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Farndon DJ, Bennett PC, Nunney I, Dhatariya K. Glycemic Variability as a Predictor of Graft Failure Following Infrainguinal Bypass for Peripheral Arterial Disease: A Retrospective Cohort Study. Ann Vasc Surg 2024; 105:132-139. [PMID: 38588955 DOI: 10.1016/j.avsg.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/14/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Glycemic variability (GV), measured as the change in visit-to-visit glycated hemoglobin (HbA1c), increases the risk of multiple adverse outcomes. However, the impact of GV on graft patency following infrainguinal bypass (IIB) is unknown. A retrospective cohort study was undertaken to assess the impact of GV on graft patency. METHODS A 3-year single-center retrospective case notes analysis of all people undergoing IIB between 2017 and 2019. Rutherford stage, graft conduit, level of bypass, procedure details, baseline demographics, comorbidities, and GV were assessed. Time to reintervention, ipsilateral amputation, or death was recorded to determine primary patency (PP). RESULTS One hundred six IIB outcomes were analyzed: mean (± standard deviation) age 68.0 (9.2) years; 69 (65.1%) male, 37 (33.9%), 75 (70.8%) had diabetes mellitus; and 46 (43.4%) underwent elective procedures. GV > 9.1% was associated with significantly lower median PP than GV < 9.1%, 198 (97-753.5) vs. 713 (166.5-1,044.5) days (P = 0.045). On univariate analysis, GV > 9.1% vs. < 9.1% was significantly associated with PP (hazard ratio [HR] 1.85 [confidence interval {CI} 1.091-3.136], P = 0.022). Bypass level was also a univariate predictor, with below knee bypasses (HR 2.31 [CI 1.164-4.564], P = 0.017), and tibial (HR 2.00 [CI 1.022-3.090], P < 0.043) having lower PP than above knee bypasses. On multivariate adjustment, GV > 9.1% and level of bypass remained independent predictors of PP, HR 1.96 (95% CI: 1.12-3.42, P = 0.018) and HR 2.54 (95% CI: 1.24-5.22, P = 0.011), respectively. CONCLUSIONS GV is an independent predictor of PP following infrainguinal bypass, thus optimizing GV should be a therapeutic target.
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Affiliation(s)
- Daniel J Farndon
- Norfolk and Norwich Vascular Unit, Norfolk & Norwich University Hospital, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK
| | - Philip C Bennett
- Norfolk and Norwich Vascular Unit, Norfolk & Norwich University Hospital, Norwich, UK.
| | - Ian Nunney
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Ketan Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, UK; Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospital, Norwich, UK
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Yuan F, Tracci MC, Clouse WD, Robinson WP. Outcomes of open and endovascular infra-inguinal revascularization are poor in young patients with atherosclerotic peripheral artery disease but do not differ between genders. Vascular 2024; 32:337-346. [PMID: 36377515 DOI: 10.1177/17085381221140160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES The effect of gender on the outcomes of revascularization procedures in young patients with premature atherosclerotic peripheral arterial disease (PAD) is not known. The objective of this study was to compare short-term and long-term outcomes between young males and females undergoing infra-inguinal revascularization procedures. METHODS We examined postoperative outcomes of male and female PAD patients under the age of 55 who underwent infra-inguinal revascularization procedures at a single tertiary institution from 2011 to 2019. Primary outcomes included 30-day morbidity, patency of the revascularization procedures, and major adverse limb events (MALE). Secondary outcomes included survival, amputation rate, reintervention rate, improvement of ankle-brachial index (ABI), and number of reinterventions. RESULTS Eighty-one infra-inguinal revascularization procedures (46 endovascular and 35 open procedures) were reviewed including 45 procedures in 37 males and 36 procedures in 31 females. Fifty-three (65.4%) of the procedures were performed in patients with chronic limb-threatening ischemia symptoms. The rest were treated for life-disabling claudication. The female patients were younger, had higher body mass index, and were more likely to have diabetes, hyperlipidemia, or chronic obstructive pulmonary disease in comparison to males. Thirty-day major adverse cardiovascular event was 0.0% and MALE was 16.0%. Mean follow-up was 806.2 days. At 1 year, primary patency was 34.4 ± 6.2%, primary assisted patency was 52.7 ± 6.5%, secondary patency was 61.8 ± 6.3%, and MALE-free rate was 47.0 ± 6.4%. For secondary outcomes at 1 year, amputation-free rate was 92.5 ± 3.2%, reintervention-free rate was 50.2 ± 6.4%, and survival was 96.2 ± 2.6%. By the end of the study, overall mortality rate was 14.8% and major amputation rate was 13.6%. No major differences were observed between males and females among these outcomes. A smaller improvement in ABI after revascularization was noted in females compared to males (female 0.2 ± 0.2 vs male 0.4 ± 0.2, p = .04). Among patients who required reintervention, females required a higher number of reinterventions than males (female 1.7 ± 2.5 vs male 0.8 ± 1.1, p = .03). CONCLUSIONS There were no significant differences in short-term and long-term outcomes between males and females under the age of 55 after infra-inguinal revascularization. Poor patency, high MALE rate, and high mid-term mortality, and amputation rates after revascularization in young PAD patients highlight the need for improved strategies to treat premature PAD.
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Affiliation(s)
- Fang Yuan
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - William P Robinson
- Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
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Kim Y, Weissler EH, Long CA, Williams ZF, Dua A, Southerland KW. Sex-based differences in outcomes after lower extremity bypass for chronic limb-threatening ischemia. Atherosclerosis 2023; 384:117157. [PMID: 37349195 DOI: 10.1016/j.atherosclerosis.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND AIMS Lower extremity bypass surgery is an effective treatment option for patients with chronic limb-threatening ischemia (CLTI). Recent studies have suggested that sex-based differences may impact patient outcomes following lower extremity revascularization, however, results have been inconsistent. METHODS In this multicenter analysis, we retrospectively identified all infrainguinal bypass procedures performed for CLTI from 2002 to 2021. Patients were separated into two groups based on sex. Primary outcomes were major limb amputation and reintervention for graft patency. RESULTS Of 843 bypasses performed over the study period, 347 (41.2%) patients were female. Racial/ethnic distribution and medical comorbidities were similar across sex groups. Surgical indications and operative details were also similar between groups, including conduit type (49.9% autogenous), bypass target (65.4% infrageniculate), and concurrent endarterectomy (38.9%). Female and male patients had similar hospital length of stay (6 days [4-9] vs 6 days [4-9]), hospital readmission (25.6% vs 25.0%), and postoperative complications (p=NS each). Female patients had higher major amputation rates (10.1% vs 6.3%, p=0.04) after one year, whereas reintervention rates were similar between groups (26.2% vs 24.6%, p=NS). After accounting for patient factors, female sex (odds ratio [OR] 1.02 [1.00-1.04]), infrageniculate target (OR 1.02 [1.00-1.04]), and bypass for tissue loss (OR 1.02 [1.00-1.04]) were associated with major amputation after bypass (p<0.05 each). CONCLUSIONS Female sex is associated with a small but significant increase major amputation after lower extremity bypass surgery for CLTI, despite similar clinical presentation, medical comorbidities, and operative details. These data support the increasingly recognized sex disparities in peripheral arterial disease.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA.
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
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Iacopi E, Pieruzzi L, Riitano N, Abbruzzese L, Goretti C, Piaggesi A. The Weakness of the Strong Sex: Differences Between Men and Women Affected by Diabetic Foot Disease. INT J LOW EXTR WOUND 2023; 22:19-26. [PMID: 33480296 DOI: 10.1177/1534734620984604] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We aimed to analyze sex-related differences in clinical outcomes among patients with diabetic foot disease (DFD) managed in a third-level referral center. We retrospectively analyzed data of admissions performed in our department between 2011 and 2015 for DFD. We collected demographic and clinical data, procedures performed during the admission, and short- and long-term outcomes in terms of healing rate and healing time, major amputation, and mortality rates during the follow-up. We focused on differences between genders and tried to figure out if sex could be considered a predictive factor. We collected data from 1237 admission performed in 842 patients (615 men [73%] and 227 women [27%]; age: 68.6 ± 27.9 years; diabetes duration: 16.4 ± 13.4 years; body mass index: 28.2 ± 6.4 kg/m2; hemoglobin A1c 7.9 ± 1.9%). Men showed a higher prevalence of comorbidities and previous ulcers or revascularization procedures. Men had a significantly higher healing rate compared with women (85.4% vs 63.2%, P < .001), but a longer healing time (124 ± 27 days vs 87 ± 14 days, P = .02). Major amputation did not differ between groups, while mortality rate was significantly higher in men (24.5% vs 16.1%, P = .02). In Cox's regression analysis, male sex was a positive predictive factor for healing and a negative one for time to heal and mortality. The difference in mortality was confirmed by a Kaplan-Meier analysis (log rank test: P = .03). DFD represents a severe disease and a strong marker of mortality affecting more severely on clinical outcomes and survival on men.
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Demsas F, Joiner MM, Telma K, Flores AM, Teklu S, Ross EG. Disparities in peripheral artery disease care: a review and call for action. Semin Vasc Surg 2022; 35:141-154. [PMID: 35672104 PMCID: PMC9254894 DOI: 10.1053/j.semvascsurg.2022.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
Abstract
Peripheral artery disease (PAD), the pathophysiologic narrowing of arterial blood vessels of the lower leg due to atherosclerosis, is a highly prevalent disease that affects more than 6 million individuals 40 years and older in the United States, with sharp increases in prevalence with age. Morbidity and mortality rates in patients with PAD range from 30% to 70% during the 5- to 15-year period after diagnosis and PAD is associated with poor health outcomes and reduced functionality and quality of life. Despite advances in medical, endovascular, and open surgical techniques, there is striking variation in care among population subgroups defined by sex, race and ethnicity, and socioeconomic status, with concomitant differences in preoperative medication optimization, amputation risk, and overall health outcomes. We reviewed studies from 1995 to 2021 to provide a comprehensive analysis of the current impact of disparities on the treatment and management of PAD and offer action items that require strategic partnership with primary care providers, researchers, patients, and their communities. With new technologies and collaborative approaches, optimal management across all population subgroups is possible.
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Kim S, Pendleton AA, McGinigle K. Peripheral Artery Disease: Diagnosis, Treatment, and Outcomes in Females. Semin Vasc Surg 2022; 35:155-161. [DOI: 10.1053/j.semvascsurg.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022]
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7
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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Abstract
Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.
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Affiliation(s)
- Maria Pabon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital (M.P.)
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center (S.C.)
| | - S Elissa Altin
- Division of Cardiology, Yale University School of Medicine (S.E.A.)
| | - Sanjum S Sethi
- Columbia Interventional Cardiovascular Care, Division of Cardiology, Columbia University Irving Medical Center (S.S.S.)
| | - Michael D Nelson
- Department of Kinesiology, University of Texas at Arlington (M.D.N.)
| | - Kerrie L Moreau
- Division of Geriatrics, University of Colorado School of Medicine, and Eastern Colorado Geriatric Research Education and Clinical Center (K.L.M.)
| | | | - Connie N Hess
- Division of Cardiology, University of Colorado School of Medicine (C.N.H.)
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9
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Kobayashi T, Hamamoto M, Okazaki T, Tomota M, Fujiwara T, Hasegawa M, Takahashi S. Prognostic Significance of Intraoperative Graft Flow in Distal Bypass on Long-Term Outcomes in Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2021; 82:156-164. [PMID: 34890754 DOI: 10.1016/j.avsg.2021.10.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/09/2021] [Accepted: 10/27/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The aim of the study was to determine the prognostic significance of measurement of graft flow on the patency of distal bypass. METHODS A retrospective analysis was performed for 208 distal bypasses (208 limbs, 170 patients) with a single segment great saphenous vein conducted in a nonreversed manner from January 2009 to December 2019 in Japan. Patient backgrounds, operative details (including intraoperative mean graft flow), hospital outcomes, and long-term outcomes were evaluated. The primary endpoints were the primary, assisted primary, and secondary patency of the distal bypass graft and the secondary endpoints were limb salvage and wound healing. RESULTS The median intraoperative graft flow was 18 [10-30] mL/min. The follow-up rate was 98% in a mean follow-up period of 31 ± 26 months. Primary, assisted primary, and secondary patency in the cohort were 51%, 72%, and 73% at 1 year, and 39%, 59%, and 61% at 3 years, respectively. In multivariate analysis, the independent risk factors for primary patency were low graft flow (P = 0.0022) and female sex (P = 0.0016), and those for secondary patency were also low graft flow (P = 0.0025) and female sex (P < .001). The cut-offs for graft flow predicting primary and secondary patency were both 16 mL/min. The limb salvage rate was 94% at 1 year and 89% at 3 years; and the wound healing rates were 55%, 71% and 84% at 3, 6, and 12 months, respectively. Limb salvage and wound healing were not significantly associated with intraoperative graft flow. CONCLUSIONS Intraoperative graft flow was an independent predictor for graft patency in distal bypass, but had no influence on limb salvage and wound healing. The cut-off value for the mean graft flow predicting primary and secondary patency was 16 mL/min.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Minami-ku, Hiroshima, Japan
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Yeo JL, Brady EM, McCann GP, Gulsin GS. Sex and ethnic differences in the cardiovascular complications of type 2 diabetes. Ther Adv Endocrinol Metab 2021; 12:20420188211034297. [PMID: 34408835 PMCID: PMC8365016 DOI: 10.1177/20420188211034297] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.
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Affiliation(s)
- Jian L Yeo
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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Mentias A, Sarrazin MV, Saad M, Girotra S. Sex Differences in Management and Outcomes of Critical Limb Ischemia in the Medicare Population. Circ Cardiovasc Interv 2020; 13:e009459. [PMID: 33079598 PMCID: PMC7583656 DOI: 10.1161/circinterventions.120.009459] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Evidence about sex differences in management and outcomes of critical limb ischemia (CLI) is conflicting. METHODS We identified Fee-For-Service Medicare patients within the 5% enhanced sample file who were diagnosed with new incident CLI between 2015 and 2017. For each beneficiary, we identified all hospital admissions, outpatient encounters and procedures, and pharmacy prescriptions. Outcomes included 90-day mortality and major amputation. RESULTS Incidence of CLI declined from 2.80 (95% CI, 2.72-2.88) to 2.47 (95% CI, 2.40-2.54) per 1000 person from 2015 to 2017, P<0.01. Incidence was lower in women compared with men (2.19 versus 3.11 per 1000) but declined in both groups. Women had a lower prevalence of prescription of any statin (48.4% versus 52.9%, P<0.001) or high-intensity statins (15.3% versus 19.8%, P<0.01) compared with men. Overall, 90-day revascularization rate was 52%, and women were less likely to undergo revascularization (50.1% versus 53.6%, P<0.01) compared with men. Women had a similar unadjusted (9.9% versus 10.3%, P=0.5) and adjusted 90-day mortality (adjusted rate ratio, 0.98 [95% CI, 0.85-1.12], P=0.7) compared with men. Over the study period, unadjusted 90-day mortality remained unchanged for men (10.4% in 2015 to 9.9% in 2017, Pfor trend=0.3), and women (9.5% in 2015 to 10.6% in 2017, Pfor trend=0.2). Men had higher unadjusted (12.9% versus 8.9%, P<0.001) and adjusted risk of 90-day major amputation (adjusted rate ratio, 1.30 [95% CI, 1.14-1.48], P<0.001). One-third of patients with CLI underwent major amputation without a diagnostic angiogram or trial of revascularization in the preceding 90 days regardless of the sex. CONCLUSIONS Women with new incident CLI are less likely to receive statin or undergo revascularization at 90 days compared with men. However, the differences were small. There was no difference in risk of 90-day mortality between both sexes. Graphic Abstract: A graphic abstract is available for this article.
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Affiliation(s)
- Amgad Mentias
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Cleveland Clinic Foundation, Heart and Vascular Institute Section of Clinical Cardiology 9500 Euclid Avenue, J2-4 Cleveland, OH 44195
| | - Mary-Vaughan Sarrazin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa City, IA
| | - Marwan Saad
- Cardiovascular Institute, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa City, IA
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Giannopoulos S, Shammas NW, Cawich I, Staniloae CS, Adams GL, Armstrong EJ. Sex-Related Differences in the Outcomes of Endovascular Interventions for Chronic Limb-Threatening Ischemia: Results from the LIBERTY 360 Study. Vasc Health Risk Manag 2020; 16:271-284. [PMID: 32753875 PMCID: PMC7354949 DOI: 10.2147/vhrm.s246528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Previous studies have suggested that women with chroniclimb-threatening ischemia (CLTI) may have worse outcomes than men. The aim of this study was to determine whether there are sex-related differences in outcomes of patients with CLTI undergoing endovascular treatment with current endovascular technologies. PATIENTS AND METHODS Data were derived from the LIBERTY 360 study (NCT01855412). Hazard ratios and the respective 95% confidence intervals were synthesized to examine the association between sex and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE) and major amputation/death up to 3 years of follow-up. RESULTS A total of 689 patients with CLTI (female: N=252 vs male: N=437) treated with any FDA approved or cleared device were included. The mean lesion length was 126.9±117.3mm and 127.4±113.3mm for the female and male patients, respectively. Although a slightly higher incidence of in-hospital mortality was observed in the female group (1.2% vs 0.0%, p=0.049), there was no difference in female vs male survival rates during follow-up. However, the risk of major amputation at 18 months was higher for the male group (male vs female: HR: 2.36; 95% CI: 1.09-5.12; p=0.030). No difference between the two groups was detected in terms of TVR or MAE during follow-up. DISCUSSION Data regarding sex-related disparity in outcomes after endovascular therapy of patients with CLTI are conflicting. Gender-related characteristics rather than biological sex characteristics might be the cause of these conflicting findings. Further studies are needed to evaluate the role of sex in revascularization outcomes among this high-risk population.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | - Ian Cawich
- Arkansas Heart Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Cezar S Staniloae
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, NY, USA
| | - George L Adams
- Department of Cardiology, North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Wu B, Lancaster EM, Ramirez JL, Zarkowsky DS, Reyzelman AM, Gasper WJ, Conte MS, Hiramoto JS. Increased Reintervention After Infrainguinal Revascularization for Chronic Limb-Threatening Ischemia in Women. Ann Vasc Surg 2020; 69:307-316. [PMID: 32561241 DOI: 10.1016/j.avsg.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/15/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective of this study was to determine if there are gender-based differences in major adverse limb events after revascularization for chronic limb-threatening ischemia (CLTI) and to identify potential associated factors. METHODS This was a single-center retrospective analysis of 151 patients who underwent infrainguinal revascularization for CLTI between April 2013 and December 2015. Only the first revascularized limb was included in patients with bilateral CLTI. Demographic data and clinical outcomes were collected using electronic medical records. RESULTS The mean age was 68.1 ± 12.1 years, and 55 of 151 (36%) were women. Women were less likely to carry a diagnosis of hyperlipidemia (60% vs. 83%; P = 0.003), less likely to be on a statin medication (58% vs. 81%; P = 0.004), and less likely to undergo an infrapopliteal revascularization (60% vs. 77%; P = 0.04) compared with men. There were no differences between genders with regard to the Society for Vascular Surgery Wound Ischemia and Foot Infection stage at presentation or utilization of open versus endovascular intervention. During the median follow-up time of 678 days (interquartile range, 167-1277 days), 48 of 151 patients (32%) underwent reintervention on the threatened limb and 23 of 151 patients (15%) underwent major amputation. Women were more likely than men to need reintervention (P = 0.02). There was no difference between genders for major amputation (P = 0.48) or overall survival (P = 0.65). In a multivariable Cox proportional hazards model for reintervention that included gender, preoperative body mass index, hyperlipidemia, preoperative anticoagulation, and ischemia score ≥2 (all P < 0.20 in univariate analysis), female gender (hazard ratio [HR], 1.96 [1.10-3.54]; P = 0.02) and hyperlipidemia (HR, 2.32 [1.07-5.03]; P = 0.03) were significantly associated with increased rates of reintervention. CONCLUSIONS Women undergoing lower extremity revascularization for CLTI were more likely to require reintervention compared with men but had similar rates of limb preservation. Further study is required to understand potential causative factors to improve treatment outcomes in women.
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Affiliation(s)
- Bian Wu
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Elizabeth M Lancaster
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Joel L Ramirez
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Alexander M Reyzelman
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA.
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Krishnan P, Tarricone A, Purushottam B, Chen S, Kapur V, Gujja K, Kini A, Sharma S. Gender Differences in the Outcomes of Drug-Coated Balloon Treatment in Symptomatic Femoropopliteal Arterial Disease. Vasc Endovascular Surg 2020; 54:348-354. [DOI: 10.1177/1538574420911508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: To assess 24-month outcome differences based on sex in symptomatic femoro-popliteal arterial disease of patients treated with drug-coated balloon (DCB). Background: Peripheral artery disease affects over 12 million people in the United States. Drug-coated balloons have shown to be effective in treating patients with symptomatic femoropopliteal arterial occlusive disease. Debate remains regarding its safety and efficacy in female gender. We investigated the differential treatment effect between genders. Methods: Patients (93 females and 102 males) with symptomatic femoropopliteal arterial disease treated with DCB from November 2014 to November 2015 were included in this retrospective study. We compared the resting ankle-brachial indices (ABIs) and peak systolic velocities (PSVs) by arterial duplex between the male and female patients at 6, 12, and 24 months postintervention. Results: Females had significantly smaller vessels (4.70 ± 0.9, P = .02) and higher body mass index (BMI; 30.0 ± 3.7, P = .002) than males. Females had significantly decreased ABI and PSV at the 6-month (ABI: 0.90 ± 0.15, P = .05 and PSV: 188.30 ± 103.1, P = .02), 12-month (ABI: 0.86 ± 0.15, P < .0001 and PSV: 219.10 ± 100.10, P = .001), and at 24-month (ABI: 0.84 ± 0.2, P = .0001 and PSV: 251.0 ± 135.9, P < .0001) intervals when compared to males. Females had increased clinically driven target lesion revascularization (TLR) at 6 months (females = 8 vs males = 4, P = .22), 12 months (females = 12 vs males = 4, P = .02), and 24 months (females = 14 vs males = 6, P = .03). In simple logistic regression analysis, BMI, age, reference vessel diameter (RVD), and gender were strongly associated with target lesion restenosis. The final model included the above and it produced the following odds ratios (ORs): BMI (OR = 1.07, 95% confidence interval [CI]: 0.98-1.2), age (OR: 1.0, CI: 0.96-1.03), RVD (OR: 1.6, CI: 1.02-2.4), and gender (OR: 3.5, CI: 1.6-7.8). Conclusion: Females treated with DCBs have significantly decreased ABI, PSVs, and an increased rate of TLR than their male counterparts.
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Affiliation(s)
- Prakash Krishnan
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Arthur Tarricone
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | | | - Simon Chen
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Vishal Kapur
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Karthik Gujja
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Annapoorna Kini
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Samin Sharma
- Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
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Uhl C, Götzke H, Zeman F, Woronowicz S, Betz T, Töpel I, Steinbauer M. Long-Term Outcome of Common Femoral Artery Endarterectomy In Octogenarians and Non-Octogenarians. Scand J Surg 2020; 110:400-406. [PMID: 32098583 DOI: 10.1177/1457496920907733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Arteriosclerotic disease of the common femoral artery can be treated by surgical or endovascular intervention. Elderly patients are said to have a worse outcome if treated by surgical means; however, data to support this theory are missing. METHODS Retrospective analysis of all patients who underwent common femoral artery endarterectomy between March 2007 and July 2018 in our clinic. Group 1 included all patients <80 years and Group 2 included all patients ⩾80 years. Endpoints were patency rates, limb salvage, and overall survival. RESULTS During this time period, 977 common femoral artery endarterectomies were performed. Indication was claudication in 61.5% and critical limb ischemia in 38.5%. Group 1 included 805 cases (82.4%) and Group 2 included 172 cases (17.6%). Thirty-day mortality was 2.7% (Group 1 = 1.6% versus Group 2 = 7.6%; p < 0.001) and 30-day major amputation was 1.1% (Group 1 = 0.7% versus Group 2 = 2.9%; p = .043). Primary patency and secondary patency were 84.2% and 96.8%, respectively, after 7 years. Limb salvage (93.7%, Group 1 = 94.1% versus Group 2 = 91.8%; p = .088) and overall survival (52.0%, Group 1 = 59.1% versus Group 2 = 15.7%; p = .006) were significantly different after the same time period. Multivariable analysis showed female gender to be a risk factor for loss of primary patency. Age ⩾ 80 years and ulcer or gangrene were risk factors for death. Statin use was beneficial to survival. CONCLUSIONS Common femoral artery endarterectomy is a safe procedure with excellent long-term results. Octogenarians have an increased risk for perioperative mortality and major amputation.
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Affiliation(s)
- Christian Uhl
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Pruefeningerstrasse 81, Regensburg, 93049, Germany
| | - Hannah Götzke
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Sandra Woronowicz
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Thomas Betz
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Ingolf Töpel
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Markus Steinbauer
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
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Miller SM, Sumpio BJ, Miller MS, Erben Y, Cordova AC, Sumpio BE. Higher Inpatient Mortality for Women after Intervention for Lifestyle Limiting Claudication. Ann Vasc Surg 2019; 58:54-62. [DOI: 10.1016/j.avsg.2019.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/23/2018] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
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Affiliation(s)
- Ellen K Brinza
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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18
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Kostova-Lefterova DD, Nikolov NN, Stanev SS, Stoyanova BB. Patient doses in endovascular and hybrid revascularization of the lower extremities. Br J Radiol 2018; 91:20180176. [PMID: 30028182 DOI: 10.1259/bjr.20180176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE: Hybrid surgical methods such as remote endarterectomy and endovascular revascularization are fluoroscopy-guided procedures successfully replacing conventional open surgery for treatment of peripheral artery disease (PAD). The aim of this study was to: (1) evaluate the dose parameters describing exposure of patients undergoing endovascular or hybrid revascularization of the lower limb (below the inguinal ligament); (2) compare the data available in the literature with the evaluations of patients' dose values and related factors for patients undergoing such procedures; (3) examine the correlation of doses with certain parameters; (4) estimate the peak skin dose and assess the potential for radiation-induced skin injuries during the procedures. METHODS: Data for 259 patients were extracted retrospectively and analyzed. The procedures were grouped by type of intervention, vascular approach, and level of complexity. The analyses included the correlation of dose values with the operating team. RESULTS: The air kerma-area product (KAP) and fluoroscopy time (FT) values greatly varied depending on the procedure type but also among patients undergoing the same procedure. The type of vascular access has the largest impact on patients' doses. The KAP and FT values for brachial artery were: 347 Gy.cm2 and FT: NA; for contralateral common femoral artery (CFA) approach: 207 Gy.cm2 and 153 s; e.g. significantly higher than for ipsilateral CFA: 96 Gy.cm2 and 78 s; for hybrid surgery: 77 Gy.cm2 and 41 s; and for ipsilateral retrograde popliteal approach: 61 Gy.cm2 and 53 s. The same tendency is observed for the peak skin dose (PSD) values: the highest are for brachial artery (2053 mGy) and contralateral CFA (1325 mGy) approach, followed by the ipsilateral CFA (748 mGy), hybrid surgery (649 mGy), and ipsilateral retrograde popliteal approach (566 mGy). CONCLUSION: Registered dose values and FT for the different procedures do not exceed the International Atomic Energy Agency (IAEA) proposed trigger values for patients' follow-up for radiation-induced skin injuries. The type of vascular access has the highest negative impact on radiation dose levels and resultant KAP, PSD, and FT values. There is a significant increase of the dose values with increase of the number of inserted stents and the level of complexity. This should be considered in planning, especially for patients who undergo multiple diagnostic and therapeutic procedures. ADVANCES IN KNOWLEDGE: This study gives a systematic understanding for patient radiation exposure in endovascular and hybrid revascularization of the lower extremities, thus far absent in the literature.
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Affiliation(s)
- Desislava D Kostova-Lefterova
- 1 Clinic of Vascular Surgery, National Cardiology Hospital , Sofia , Bulgaria.,2 Medical College, Medical University - Pleven , Pleven , Bulgaria
| | - Nadelin N Nikolov
- 1 Clinic of Vascular Surgery, National Cardiology Hospital , Sofia , Bulgaria
| | - Stefan S Stanev
- 1 Clinic of Vascular Surgery, National Cardiology Hospital , Sofia , Bulgaria
| | - Boyka B Stoyanova
- 1 Clinic of Vascular Surgery, National Cardiology Hospital , Sofia , Bulgaria
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Reusch JEB, Kumar TR, Regensteiner JG, Zeitler PS. Identifying the Critical Gaps in Research on Sex Differences in Metabolism Across the Life Span. Endocrinology 2018; 159:9-19. [PMID: 29300998 PMCID: PMC5761606 DOI: 10.1210/en.2017-03019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/13/2017] [Indexed: 12/12/2022]
Abstract
The National Institutes of Health (NIH) Office of Research in Women's Health now functions under a mandate calling for the systematic inclusion of both female and male cells, animals, and human subjects in all types of research, so that sex as a biological variable is understood in health and disease. Sex-specific data can improve disease prevention, diagnosis, and treatment as well as reduce inequities. Inclusion of women in research studies has modestly improved over the last 20 years, yet preclinical research is still primarily done using male animal models and male-derived cells, with the result that many conclusions are made based on incomplete and sex-biased data. There are important, yet poorly studied, sex differences in cardiometabolic disease. To begin to address these sex differences, the Center for Women's Health Research at the University of Colorado held its inaugural National Conference, "Sex Differences Across the Lifespan: A Focus on Metabolism," in September 2016 (cwhr@ucdenver.edu). Research to address the important goal of understanding key sex differences in cardiometabolic disease across the life span is lacking. The goal of this article is to discuss the current state of research addressing sex differences in cardiometabolic health across the life span, to outline critical research gaps that must be addressed in response to NIH mandates, and, importantly, to develop strategies to address sex as a biological variable to understand disease mechanisms as well as develop diagnostic and therapeutic modalities.
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Affiliation(s)
- Jane E. B. Reusch
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045
- Center for Women’s Health Research, University of Colorado School of Medicine, Aurora, Colorado 80045
- Veterans Administration Eastern Colorado Health Care System, Denver, Colorado 80220
| | - T. Rajendra Kumar
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Judith G. Regensteiner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045
- Center for Women’s Health Research, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Philip S. Zeitler
- Department of and Pediatrics, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - on Behalf of the Conference Participants
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045
- Center for Women’s Health Research, University of Colorado School of Medicine, Aurora, Colorado 80045
- Veterans Administration Eastern Colorado Health Care System, Denver, Colorado 80220
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado 80045
- Department of and Pediatrics, University of Colorado School of Medicine, Aurora, Colorado 80045
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20
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Doshi R, Shah P, Meraj P. Gender disparities among patients with peripheral arterial disease treated via endovascular approach: A propensity score matched analysis. J Interv Cardiol 2017; 30:604-611. [PMID: 28815727 DOI: 10.1111/joic.12431] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Remarkable improvement in the treatment of Peripheral Arterial Disease (PAD) has led to changes in revascularization strategies from traditional open surgery to less invasive endovascular management. However, few studies are available on gender disparities in patients with PAD treated via an endovascular approach. This study was designed to analyze gender related differences with respect to in-hospital outcomes in PAD patients. METHODS Our data was obtained from National Inpatient Sample (NIS) 2012 through 2014. We used International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedural codes appropriate for PAD and endovascular treatment. Endovascular treatment included drug eluting stent, bare metal stent, atherectomy or angioplasty of lower extremity arteries. A propensity score matching was performed to adjust for imbalances between variables. RESULTS Females presented late with more comorbidities and underwent more emergent/urgent procedures. After performing propensity score matched analysis, 25 758 patients were included in each group. There was no difference in in-hospital mortality between males and females in matched cohorts (2.3% vs 2.4%, P = 0.25). Acute renal failure, gangrene, infection, and composite of all complications were higher in males. Only blood transfusion was noted higher in females. CONCLUSION This study revealed no difference in in-hospital mortality between males and females undergoing endovascular peripheral intervention. Males have a higher rate of complications compared to females which explains the higher cost of care in males. Further research with long-term follow up is needed to see if there is any difference with regards to long-term outcomes and re-admission.
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Affiliation(s)
- Rajkumar Doshi
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Priyank Shah
- Department of Cardiology, Medical College of Georgia-Southwest Clinical Campus, Albany, Georgia
| | - Perwaiz Meraj
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
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21
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Lagergren E, Kempe K, Craven TE, Kornegay ST, Hurie JB, Garg N, Velazquez-Ramirez G, Edwards MS, Corriere MA. Superior Lower Extremity Vein Graft Bypass Patency among Married Patients with Peripheral Artery Disease. Ann Vasc Surg 2017; 44:48-53. [PMID: 28479461 DOI: 10.1016/j.avsg.2017.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Outcome disparities associated with lower extremity bypass (LEB) for peripheral artery disease (PAD) have been identified but are poorly understood. Marital status may affect outcomes through factors related to health risk behaviors, adherence, and access to care but has not been characterized as a predictor of surgical outcomes and is often omitted from administrative data sets. We evaluated associations between marital status and vein graft patency following LEB using multivariable models adjusting for established risk factors. METHODS Consecutive patients undergoing autogenous LEB for PAD were identified and analyzed. Survival analysis and Cox proportional hazards models were used to evaluate patency stratified by marital status (married versus single, divorced, or widow[er]) adjusting for demographic, comorbidity, and anatomic factors in multivariable models. RESULTS Seventy-three participants who underwent 79 autogenous vein LEB had complete data and were analyzed. Forty-three patients (58.9%) were married, and 30 (41.1%) were unmarried. Compared with unmarried patients, married patients were older at the time of their bypass procedure (67.3 ± 10.8 years vs. 62.2 ± 10.6 years; P = 0.05). Married patients also had a lower prevalence of female gender (11.6% vs. 33.3%; P = 0.02). Diabetes, hypertension, hyperlipidemia, and smoking were common among both married and unmarried patients. Minimum great saphenous vein conduit diameters were larger in married versus unmarried patients (2.82 ± 0.57 mm vs. 2.52 ± 0.65 mm; P = 0.04). Twenty-four-month primary patency was 66% for married versus 38% for unmarried patients. In a multivariable proportional hazards model adjusting for proximal and distal graft inflow/outflow, medications, gender, age, race, smoking, diabetes, and minimum vein graft diameter, married status was associated with superior primary patency (hazard ratio [HR] = 0.33; 95% confidence limits [0.11, 0.99]; P = 0.05); other predictive covariates included preoperative antiplatelet therapy (HR = 0.27; 95% confidence limits [0.10, 0.74]; P = 0.01) and diabetes (HR = 2.56; 95% confidence limits [0.93-7.04]; P = 0.07). CONCLUSIONS Marital status is associated with vein graft patency following LEB. Further investigation into the mechanistic explanation for improved patency among married patients may provide insight into social or behavioral factors influencing other disparities associated with LEB outcomes.
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Affiliation(s)
- Emily Lagergren
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Kelly Kempe
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Timothy E Craven
- Division of Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, NC
| | - Susan T Kornegay
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Nitin Garg
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Gabriela Velazquez-Ramirez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Matthew S Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Matthew A Corriere
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC.
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Wang J, He Y, Shu C, Zhao J, Dubois L. The effect of gender on outcomes after lower extremity revascularization. J Vasc Surg 2017; 65:889-906.e4. [DOI: 10.1016/j.jvs.2016.11.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 11/10/2016] [Indexed: 01/24/2023]
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23
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Lagergren ER, Kempe K, Craven TE, Kornegay ST, Garg N, Velazquez-Ramirez G, Hurie JB, Edwards MS, Corriere MA. Gender-specific Differences in Great Saphenous Vein Conduit. A Link to Lower Extremity Bypass Outcomes Disparities? Ann Vasc Surg 2017; 38:36-41. [DOI: 10.1016/j.avsg.2016.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 08/18/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
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Nguyen L, Liles DR, Lin PH, Bush RL. Hormone Replacement Therapy and Peripheral Vascular Disease in Women. Vasc Endovascular Surg 2016; 38:547-56. [PMID: 15592636 DOI: 10.1177/153857440403800609] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Women have been shown to have a lower incidence of vascular disease when compared to men. However, the incidence of vascular disease increases as women progress through menopause and reaches an incidence similar to that of men later in life. Women with peripheral vascular disease often have a delay in diagnosis, a higher incidence of asymptomatic disease, and poorer outcome after interventions. The differences in outcome have been attributed to a number of factors such as anatomic and hormonal differences. It is thought that estrogen deficiency is at least partially responsible for the increased risk of developing vascular disease after menopause, and thus hormone replacement therapy has been considered as a method to prevent progression of vascular disease. Conclusions drawn from a number of recent studies have resulted in a divergent view of hormone replacement therapy (HRT). This article explores the risk of peripheral vascular disease in women and the current state of research on hormone replacement therapy. The aims of this review are to present current perspectives on gender differences in the pathogenesis and outcomes of peripheral arterial disease (PAD). The effect of estrogen on atherogenesis, the role it plays in modulating the vascular endothelium, and the current evidence of the effects of HRT on vascular pathology is discussed. The most recent HRT clinical trials and present evidence for the benefits and risks of postmenopausal hormone replacement therapy are summarized. The effect of these issues on treatment practices is explained and suggestions are made for future directions of HRT and PAD research.
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Affiliation(s)
- Liz Nguyen
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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25
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Regensteiner JG, Golden S, Huebschmann AG, Barrett-Connor E, Chang AY, Chyun D, Fox CS, Kim C, Mehta N, Reckelhoff JF, Reusch JEB, Rexrode KM, Sumner AE, Welty FK, Wenger NK, Anton B. Sex Differences in the Cardiovascular Consequences of Diabetes Mellitus: A Scientific Statement From the American Heart Association. Circulation 2015; 132:2424-47. [PMID: 26644329 DOI: 10.1161/cir.0000000000000343] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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26
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Budtz-Lilly J, Petersen C, Pedersen T, Eldrup N. Male Sex Associated with Increased Long-term Cardiovascular Mortality after Peripheral Vascular Surgery for Atherosclerosis Despite Optimal Medical Treatment. Eur J Vasc Endovasc Surg 2015; 50:767-73. [DOI: 10.1016/j.ejvs.2015.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 08/07/2015] [Indexed: 11/26/2022]
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Hedayati N, Brunson A, Li CS, Baker AC, Pevec WC, White RH, Romano PS. Do Women Have Worse Amputation-Free Survival Than Men Following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database. Vasc Endovascular Surg 2015; 49:166-74. [DOI: 10.1177/1538574415608269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Female gender has been shown to negatively affect the outcomes of surgical bypass for peripheral arterial disease (PAD). We examined gender-related disparities in outcomes of endovascular PAD procedures in a large population-based study. Methods: We used discharge data from California hospitals to identify patients who had PAD interventions during 2005 to 2009. Logistic regression was used for 12-month reintervention, and Cox proportional hazard regression was used for amputation-free survival comparisons. Results: A total of 25 635 patients had endovascular procedures (11 389 [44.4%] women). Women were more likely than men (34.5% vs 30.1%, P < .0001) to have critical limb ischemia (CLI). Twelve-month reintervention rate in women was similar to men. Amputation-free survival was better among women than men (hazard ratio 0.84, 95% confidence interval [CI] 0.76-0.93, P = .0006). Conclusion: Despite presenting more frequently with CLI, women had better amputation-free survival than men following endovascular procedures. Future research should determine whether findings favor one type of PAD treatment modality over another for women.
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Affiliation(s)
- Nasim Hedayati
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, CA, USA
| | - Ann Brunson
- Department of Internal Medicine, University of California, Davis Medical Center, CA, USA
| | - Chin-Shang Li
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, Sacramento, CA, USA
| | - Aaron C. Baker
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, CA, USA
| | - William C. Pevec
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, CA, USA
| | - Richard H. White
- Department of Internal Medicine, University of California, Davis Medical Center, CA, USA
| | - Patrick S. Romano
- Department of Internal Medicine, University of California, Davis Medical Center, CA, USA
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Ferranti KM, Osler TM, Duffy RP, Stanley AC, Bertges DJ. Association between gender and outcomes of lower extremity peripheral vascular interventions. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.03.066] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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29
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Lejay A, Schaeffer M, Georg Y, Lucereau B, Roussin M, Girsowicz E, Delay C, Schwein A, Thaveau F, Geny B, Chakfe N. Gender related Long-term Differences after Open Infrainguinal Surgery for Critical Limb Ischemia. Eur J Vasc Endovasc Surg 2015; 50:506-12. [DOI: 10.1016/j.ejvs.2015.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 07/06/2015] [Indexed: 11/29/2022]
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Dreyer RP, van Zitteren M, Beltrame JF, Fitridge R, Denollet J, Vriens PW, Spertus JA, Smolderen KG. Gender differences in health status and adverse outcomes among patients with peripheral arterial disease. J Am Heart Assoc 2014; 4:e000863. [PMID: 25537275 PMCID: PMC4330046 DOI: 10.1161/jaha.114.000863] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Few studies have examined gender differences in health status and cardiovascular outcomes in patients with peripheral artery disease (PAD). This study assessed (1) self-reported health status at PAD diagnosis and 12-months later, and explored (2) whether outcomes in women with PAD differ with regard to long-term major adverse events. METHODS AND RESULTS A total of 816 patients (285 women) with PAD were enrolled from 2 vascular clinics in the Netherlands. Baseline clinical data and subsequent adverse events were recorded and patients completed the Short Form-12 (SF-12, Physical Component Score [PCS] and Mental Component Score [MCS]) upon PAD diagnosis and 12-months later. Women had similar ages and clinical characteristics, but poorer socio-economic status and more depressive symptoms at initial diagnosis, as compared with men. Women also had poorer physical (PCS: 37±10 versus 40±10, P=0.004) and mental ( MCS 47±12 versus 49±11, P=0.005) health status at the time of presentation. At 12-months, women still reported a poorer overall PCS score (41±12 versus 46±11, P=0.006) and MCS score (42±14 versus 49±12, P=0.002). Female gender was an independent determinant of a poorer baseline and 12-month PCS and MCS scores. However, there were no significant differences by gender on either mortality (unadjusted hazard ratio [HR]=0.93, 95% CI 0.60;1.44, P=0.74) or major adverse events (unadjusted HR=0.90, 95% CI 0.63;1.29, P=0.57), after a median follow-up of 3.2 years. CONCLUSIONS Women's physical and mental health status is compromised both at initial PAD diagnosis and at 12-month follow-up, despite experiencing a similar magnitude of change in their health scores throughout the first 12-months after diagnosis.
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Affiliation(s)
- Rachel P Dreyer
- Center for Outcomes Research and Evaluation (CORE), New Haven, CT (R.P.D.) Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.P.D.)
| | - Moniek van Zitteren
- CoRPS-Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands (M.Z., J.D.) Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands (M.Z., P.W.V.)
| | - John F Beltrame
- Discipline of Medicine, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia (J.F.B.)
| | - Robert Fitridge
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia (R.F.)
| | - Johan Denollet
- CoRPS-Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands (M.Z., J.D.)
| | - Patrick W Vriens
- Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands (M.Z., P.W.V.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., K.G.S.) UMKC-University of Missouri-Kansas City, Kansas City, MO (J.A.S., K.G.S.)
| | - Kim G Smolderen
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., K.G.S.) UMKC-University of Missouri-Kansas City, Kansas City, MO (J.A.S., K.G.S.)
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Jain AK, Kalbaugh CA, Farber MA, Marston WA, Vallabhaneni R. Race and gender affect outcomes of lower extremity bypass. J Vasc Surg 2014; 60:1275-1281. [DOI: 10.1016/j.jvs.2014.04.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
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Vrijenhoek JEP, Haitjema S, de Borst GJ, de Vries JPPM, Vaartjes I, Moll FL, Pasterkamp G, den Ruijter HM. The impact of female sex on long-term survival of patients with severe atherosclerosis undergoing endarterectomy. Atherosclerosis 2014; 237:521-7. [PMID: 25463084 DOI: 10.1016/j.atherosclerosis.2014.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/15/2014] [Accepted: 10/02/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Long-term age- and sex-specific mortality data in patients undergoing carotid endarterectomy (CEA) and iliac/femoral endarterectomy (FEA) are scarce. We examined long-term mortality in these patient groups, stratified by age and sex. METHODS Between 2002 and 2012, 1771 patients (1200 men, 571 women) treated by CEA, and 685 patients (495 men, 190 women) who underwent FEA, were included and linked to the national mortality registry of the Netherlands. Absolute mortality risks during follow-up were analyzed by life-table and Kaplan Meier survival analyses in two age groups and stratified by sex, and compared to a matched sample from the general population. In addition, multivariable Cox regression analyses were performed. RESULTS After CEA, with a median follow-up duration of 4.3 years (interquartile range 2.0-7.1), 298 all-cause deaths had occurred in men (25%) and 105 (18%) in women. As in the general population, cumulative survival after CEA was significantly better in women compared to men (P = 0.002) and absolute CEA-associated mortality risk in women was similar to that of the general population. For FEA patients, mortality risk was worse than for CEA patients and the general population in both sexes and surprisingly, female sex did not have a favorable effect on survival. Following FEA, 130 men (26%) and 51 women (27%) died after a median follow-up time of 3.0 years (interquartile range 1.5-5.9). Stratifying by age, and adjusting for cardiovascular risk factors did not change these trends. CONCLUSIONS Long-term mortality after CEA is higher in men than in women, and in women mortality risk is similar to the general population. After FEA, the benefit of women as seen after CEA is lost.
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Affiliation(s)
- Joyce E P Vrijenhoek
- Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Saskia Haitjema
- Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ilonca Vaartjes
- Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerard Pasterkamp
- Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
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Duffy RP, Adams JE, Callas PW, Schanzer A, Goodney PP, Ricci MA, Cronenwett JL, Bertges DJ. The influence of gender on functional outcomes of lower extremity bypass. J Vasc Surg 2014; 60:1282-1290.e1. [PMID: 25242270 DOI: 10.1016/j.jvs.2014.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 05/08/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Our aim was to evaluate the effect of gender on early and late procedural and functional outcomes of lower extremity bypass (LEB). METHODS We reviewed the records of 2576 patients (828 women; 32%) who underwent LEB for claudication or critical limb ischemia (CLI) in the Vascular Study Group of New England from 2003 to 2010. Logistic regression and proportional hazards models were used to adjust for potential confounding differences between genders. Morbidity, mortality, graft patency, freedom from major amputation, ambulation, and living status were analyzed postoperatively and over 1 year. RESULTS Women were older (70 vs 68 years; P < .001), had more hypertension (89% vs 85%; P = .006), less coronary artery disease (35% vs 39%; P = .03), smoking (73% vs 88%; P < .001), and preoperative statin use (60% vs 64%; P = .04). Women were more likely to have CLI (76% vs 71%; P = .003), and ambulate with assistance at presentation (19% vs 16%; P = .02). Morbidity was similar except women had higher rates of reoperation for thrombosis (4% vs 2%; P < .001) without differences in major amputation (2% vs 1%; P = .13) or in-hospital mortality (1.7% vs 1.7%; P = .96). Women and men with claudication had similar 1-year graft patency rates. Women with CLI had lower rates of primary (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.03-1.48; P = .02), assisted primary (HR, 1.42; 95% CI, 1.15-1.76; P = .001) and secondary patency (HR, 1.40; 95% CI, 1.10-1.77; P = .006) during the first year compared with men. Freedom from amputation was similar for men and women with CLI (HR, 1.17; 95% CI, 0.84-1.63; P = .36). There were no differences in late survival between women and men with claudication (HR, 0.89; 95% CI, 0.60-1.31; P = .36) or CLI (HR, 0.94; 95% CI, 0.81-1.09; P = .39). More female claudicants were not independently ambulatory at discharge (30% vs 19%; P = .002) and were discharged to a nursing home (15% vs 5%; P < .001) but these differences did not persist at 1 year. Women with CLI were more likely to be nonambulatory at discharge (13% vs 9%; P = .006) and at 1 year (13% vs 8%; P < .001). More women with CLI were discharged to a nursing home (44% vs 35%; P = .01) and resided there at 1 year (11% vs 7%; P = .02). CONCLUSIONS Women have complication rates similar to men with inferior early and late functional outcomes after LEB. The reduced patency rates in women with CLI did not translate into differences in limb salvage. These findings might help define physician and patient expectations for women before revascularization.
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Affiliation(s)
- Reshma P Duffy
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt
| | - Julie E Adams
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt
| | - Peter W Callas
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Michael A Ricci
- Division of Vascular Surgery, Central Maine Heart and Vascular Institute, Lewiston, Me
| | - Jack L Cronenwett
- Division of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Daniel J Bertges
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt.
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Sinnamon AJ, Sonnenberg EM, Bartlett EK, Meise CK, Wang GJ, Kelz RR. The influence of socioeconomic factors on gender disparities in lower extremity bypass. J Surg Res 2014; 188:537-44. [DOI: 10.1016/j.jss.2014.01.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/21/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022]
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Hiramoto JS, Katz R, Weisman S, Conte M. Gender-specific risk factors for peripheral artery disease in a voluntary screening population. J Am Heart Assoc 2014; 3:e000651. [PMID: 24627420 PMCID: PMC4187488 DOI: 10.1161/jaha.113.000651] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Women have high rates of peripheral artery disease (PAD) despite fewer cardiovascular disease (CVD) risk factors, compared to men. We sought to determine the gender‐specific prevalence of low ankle brachial index (ABI) and the relationship to C‐reactive protein (CRP) levels and CVD risk factors in the Life Line Screening population. Methods and Results Between April 2005 and August 2011, 133 750 women and 71 996 men had ABI and CRP measured at a Life Line Screening Center. Women were slightly older than men, whereas men were more likely to be current smokers, have diabetes mellitus (DM), and coronary artery disease (CAD) (P<0.001 for each). Women were more likely to have ABI≤1.0, compared to men (26.6% versus 14.4%, respectively; P<0.001), as well as ABI≤0.9 (4.1% women versus 2.6% men; P<0.001). Women had higher median CRP levels (1.94 mg/L; interquartile range [IQR], 0.89, 4.44 mg/L), compared to men (1.35 mg/L; IQR, 0.73, 2.80 mg/L; P<0.001). Men and women shared similar risk factors for ABI≤0.9, including older age, black race, smoking, DM, hypertension, hypercholesterolemia, CAD, and elevated CRP levels. In an adjusted model, there were significant interactions between gender and age (P<0.001), CRP (P<0.001), CAD (P=0.03), and DM (P=0.06) with ABI as the outcome. The associations between age, CRP, CAD, and DM with ABI≤0.9 were stronger in men than in women. Conclusions Women participating in the Life Line Screening had higher CRP levels and a higher prevalence of PAD, compared to men. Neither higher CRP levels nor conventional CVD risk factors explained the excess prevalence of PAD in women.
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Affiliation(s)
- Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, UCSF, San Francisco, CA
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Kropman RH, van Meurs A, Fioole B, Vos JA, van Santvoort HC, van Sambeek M, Moll FL, de Vries JPP. Association of Sex with Long-Term Outcomes after Popliteal Artery Aneurysm Repair. Ann Vasc Surg 2014; 28:338-44. [DOI: 10.1016/j.avsg.2013.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 04/17/2013] [Accepted: 04/27/2013] [Indexed: 11/24/2022]
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Hedayati N, Humphries MD, Zhou W. Gender and Outcomes of Carotid Artery Interventions. Vasc Endovascular Surg 2013; 48:99-105. [DOI: 10.1177/1538574413510978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The benefits of carotid artery revascularization in women have been debated since the publication of large randomized clinical trials comparing carotid endarterectomy (CEA) to medical therapy. Institutional series have historically had an underrepresentation of women and/or have lacked power for adequate analysis. Recent evidence from large databases reveals possible gender-based differences in outcomes of carotid artery stenting versus CEA. In this review, we evaluated clinical articles from 1991 to 2012, using Pubmed and Web of Science, which addressed gender and outcomes of carotid artery revascularization procedures. Our goal was to determine whether gender is associated with adverse outcomes following carotid artery interventions in patients with carotid artery disease.
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Affiliation(s)
- Nasim Hedayati
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Misty D. Humphries
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Wei Zhou
- Division of Vascular and Endovascular Surgery, Stanford University, Palo Alto, CA, USA
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Lo RC, Bensley RP, Dahlberg SE, Matyal R, Hamdan AD, Wyers M, Chaikof EL, Schermerhorn ML. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg 2013; 59:409-418.e3. [PMID: 24080134 DOI: 10.1016/j.jvs.2013.07.114] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/24/2013] [Accepted: 07/29/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality. METHODS We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey. RESULTS From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons). CONCLUSIONS There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.
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Affiliation(s)
- Ruby C Lo
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Rodney P Bensley
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Suzanne E Dahlberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Robina Matyal
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Mark Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Elliot L Chaikof
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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McCoach CE, Armstrong EJ, Singh S, Javed U, Anderson D, Yeo KK, Westin GG, Hedayati N, Amsterdam EA, Laird JR. Gender-related variation in the clinical presentation and outcomes of critical limb ischemia. Vasc Med 2013; 18:19-26. [PMID: 23439776 DOI: 10.1177/1358863x13475836] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Critical limb ischemia (CLI) is a major cause of limb loss and mortality among patients with advanced peripheral artery disease. Our objective was to evaluate the gender-specific differences in patient characteristics and clinical outcomes among patients with CLI. We performed a retrospective analysis of 97 women and 122 men presenting with CLI who underwent angiography from 2006 to 2010. Baseline demographics, procedural details, and lesion characteristics were assessed for each patient. Kaplan-Meier analysis was used to assess long-term patient and lesion-level outcomes. Cox proportional hazard modeling was used to evaluate the relationship between gender and major adverse cardiovascular events (MACE). Compared to men, women were less likely to have a history of coronary artery disease (39% vs 54%, p = 0.02) or diabetes (57% vs 70%, p = 0.05) but had similar baseline medical therapy. At angiography, women were more likely to have significant femoropopliteal (77% vs 67%, p = 0.02) and multi-level infrainguinal disease (63% vs 51%, p = 0.02). Women were also more likely to undergo multi-vessel percutaneous intervention (69% vs 55%, p = 0.05), but had similar rates of limb salvage after percutaneous intervention or surgical bypass (HR 0.94 [95% CI 0.45-1.94], p = 0.9). During follow-up, women had higher rates of subsequent major adverse cardiovascular events (HR 1.63 [95% CI 1.01-2.63], p = 0.04). In conclusion, women with CLI are more likely to present with femoropopliteal and multi-level infrainguinal disease. Despite similar rates of limb salvage, women with CLI have an increased rate of subsequent major adverse cardiovascular events.
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Affiliation(s)
- Caroline E McCoach
- Department of Internal Medicine, University of California, Davis, Sacramento, CA 95817, USA
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Teodorescu VJ, Vavra AK, Kibbe MR. Peripheral arterial disease in women. J Vasc Surg 2013; 57:18S-26S. [DOI: 10.1016/j.jvs.2012.10.115] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 08/31/2012] [Accepted: 10/26/2012] [Indexed: 12/14/2022]
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Tye A, Han DK, Tadros RO, Spyris CT, Teodorescu V, Marin ML, Faries PL, Vouyouka AG. Percutaneous intervention for infrageniculate arterial disease in women may be associated with better outcomes when compared to men. J Vasc Surg 2013; 57:706-13. [DOI: 10.1016/j.jvs.2012.05.072] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 05/12/2012] [Accepted: 05/14/2012] [Indexed: 11/30/2022]
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Ballotta E, Gruppo M, Lorenzetti R, Piatto G, DaGiau G, Toniato A. The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease. J Vasc Surg 2012; 56:343-52. [DOI: 10.1016/j.jvs.2012.01.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 01/12/2012] [Accepted: 01/12/2012] [Indexed: 11/28/2022]
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Young Women with PAD are at High Risk of Cardiovascular Complications. Eur J Vasc Endovasc Surg 2012; 43:441-5. [DOI: 10.1016/j.ejvs.2012.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 01/03/2012] [Indexed: 11/23/2022]
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Hirsch AT, Allison MA, Gomes AS, Corriere MA, Duval S, Ershow AG, Hiatt WR, Karas RH, Lovell MB, McDermott MM, Mendes DM, Nussmeier NA, Treat-Jacobson D. A Call to Action: Women and Peripheral Artery Disease. Circulation 2012; 125:1449-72. [DOI: 10.1161/cir.0b013e31824c39ba] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ortmann J, Nüesch E, Traupe T, Diehm N, Baumgartner I. Gender is an independent risk factor for distribution pattern and lesion morphology in chronic critical limb ischemia. J Vasc Surg 2012; 55:98-104. [DOI: 10.1016/j.jvs.2011.07.074] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Revised: 05/19/2011] [Accepted: 07/16/2011] [Indexed: 10/15/2022]
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Grootenboer N, Hunink M, Hoeks S, Hendriks J, van Sambeek M, Poldermans D. The Impact of Gender on Prognosis After Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2011; 42:510-6. [DOI: 10.1016/j.ejvs.2011.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 06/15/2011] [Indexed: 11/30/2022]
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Weis-Müller BT, Römmler V, Lippelt I, Porath M, Godehardt E, Balzer K, Sandmann W. Critical Chronic Peripheral Arterial Disease: Does Outcome Justify Crural or Pedal Bypass Surgery in Patients With Advanced Age or With Comorbidities? Ann Vasc Surg 2011; 25:783-95. [DOI: 10.1016/j.avsg.2011.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 11/28/2010] [Accepted: 01/01/2011] [Indexed: 10/18/2022]
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Jain AK, Velazquez-Ramirez G, Goodney PP, Edwards MS, Corriere MA. Gender-Based Analysis of Perioperative Outcomes Associated with Lower Extremity Bypass. Am Surg 2011. [DOI: 10.1177/000313481107700717] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We analyzed gender-based differences in preoperative factors, procedural characteristics, and 30-day outcomes after lower extremity bypass (LEB). LEB procedures were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant User File. Groupwise comparisons of preoperative and procedural variables were made using chi square, t tests, and nonparametric methods; gender influences on mortality, systemic, and surgical site complications were evaluated using logistic regression. Women (4,107 of 11,011 [37.3%]) were older and had greater prevalence of hypertension, diabetes, chronic obstructive pulmonary disease, rest pain, dialysis, previous stroke, open/infected wound, and dependent functional status ( P < 0.01 for all comparisons). Women more commonly underwent emergent and extra-anatomic procedures but had lower rates of venous conduit or tibial level outflow use. Univariable associations between female gender and risk of 30-day mortality, systemic, and surgical site complications were identified; only the association with surgical site complications remained significant in multivariable modeling (OR, 1.8; 95% CI, 1.6 to 2.1; P < 0.0001). Gender-based differences in demographic, comorbidity, and procedural factors may contribute to disparities in perioperative outcomes associated with LEB. Female gender may be associated with increased risk for surgical site complications, but 30-day mortality and systemic complication rates in women may reflect effects of confounding factors rather than gender-specific influence.
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Affiliation(s)
- Ashish K. Jain
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | - Gabriela Velazquez-Ramirez
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
| | | | - Matthew S. Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Matthew A. Corriere
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, Georgia
- Atlanta VA Medical Center, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Sadrzadeh Rafie AH, Stefanick ML, Sims ST, Phan T, Higgins M, Gabriel A, Assimes T, Narasimhan B, Nead KT, Myers J, Olin J, Cooke JP. Sex differences in the prevalence of peripheral artery disease in patients undergoing coronary catheterization. Vasc Med 2011; 15:443-50. [PMID: 21183651 DOI: 10.1177/1358863x10388345] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
To determine whether there are sex differences in the prevalence of peripheral artery disease, we performed an observational study of 1014 men and 547 women, aged ≥ 40 years, referred for elective coronary angiography. Women were slightly older, more obese, had higher low-density lipoprotein cholesterol (LDL-C) levels and systolic blood pressure (BP), and were more likely to be African American. Women had higher high-density lipoprotein cholesterol (HDL-C) levels, lower diastolic BP, and were less likely to smoke or to have a history of cardiovascular disease. Women had less prevalent (62% vs 81%) and less severe coronary artery disease (CAD) (p < 0.001 for both) by coronary angiography, but more prevalent peripheral artery disease (PAD) as determined by the ankle-brachial index (ABI) than men (23.6% versus 17.2%). Independent predictors of lower ABI were female sex, black race, older age, tobacco use, CAD, diabetes, and triglyceride level. In a full multivariable logistic regression model, women had a risk-adjusted odds ratio for PAD of 1.78 (95% CI 1.25-2.54) relative to men. Among patients referred for coronary angiography, women have less prevalent and less severe CAD, but more prevalent PAD, a sex difference that is not explained by traditional cardiovascular disease risk factors or CAD severity. Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT00380185.
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50
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Seymour KA, Sadowitz B, Amankwah KS, Gahtan V. Outcome of lower extremity revascularization for peripheral artery occlusive disease: is there a difference between men and women? Vascular 2011; 19:59-67. [DOI: 10.1258/vasc.2010.ra0042] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The incidence of peripheral arterial occlusive disease (PAD) increases with age. Women represent a growing percentage of the elderly population who present with PAD. While speculation exists that gender affects outcome after revascularization procedures, the literature is confusing and often conflicting. This review compares outcomes by gender after open surgical and endovascular lower extremity revascularization (LER) procedures including: demographic differences, patency rates, limb salvage rates, long-term survival, perioperative complications and 30-day mortality. This review summarizes the existing data and discusses current influences on outcome after LER.
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Affiliation(s)
- Keri A Seymour
- Division of Vascular Surgery and Endovascular Services, SUNY Upstate Medical University, 750 East Adams Street
- Department of Veterans Affairs, VA Healthcare Network Upstate New York at Syracuse, 800 Irving Avenue, Syracuse, NY 13210, USA
| | - Benjamin Sadowitz
- Division of Vascular Surgery and Endovascular Services, SUNY Upstate Medical University, 750 East Adams Street
- Department of Veterans Affairs, VA Healthcare Network Upstate New York at Syracuse, 800 Irving Avenue, Syracuse, NY 13210, USA
| | - Kwame S Amankwah
- Division of Vascular Surgery and Endovascular Services, SUNY Upstate Medical University, 750 East Adams Street
- Department of Veterans Affairs, VA Healthcare Network Upstate New York at Syracuse, 800 Irving Avenue, Syracuse, NY 13210, USA
| | - Vivian Gahtan
- Division of Vascular Surgery and Endovascular Services, SUNY Upstate Medical University, 750 East Adams Street
- Department of Veterans Affairs, VA Healthcare Network Upstate New York at Syracuse, 800 Irving Avenue, Syracuse, NY 13210, USA
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