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Sex differences in rate and outcomes of endovascular revascularization for chronic limb-threatening ischemia
Katerina Dangas1, Joseph M Kim2, Siling Li2
1Division of Cardiology, Richard and Susan Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA; Department of Internal Medicine, Massachusetts General Hospital, Boston, MA.
Insights
Women with chronic limb-threatening ischemia (CLTI) underwent endovascular revascularization less often than men but had better survival rates. However, females experienced greater declines in walking ability post-procedure.
Area of Science:
- Vascular Surgery
- Health Services Research
- Sex Differences in Medicine
Background:
- Chronic limb-threatening ischemia (CLTI), a severe form of peripheral arterial disease (PAD), necessitates prompt revascularization.
- Limited contemporary data exist regarding sex-based disparities in CLTI endovascular revascularization rates and patient outcomes.
- Understanding these differences is crucial for optimizing vascular care for all patients.
Purpose of the Study:
- To investigate sex differences in the rates of CLTI-related endovascular revascularization.
- To compare outcomes, including mortality, amputation, and functional status, between male and female patients undergoing revascularization for CLTI.
- To identify potential disparities in vascular care delivery and outcomes based on sex.
Main Methods:
- Retrospective cohort study utilizing Medicare Fee-for-Service claims from 2016-2023.
- Inclusion of all patients undergoing lower-extremity endovascular revascularizations for CLTI.
- Analysis of population rates, baseline characteristics, and outcomes (mortality, major/minor amputation, repeat revascularization, ambulatory status) stratified by sex, using Kaplan-Meier and Cox regression models.
Main Results:
- A total of 333,173 patients underwent revascularization; 44.0% were female, who were older and more likely to be from socioeconomically distressed communities.
- Female patients exhibited a significantly lower adjusted risk of mortality or major amputation (HR 0.91), major amputation (HR 0.82), and mortality (HR 0.93) compared to males.
- Despite better survival, females had a higher adjusted risk of ambulatory function decline post-revascularization (HR 1.06).
Conclusions:
- Females are revascularized for CLTI at lower rates than males and experience superior survival outcomes but a greater decline in ambulatory function.
- These findings highlight significant sex-based differences in CLTI management and outcomes.
- Further research into modifiable factors driving these sex disparities is essential to enhance vascular care quality for both men and women with PAD.
Background:
The mainstay of treatment for chronic limb-threatening ischemia (CLTI), late-stage peripheral artery disease, is prompt revascularization. However, contemporary data on sex differences in CLTI-related endovascular revascularization rates and outcomes remain limited.
Methods:
This retrospective cohort study used a 100% sample of Medicare fee-for-service claims from 2016 to 2023. We identified patients undergoing lower extremity endovascular revascularizations for CLTI. Male and female sex was the exposure. Population rates of CLTI-related endovascular revascularization were calculated by sex. Baseline characteristics were compared using standardized mean differences. The primary outcome, a composite of major amputation and death, was analyzed using Kaplan-Meier methods and multivariable Cox regression models adjusted for demographics, comorbidities, revascularization modality, disease severity, and other mediators. Nondeath outcomes included major amputation, minor amputation, repeat revascularization, and worsening of ambulatory status.
Results:
Among 333,173 patients undergoing endovascular revascularization for CLTI from 2016 to 2023, 146,644 (44.0%) were female. Females were older (75.7 years vs 73.3 years) and more likely to be Black and from socioeconomically distressed communities. Compared with males, female patients had a lower adjusted risk of mortality or major amputation (hazard ratio [HR], 0.91; 95% CI, 0.90-0.92; P < .0001), major amputation (HR, 0.82; 95% CI, 0.81-0.84; P < .0001), and mortality (HR, 0.93; 95% CI, 0.92-0.94; P < .0001). However, female patients were more likely to experience restriction in ambulatory function after revascularization (HR, 1.06; 95% CI, 1.05-1.08; P < .0001).
Conclusions:
Females underwent CLTI endovascular revascularization at lower rates than males and experienced lower risks of mortality and major amputation, with higher rates of ambulatory decline. Continued investigation into modifiable drivers of sex differences can improve the quality of vascular care for both men and women with peripheral arterial disease.
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