Contemporary patterns of lower extremity revascularization for chronic limb-threatening ischemia in the United...

Chronic limb-threatening ischemia (CLTI) is a major contributor to morbidity and mortality. Although revascularization improves limb outcomes in CLTI, contemporary practice patterns and real-world outcomes remain poorly characterized, particularly amid conflicting evidence from randomized trials regarding optimal revascularization and nonoperative management strategies. Our study utilized the National Inpatient Sample (NIS) coupled with U.S. Census data to characterize contemporary trends of incidence, revascularization approach, and in-hospital outcomes for adults hospitalized for CLTI.

We utilized the NIS (2016-2022) to generate survey-weighted national estimates of U.S. adult hospitalizations for CLTI. Age-normalized incidence rates per 100,000 person-years were calculated using population denominators from the U.S. Census Bureau. Admissions with secondary diagnoses of trauma or arterial dissection were excluded. Our outcomes evaluated the incidence of CLTI hospitalizations and rates of in-hospital revascularization type (open, endovascular, or no revascularization), major amputation, and mortality. Outcomes by revascularization strategies (open vs. endovascular) were stratified a priori by sex, frailty (Risk Analysis Index), diabetes status, and clinical presentation subgroups. Mann-Kendal trend tested monotonic temporal trends.

An estimated 46,915 adult CLTI hospitalizations were included (mean age 69.7 years, 40.0% women, 69.5% White). Overall CLTI incidence was 7.28 per 100,000 person-years, initially declining until nadir in 2020 with reversal and steady rise thereafter. A total of 28,763 (61.3%) CLTI hospitalizations included revascularization (n=14,252 [49.5%] open and/or n=16,950 [58.9%] endovascular). The proportion of open revascularization decreased (p_trend=0.016), while endovascular remained stable (p_trend=0.368), and hospitalizations without revascularization increased (p_trend=0.016) over time. Endovascular revascularization rates did rise among females, non-frail patients, and those presenting with rest pain (all p_trend>0.05). Overall, in-hospital amputation (n=6,270 [13.4%]) and mortality (n=1,086 [2.3%]) remained stable (p_trend>0.05). However, the proportion of patients discharged alive and without amputation increased most substantially among hospitalizations without revascularization (p_trend=0.007).

We provide contemporary analysis of U.S. hospitalizations for CLTI, demonstrating increasing rates following 2020. Overall, in-hospital rates of open revascularization declined in favor of nonoperative strategies corresponding with the greatest increase in alive discharges without amputations. Relative selection of endovascular strategies varied notably by sex, frailty, and clinical presentation. Our findings underscore the need for further investigation into optimal CLTI patient selection and coordinated integration of non-operative care, such as medical optimization, with revascularization strategies.