program database includes 30-day outcomes for inpatient operations at participating hospitals. Descriptive statistics and multivariable analyses were performed. There were a total of 32,902 LE interventions, of which 22,111 (67%) were for patients with CLI (rest pain or tissue loss). Women were significantly more likely to have CLI on presentation (71% vs 65%; P < .001) compared to men. In the cohort of patients undergoing LE intervention for CLI, women were more likely to be older (mean, 70 ± 12 years vs 68 ± 11 years; P < .001), black (25% vs 18%; P < .001), and hypertensive (86% vs 82%; P < .001), and less likely to be smokers (31% vs 38%; P < .001), on a statin medication (69% vs 71%; P < .001), or functionally independent (84% vs 89%; P < .001). Women were more likely to have a preoperative ankle-brachial index of <0.4 (20% vs 16%; P < .001) compared to men (Table I). Women with CLI were more likely to undergo endovascular intervention compared to men (44% vs 38%; P < .001) and were less likely to have distal/tibial artery revascularization (Table I). Women who underwent open operations had a higher risk of surgical site infection (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.3-1.6) and 30-day reintervention (OR, 1.2; 95% CI, 1.01-1.4) compared to men (Table II). Men with CLI who underwent endovascular intervention were more likely to undergo a major amputation within 30 days compared to women (OR, 1.3; 95% CI, 1.1-1.6). Overall, women had a higher risk of postoperative myocardial infarction (MI) and death compared to men (OR, 1.2; 95% CI, 1.02-1.4). Women undergoing LE revascularization for CLI are older, present with more advanced ischemia, and are more likely to undergo endovascular intervention compared to men. Despite increased use of less invasive strategies to treat CLI, women have higher rates of 30-day death and MI. Women with cardiovascular risk factors may benefit from more aggressive screening and medical treatment for PAD in order to mitigate the negative consequences of CLI.Table IBaseline patient and operative characteristicsFemale n = 8441Male n = 13,670P valueAge in years, mean (SD)70 (12)68 (11)<.001Race<.001 White4964 (59%)8944 (65%) Black or African American2078 (25%)2416 (18%) Other/unknown1399 (17%)2310 (17%)Diabetes4536 (54%)7619 (56%).004Hypertension7238 (86%)11,262 (82%)<.001Dialysis828 (10%)1450 (11%).06Smoking2635 (31%)5121 (38%)<.001Preoperative aspirin6804 (81%)10,974 (81%).55Preoperative statin5763 (69%)9684 (71%)<.001Preoperative beta-blocker5104 (61%)8369 (62%).23Preoperative function status<.001 Independent7122 (84%)12,196 (89%) Partially dependent1148 (14%)1256 (9%) Totally dependent118 (1%)134 (1%)Preoperative ABI <0.41698 (20%)2239 (16%)<.001Prior ipsilateral intervention3401 (40.3%)5146 (37.6%)<.001Open Intervention4717 (56%)8531 (62%)<.001 Operation type<.001Femoral popliteal bypass2623 (56%)3997 (47%)Femoral distal bypass1521 (32%)3152 (37%)Popliteal distal bypass435 (9%)1060 (13%)Femoral endarterectomy51 (1%)105 (1%) Conduit<.001Single segment vein2309 (49%)4411 (52%)Prosthetic/spliced vein2270 (48%)3798 (45%)Endovascular intervention3724 (44%)5139 (38%)<.001 Operation type<.001Femoral/popliteal angioplasty/stent2831 (77%)3362 (66%)Tibial angioplasty/stent867 (23%)1739 (34%)Operative time in minutes, mean (SD)186 (117)200 (121)<.001ABI, Ankle-brachial index; SD, standard deviation. Open table in a new tab Table IIThirty-day outcomesOpenEndovascularFemale n = 4717Male n = 8531P valueFemale n = 3724Male n = 5139P valueMyocardial infarction183 (3.9%)287 (3.3%)0.1284 (2.3%)92 (1.8%).12Surgical site infection496 (10.5%)639 (7.5%)<.00151 (1.4%)61 (1.2%).45Reintervention290 (6.1%)449 (5.3%)0.034152 (4.1%)258 (5.0%).038Major amputation209 (4.4%)375 (4.4%)0.93162 (4.4%)296 (5.8%).003Death77 (1.6%)119 (1.4%)0.2855 (1.5%)69 (1.3%).60 Open table in a new tab