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Published on: September 22, 2020
One-Year Readmission after Open and Endovascular Revascularization for Critical Limb Ischemia
Cassius Iyad Ochoa Chaar1, Navid Gholitabar1, Philip Goodney2
1Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT.
Insights
Open lower extremity revascularization for critical limb ischemia (CLI) is associated with lower readmission rates compared to endovascular procedures. Patients undergoing either procedure often require repeat revascularization during readmissions.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- Critical limb ischemia (CLI) management involves complex revascularization procedures.
- Readmissions and repeat interventions increase healthcare costs and reduce treatment value.
- Clinical equipoise exists regarding optimal revascularization strategies for CLI.
Purpose of the Study:
- To compare readmissions, repeat revascularization, and major amputation rates after open versus endovascular lower extremity revascularization.
- To analyze patient characteristics associated with different revascularization modalities.
- To assess 1-year outcomes including inpatient mortality.
Main Methods:
- Utilized the 2014 Nationwide Readmissions Database (NRD) for patient data.
- Selected a cohort undergoing lower extremity revascularization in January.
- Compared open and endovascular groups using International Classification of Diseases, Ninth Revision, Clinical Modification codes and procedural codes, adjusting for patient demographics and comorbidities (Charlson Comorbidity Index).
Main Results:
- Endovascular patients were older, more likely female, and had higher comorbidity scores.
- Endovascular revascularization had significantly higher readmission rates (49% vs. 33.7%) and mortality (10.4% vs. 5.3%).
- No significant difference was found in repeat revascularization or major amputation rates between groups; open revascularization was linked to decreased readmission.
Conclusions:
- Endovascular lower extremity revascularization for CLI is performed on older, sicker patients and is associated with higher 1-year readmission rates than open procedures.
- Patients undergoing revascularization, regardless of initial method, are likely to require at least one repeat revascularization during readmissions.
Background:
Lower extremity revascularization for critical limb ischemia (CLI) remains a subject of clinical equipoise. Readmissions and repeat lower extremity revascularization increase the cost of care and decrease the value of initial treatment. This study examines readmissions and repeat inpatient revascularization and major amputation up to 1 year after initial open and endovascular lower extremity revascularization.
Methods:
The 2014 Nationwide Readmissions Database (NRD) was reviewed. The NRD provides all subsequent readmissions of any hospitalization for the calendar year. A cohort of patients undergoing lower extremity revascularization in January only was selected based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were divided into open and endovascular groups. Readmissions for repeat lower extremity revascularization (RFR) were identified based on procedural codes. Open and endovascular lower extremity revascularization were compared in terms of patient characteristics as well as readmissions, RFR, major amputation, and inpatient mortality at 1 year. Risk-adjusted outcomes accounting for differences in age, gender, income, and Charlson Comorbidity Index (CCI) were derived using regression analysis.
Results:
There were 1,668 open and 1,410 endovascular lower extremity revascularizations. Patients in the endovascular group were significantly older (P < 0.01), more likely to be women (P < 0.01), and had higher CCI (P < 0.01). Patients undergoing endovascular lower extremity revascularization had significantly higher readmission rate (49 vs. 33.7, P < 0.01) and higher mortality (10.4 vs. 5.3, P < 0.01). Readmitted patients after endovascular lower extremity revascularization had significantly higher mean number of repeat readmissions compared to open lower extremity revascularization (2.49 ± 0.12 vs. 2.13 ± 0.08, P = 0.01). There was no difference in RFR (P = 0.82) or major amputation (P = 0.19). Open revascularization was independently associated with decreased readmission (odds ratio = 0.55 [0.43-0.71]) compared to endovascular. However, there was no significant association between the type of lower extremity revascularization and major amputation or RFR.
Conclusions:
Endovascular lower extremity revascularization for CLI is performed on older and sicker patients and seems to be associated with increased readmission at 1 year compared to open lower extremity revascularization. Regardless of the initial modality of treatment, patients are likely to undergo at least 1 revascularization during readmissions.
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