Sex Disparities in Infra-inguinal Vein Bypass for Peripheral Artery Disease

Abstract

Although studies demonstrate sex-based differences in peripheral arterial disease (PAD), contemporary outcomes in surgically managed PAD remains largely under-characterized. We sought to discern the differences in perioperative outcomes between males and females with PAD who received infra-inguinal vein bypasses. The infra-inguinal bypass Vascular Quality Initiative (VQI) registry was queried between 2010 and 2020. We evaluated patients with infra-inguinal vein bypasses for occlusive disease, excluding non-occlusive disease, asymptomatic, acute limb ischemia, and emergent procedures. Baseline demographics, comorbidities, prior medical and surgical management, and perioperative outcomes were compared between men and women using the χ2 analysis and t test. Socioeconomic status was defined using Distressed Community Index (DCI). Bypass patency at 1 year was compared between single-segment vein bypasses of the same inflow and outflow targets, using Kaplan-Meier analysis. We identified 28,845 infra-inguinal vein bypasses; 30.6% of patients were female. Female patients were older and had a higher portion of black race, non-ambulatory status, and disadvantaged socioeconomic DCI (Table I). Males had higher rates of smoking, chronic obstructive pulmonary disease, cardiac disease, and coronary percutaneous/bypass interventions. More women were on more likely to be taking P2Y inhibitors, possibly related to a significantly higher rate of prior lower extremity endovascular interventions (P < .001). Alternatively, males had higher rates of prior ipsilateral bypass. Men presented with less clinical disease severity, with a higher proportion of claudication in men vs rest pain in women. Females had a higher rate of popliteal bypass targets suggestive of proximal disease, whereas more males had tibial bypass targets suggestive distal disease (Table II). Women had a higher utilization of non-reversed GSV compared with men (24.2% vs 22.6%; P < .001). No significant differences were seen in total procedure time, blood loss, or postoperative infection. More males underwent postoperative amputation. Fewer women returned home or were ambulatory on discharge. Males were also more likely to be on aspirin and statin both prior to intervention and on discharge (P < .001). There was no significant differences between men and women in 5-year survival (74.6% vs 74.2%; P = .98) or 1-year primary patency in femoral-above knee popliteal (58.6% vs 58.0%; P = .720), femoral-below knee popliteal (57.2% vs 56.7%; P = .816), femoral-tibial (56.5% vs 57.7%; P = .520), or popliteal-tibial (58.0% vs 55.7%; P = .950) bypass. Females present with a unique demographic, socioeconomic, and PAD disease pattern, with diminished perioperative medical management and advanced clinical disease. Acknowledgment of these differences should guide increasing attention to screening programs, medical optimization, and post intervention disposition planning. Although less women were discharged on optimal medical management, bypass patency was similar to men at 1 year.Table ICategorical variables for patients receiving infra-inguinal vein bypassMaleFemaleP-valueDemographics Age, years66 ± 1067 ± 12<.001 Body mass index, kg/m227.7 ± 5.728.0 ± 6.9.042 Race<.001White82.2%76.7%Black13.8%19.7%Others4.0%3.6% Ambulatory status<.001Ambulatory95.5%93.5%Non-ambulatory4.5%6.5% DCI<.001Prosperous23.1%20.8%Comfortable21.3%20.3%Mid-tier20.7%19.4%At-risk18.3%19.6%Distressed16.7%19.9% Smoking history87.0%76%<.001 Chronic obstructive pulmonary disease24.6%26.3%<.001 Hypertension87.8%89.6%<.001 Diabetes mellitus52.6%49.0%.008 Coronary disease31.2%27.1%<.001 Heart failure17.1%16.9%.018 Peripheral endovascular42.9%47.9%<.001 Peripheral bypass25.3%23.6%.015 Minor amputation10.7%8.6%<.001 Percutaneous coronary22.6%20.1%<.001 Coronary bypass19.1%16.9%<.001 Aspirin74.3%73%.071P2Y inhibitor28.9%32.9%<.001 Statin75.1%71.7%<.001 Claudication26.6%21.0%<.001 Rest pain24.3%28.6% Tissue loss49.2%50.4%DCI, Disadvantaged Community Index. Open table in a new tab Table IIPerioperative outcomes for patients receiving infra-inguinal vein bypassMale, %Female, %P-valueBypass category<.001 Femoral-above knee popliteal13.319.8 Femoral-below knee popliteal31.635.1 Femoral-tibial42.235.3 Popliteal-tibial12.89.8Perioperative antibiotics82.779.7<.001SSI3.03.9<.002Postoperative amputation12.111.9<.001Discharge medications Aspirin86.684.7<.001 P2Y inhibitor41.645.1<.001 Statin83.979.2<.001Discharge status<.001 Home72.364.6 Rehab16.019.8 Nursing home10.914.5 Other0.81.1Discharge graft patency.002 Primary95.093.5 Primary-assisted2.53.1 Secondary1.72.2 Occluded0.81.2SSI, Surgical site infection. Open table in a new tab