A Systematic Review of Literature to Assess the Role and Utilization of Palliative Care in Vascular Surgery Patients

Vascular surgeons take care of the most medically complex patients, who are at high risk of mortality. Most surgeons are not aware of the full scope of palliative care (PC) consultations and underutilize their services. The purpose of this study is to assess the utilization, timing, predictors, and clinical impact of PC interventions in adults with high-risk vascular conditions. Additionally, it seeks to identify gaps to help streamline standardized PC pathways within vascular surgery.

A PRISMA-guided search of 191 targeted studies reporting PC consultations, advance-care planning, hospice referral, or symptom-directed management in patients with chronic limb-threatening ischemia (CLTI), major amputation, aortic aneurysm, or other vascular emergencies was performed. Reviewers worked independently and screened records, extracted data, and appraised risk of bias with ROBINS-I. Ten studies met the criteria and are the subject of this analysis.

Ten studies met inclusion criteria. PC utilization was consistently low: 2.7% after below-knee amputation, 7.4% among Medicare CLTI cohorts, 7% in unplanned vascular admissions, and 8-12% after major amputations or inoperable aneurysms. Consultations were typically late, occurring a median 3-17 days before death and sometimes within hours of demise. Predictors of referral included advanced age, frailty, acute limb ischemia, high comorbidity burden, and prolonged ICU support, yet many high-risk patients received no PC evaluation. When delivered, PC was associated with reduced in-hospital mortality (OR ≈ 0.25-0.49), lower ICU utilization, and higher hospice discharge rates. All studies displayed moderate-to-high risk of bias, chiefly from confounding and selection domains.

Across the vascular surgery spectrum, PC is under-used and introduced too late in care to capitalize on all the benefits. Criteria-driven referral and embedding PC teams into routine vascular care pathways could improve symptom control, align treatment with patient goals, and reduce non-beneficial resource use. Standardized protocols and prospective studies are needed to optimize goal-concordant care and establish benchmarks for this high-risk population.