Regional intensity of vascular care and lower extremity amputation rates

Geographic Region and Insurance Status Predict Access to Salvage Procedures for Diabetic Lower-Extremity Wounds in the United States

PURPOSE

The current study assessed factors associated with limb salvage and subsequent amputations for patients with diabetic lower-extremity wounds in the United States.

METHODS

Using national administrative data from 2010 to 2022 (PearlDiver), adults undergoing amputation or salvage procedures (skin graft, local flap, or free flap) for diabetic lower-extremity wounds were identified. Patient age, sex, Elixhauser Comorbidity Index, geographic region, and insurance status were extracted. Insulin dependence, tobacco use, end-stage renal disease, peripheral vascular disease, prior amputation, preoperative lower-extremity infection, and preoperative vascular testing or intervention were also extracted. Subsequent amputations following limb salvage were identified. Factors associated with salvage procedures and subsequent amputation were analyzed with multivariable logistic regression.

RESULTS

The final cohorts included 97,472 patients with amputation and 62,850 patients with salvage. The average follow-up was 3.9 years. Many patient and clinical factors were associated with limb salvage. Most notably, patients in the Northeast had the greatest odds of undergoing salvage, and relative to privately insured patients, those with Medicare and Medicaid were significantly less likely to undergo salvage. Of patients who underwent salvage, 11,595 (18%) underwent subsequent amputation at an average time of 1.7 years. There was minimal variation in subsequent amputation by geographic region, and patients with Medicare and Medicaid were only slightly more likely to undergo a subsequent amputation.

CONCLUSIONS

There are significant disparities in access to limb salvage procedures in the United States based on region and insurance status despite only minor differences in progression to subsequent amputation for these patients.

Racial disparities in prosthesis abandonment and mobility outcomes after lower limb amputation from a dysvascular etiology in a veteran population

BACKGROUND

Non-Hispanic Black (NHB) individuals have higher rates of amputation and increased risk of a transfemoral amputation due to dysvascular disease than non-Hispanic White (NHW) individuals. However, it is unclear if NHB individuals have differences in prosthesis use or functional outcomes following an amputation.

OBJECTIVE

To determine if there are racial disparities in prosthesis abandonment and mobility outcomes in veterans who have undergone their first major unilateral lower extremity amputation (LEA) due to diabetes and/or peripheral artery disease.

DESIGN

National cohort study that identified individuals retrospectively through the Veterans Affairs (VA) Corporate Data Warehouse (CDW) from March 1, 2018, to November 30, 2020, then prospectively collected their self-reported prosthesis abandonment and mobility. Multiple logistic regression was used to control for potential confounders and identify potential effect modifiers.

SETTING

The VA CDW, participant mailings and phone calls.

PARTICIPANTS

Three hundred fifty-seven individuals who underwent an incident transtibial or transfemoral amputation due to diabetes and/or peripheral arterial disease.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

(1) Self-reported prosthesis abandonment. (2) Level of mobility assessed using the Locomotor Capabilities Index.

RESULTS

Rurally located NHB individuals without a major depressive disorder (MDD) had increased odds of abandoning their prosthesis (adjusted odds ratios [aOR] = 5.3; 95% confidence interval [CI]: [1.3-21.1]). This disparity was nearly three times as large for rurally located NHB individuals with MDD diagnosis, compared with other races from rural areas and with MDD (aOR = 15.8; 95% CI, 2.5-97.6). NHB individuals living in an urban area were significantly less likely to achieve advanced mobility, both with MDD (aOR=0.16; 95% CI: [0.04-7.0]) and without MDD (aOR = 0.26; 95% CI: [0.09-0.73]).

CONCLUSIONS

This study demonstrated that health care disparities persist for NHB veterans following a dysvascular LEA, with increased prosthesis abandonment and worse mobility outcomes.

Short Term Outcomes of a Prospective Registry of Popliteal and Infrapopliteal Endovascular Interventions for Chronic Limb Threatening Ischaemia

OBJECTIVE

The prevalence of chronic limb threatening ischaemia (CLTI) is increasing worldwide, resulting in the need for more patients to undergo revascularisation, especially for below the knee pathology. Nevertheless, prospective data on below the knee endovascular interventions are lacking. The aim of the study was to provide large scale, real world data on procedural and short term outcomes of popliteal and infrapopliteal endovascular interventions in patients with CLTI.

METHODS

This study is an analysis of the first 1 000 interventions of the Dutch Chronic Lower Limb Threatening Ischaemia Registry (THRILLER). It includes all patients with CLTI undergoing popliteal or infrapopliteal endovascular revascularisation in seven hospitals in the Netherlands. The primary outcomes were limb salvage and amputation free survival (AFS) at three months estimated by the Kaplan-Meier method. Secondary outcomes were procedural complications and primary patency.

RESULTS

Between February 2021 and July 2023, 1 000 endovascular procedures were performed in 840 patients (947 limbs), treating 486 popliteal and 1 209 tibial lesions. Wound, Ischaemia, and foot Infection (WIfI) stages 1 - 4 were present in 16.8%, 17.2%, 25.4%, and 40.6% of the limbs, respectively. Technical success was hampered by arterial perforation, acute thrombosis, and distal embolisation in 8.7%, 1.0%, and 2.3% of the interventions, respectively. Limb salvage was 100.0%, 96.9%, 94.9%, and 86.1% (p < .001), whereas AFS was 96.9%, 93.2%, 86.6%, and 76.4% for WIfI stages 1 - 4 at three months (p < .001), respectively. Primary patency at the 6 - 8 week visit was 86.4% for popliteal and 74.3% for tibial lesions, respectively.

CONCLUSION

THRILLER presents a large prospective database on outcomes of endovascular CLTI interventions. Popliteal and infrapopliteal endovascular revascularisation for CLTI is safe. Interventions with initial technical success have high rates of limb salvage and survival at three months. The WIfI classification provides a reliable instrument to predict limb salvage and AFS independently at three months.

The Decision for Amputation Versus Limb Salvage in Patients with Limb-threatening Lower Extremity Indications: An Ethical Analysis

Ethical decision-making in the amputation versus limb salvage context requires consideration of respect for patient autonomy, beneficence, and nonmaleficence. The surgical options demonstrate near equivalent outcomes for traumatic indications, while reconstruction is generally favored for threatened limbs due to diabetic complications. The decision for amputation versus limb salvage must be considered in each individual patient's situation, with a shared decision-making process of paramount importance. Discussion should involve the best, worst, and most likely case for each surgical option to allow the patient to better understand the range of potential postoperative courses and make an informed decision.

Using Vascular Deserts as a Guide for Limb Preservation Outreach Programs Successfully Targets Underserved Populations

BACKGROUND

Vascular deserts, regions without vascular providers, previously described targets for limb salvage efforts. The Comprehensive Heart and Multidisciplinary Limb Preservation Outreach Networks (CHAMPIONS) programs targeted regions for outreach and evaluated the population using desert maps.

METHODS

At 2 events targeting underserved regions between 2022 and 2023, providers screened and educated participants on peripheral arterial and cardiovascular disease (PACD). Demographics and cardiovascular risk factors were collected. Using Arc geographic information system, vascular surgeons, and Vascular Quality Initiative (VQI) participating facilities were mapped with a 30-mile buffer. Participants were mapped with census data, and the healthy places index (HPI) was overlayed for population and social determinants of health data analysis in medical service study areas (MSSA), a geographical analysis unit. (Figure 1) Results were compared to prior statewide deserts.

RESULTS

Outreach program participants' mean age was 56 (range 6-88); 39% were male, and the majority were Hispanic (86%). 27% had no primary care provider (PCP). 30% had diabetes, 10% undiagnosed before the event, 38% had hypertension, 40% undiagnosed prior to the event, and 21% described intermittent claudication. 81% made <$30,000 annually, and 28% reported no health insurance. Similarities were observed when comparing program participant demographics to the population-level data from the targeted regions. Patients were more frequently Hispanic than other desert regions (68% vs. 36%, P < 0.001). Compared to other vascular desert regions, the target population was more disadvantaged in all HPI domains, including economic (18 vs. 38%, P < 0.001), education (21 vs. 39%, P < 0.001), and transportation (30 vs. 40%, P < 0.001). Worse education, financial, and transportation resources correspond to decreased care access due to poor literacy and travel burdens.

CONCLUSIONS

CHAMPIONS programs successfully targeted populations needing care based on vascular care desert maps, demonstrating that at-risk populations can be successfully identified and screened for cardiovascular disease.

Health Disparities Across the Spectrum of Amputation Care: A Review of Literature

Limb loss is a common and disabling experience for patients, frequently caused by critical limb ischemia or deterioration of chronic wounds. Disparities in outcomes for prevention of amputation, level of amputation, and postamputation outcomes have been described. Understanding the nature of these disparities and the populations most affected can help clinicians and policymakers target interventions and programs. This article reviews existing literature regarding disparities in amputation care, including prevention methods, surgical outcomes, and postamputation outcomes. The authors identified several potential racial, socioeconomic, and gender disparities, particularly affecting Black, Native American, and Latino/a/x patients, female gender, and those in rural settings.

The Effect of Social Determinants of Health in Treating Chronic Limb-Threatening Ischemia

Social determinants of health (SDOHs) are broadly defined as nonmedical factors that impact the outcomes of one's health. SDOHs have been increasingly recognized in the literature as profound and modifiable factors on the outcomes of vascular care in peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) despite surgical and technological advancements. In this paper, we briefly review the SDOH and its impact on the management and outcome of patients with CLTI. We highlight the importance of understanding how SDOH impacts our patient population so the vascular community may provide more effective, inclusive, and equitable care.

Exploring Prognostic Implications of Race and Ethnicity in Patients With Peripheral Arterial Disease

INTRODUCTION

Significant health inequalities in major adverse limb events exist. Ethnically minoritized groups are more prone to have a major adverse event following peripheral vascular interventions. This systematic review and meta-analysis aimed to describe the postoperative implications of racial and ethnic status on clinical outcomes following vascular interventions for claudication and chronic limb-threatening ischemia.

METHODS

Searches were conducted across seven databases from inception to June 2021 and were updated in October 2022 to identify studies reporting claudication or chronic limb-threatening ischemia in patients who underwent open, endovascular, or hybrid procedures. Studies with documented racial and ethnic status and associated clinical outcomes were selected. Extracted data included demographic and clinical characteristics, vascular interventions, and measured outcomes associated with race or ethnicity. Meta-analyses were performed using random-effect models to report pooled odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Seventeen studies evaluating the impact of Black versus White patients undergoing amputation as a primary intervention were combined in a meta-analysis, revealing that Black patients had a higher incidence of amputations as a primary intervention than White patients (OR: 1.91, 95% CI: 1.61-2.27). Another meta-analysis demonstrated that Black patients had significantly higher rates of amputation after revascularization (OR: 1.56, 95% CI: 1.28-1.89). Furthermore, multiple trends were demonstrated in the secondary outcomes evaluated.

CONCLUSIONS

Our findings suggest that Black patients undergo primary major amputation at a significantly higher rate than White patients, with similar trends seen among Hispanic and First Nations patients. Black patients are also significantly more likely to be subjected to amputation following attempts at revascularization when compared to White patients.

Using Multidisciplinary Teams to Improve Outcomes for Treating Chronic-Limb Threatening Ischemia

Multidisciplinary teams are necessary to treat complex patients with chronic limb-threatening ischemia (CLTI). The need for adequate wound care and control of comorbid conditions cannot be accomplished by the vascular specialist alone. Numerous specialties have a role in this group to include surgical podiatrists, orthopedic surgery, plastic and reconstructive surgery endocrinology, and wound care. However, the vascular specialist must drive this team as the patients are usually referred to them and numerous studies have shown a direct correlation between major amputations and the lack of vascular involvement. Creating these teams is unique in each community and must consider practice patterns that are relevant in the local region. CLTI is a challenging disease to manage, and multidisciplinary teams have demonstrated an ability to improve outcomes and deliver superior care to this patient population.

Surgical Outcomes and Sociodemographic Disparities Across All Races: An ACS-NSQIP and NHIS Multi-Institutional Analysis of Over 7.5 Million Patients

Background

This study aims to fill the gap in large-scale, registry-based assessments by examining postoperative outcomes across diverse races/ethnicities. The focus is on identifying disparities and comparing them with socioeconomic demographics.

Methods

In a registry-based cohort study using the 2008 to 2020 American College of Surgeons National Surgical Quality Improvement Program, we evaluated 24 postoperative outcomes through multivariable analysis, incorporating 28 preoperative risk factors. In a separate, independent analysis of the 2019 to 2020 National Health Interview Survey (NHIS) database, we examined sociodemographic racial/ethnic normative data.

Results

Among 7,504,734 American College of Surgeons National Surgical Improvement Database patients specifying race, 83.8% were White (WT), 11.8% Black or African American (B/AA), 3.3% Asian (AS), 0.7% American Indian or Alaska Native (AI/AN), 0.4% Native Hawaiian or Pacific Islander (NH/PI), 7.3% Hispanic. Reoperation trends reveal favorable outcomes for WT, AS, and NH/PI patients compared with B/AA and AI/AN patients. AI/AN patients exhibit higher rates of wound healing issues, while AS patients experience lower rates. AS and B/AA patients are more prone to transfusions, with B/AA patients showing elevated rates of pulmonary embolism, deep vein thrombosis, renal failure, and insufficiency. Disparities in discharge destinations exist. Hispanic patients fare better than non-WT Hispanic patients, contingent on race. Racial groups (excluding Hispanic patients) with superior surgical outcomes from the NSQIP analysis were found in the NHIS analysis to report higher wealth, better healthcare access, improved food security, greater functional and societal independence, and lower frailty.

Conclusions

Our study underscores racial disparities in surgical outcomes. Focused investigations into these complications could reveal underlying causes, informing healthcare policies to enhance surgical care universally.

Effects of L-Ornithine-L-Aspartate on Angiogenesis and Perfusion in Subacute Hind Limb Ischemia: Preliminary Study

The current treatment options for peripheral arterial disease (PAD) are limited due to a lack of significant high-level evidence to inform clinical decisions and unfavorable outcomes in terms of cost-effectiveness and amputation rates. In order to suggest the use of the commercially available L-Ornithine-L-Aspartate (LOLA) for treating PAD, we induced hind limb ischemia (HLI) by unilaterally ligating the femoral artery in a rat model. The rats were randomly divided into three groups, with seven rats assigned to each group: group 1 (control), group 2 (sorbitol), and group 3 (LOLA). Intraperitoneal injections were administered five times on post-operative days (PODs) 3, 5, 7, 10, and 12. Perfusion imaging was conducted on PODs 7 and 14 and compared to pre-operative perfusion imaging. Immunohistochemistry staining and Western blotting were performed after the final perfusion imaging. Group 3 showed a significant increase in perfusion, high CD31-positive capillary lumen density, and substantial overexpression of VEGF in the ischemic limb during the subacute phase of HLI. In conclusion, this study provides the first documented evidence of angiogenesis and perfusion recovery in the subacute phase of the HLI model following the administration of LOLA. With LOLA readily available on the commercial market, the implementation of LOLA treatment for PAD in humans can be expedited compared to other therapies still in the developmental stage.

Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions

OBJECTIVE

Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set.

METHODS

We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups.

RESULTS

Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category.

CONCLUSIONS

Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Lower-extremity inter-joint coordination variability in active individuals with transtibial amputation and healthy males during gait

This study was aimed to compare the variability of inter-joint coordination in the lower-extremities during gait between active individuals with transtibial amputation (TTAs) and healthy individuals (HIs). Fifteen active male TTAs (age: 40.6 ± 16.24 years, height: 1.74 ± 0.09 m, and mass: 71.2 ± 8.87 kg) and HIs (age: 37.25 ± 13.11 years, height: 1.75 ± 0.06 m, and mass: 74 ± 8.75 kg) without gait disabilities voluntarily participated in the study. Participants walked along a level walkway covered with Vicon motion capture system, and their lower-extremity kinematics data were recorded during gait. The spatiotemporal gait parameters, lower-extremity joint range of motion (ROM), and their coordination and variability were calculated and averaged to report a single value for each parameter based on biomechanical symmetry assumption in the lower limbs of HIs. Additionally, these parameters were separately calculated and reported for the intact limb (IL) and the prosthesis limb (PL) in TTAs individuals. Finally, a comparison was made between the averaged values in HIs and those in the IL and PL of TTAs subjects. The results showed that the IL had a significantly lower stride length than that of the PL and averaged value in HIs, and the IL had a significantly lower knee ROM and greater stance-phase duration than that of HIs. Moreover, TTAs showed different coordination patterns in pelvis-to-hip, hip-to-knee, and hip-to-ankle couplings in some parts of the gait cycle. It concludes that the active TTAs with PLs walked with more flexion of the knee and hip, which may indicate a progressive walking strategy and the differences in coordination patterns suggest active TTA individuals used different neuromuscular control strategies to adapt to their amputation. Researchers can extend this work by investigating variations in these parameters across diverse patient populations, including different amputation etiologies and prosthetic designs. Moreover, Clinicians can use the findings to tailor rehabilitation programs for TTAs, emphasizing joint flexibility and coordination.

Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort

BACKGROUND

The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI.

METHODS AND RESULTS

In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death.

CONCLUSIONS

A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.

Including socioeconomic status reduces readmission penalties to safety-net hospitals

OBJECTIVE

Medicare's Hospital Readmissions Reduction Program (HRRP) financially penalizes "excessive" postoperative readmissions. Concerned with creating a double standard for institutions treating a high percentage of economically vulnerable patients, Medicare elected to exclude socioeconomic status (SES) from its risk-adjustment model. However, recent evidence suggests that safety-net hospitals (SNHs) caring for many low-SES patients are disproportionately penalized under the HRRP. We sought to simulate the impact of including SES-sensitive models on HRRP penalties for hospitals performing lower extremity revascularization (LER).

METHODS

This is a retrospective, cross-sectional analysis of national data on Medicare patients undergoing open or endovascular LER procedures between 2007 and 2009. We used hierarchical logistic regression to generate hospital risk-standardized 30-day readmission rates under Medicare's current model (adjusting for age, sex, comorbidities, and procedure type) compared with models that also adjust for SES. We estimated the likelihood of a penalty and penalty size for SNHs compared with non-SNHs under the current Medicare model and these SES-sensitive models.

RESULTS

Our study population comprised 1708 hospitals performing 284,724 LER operations with an overall unadjusted readmission rate of 14.4% (standard deviation: 5.3%). Compared with the Centers for Medicare and Medicaid Services model, adjusting for SES would not change the proportion of SNHs penalized for excess readmissions (55.1% vs 53.4%, P = .101) but would reduce penalty amounts for 38% of SNHs compared with only 17% of non-SNHs, P < .001.

CONCLUSIONS

For LER, changing national Medicare policy to including SES in readmission risk-adjustment models would reduce penalty amounts to SNHs, especially for those that are also teaching institutions. Making further strides toward reducing the national disparity between SNHs and non-SHNs on readmissions, performance measures require strategies beyond simply altering the risk-adjustment model to include SES.

Treatment Variability Among Patients Hospitalized for Chronic Limb-Threatening Ischemia: An Analysis of the 2016 to 2018 US National Inpatient Sample

BACKGROUND

Little is known about treatment variability across US hospitals for patients with chronic limb-threatening ischemia (CLTI).

METHODS AND RESULTS

Data were collected from the 2016 to 2018 National Inpatient Sample. All patients aged ≥18 years, admitted to nonfederal US hospitals with a primary diagnosis of CLTI, were identified. Patients were classified according to their clinical presentation (rest pain, skin ulceration, or gangrene) and were further characterized according to the treatment strategy used. The primary outcome of interest was variability in CLTI treatment, as characterized by the median odds ratio. The median odds ratio is defined as the likelihood that 2 similar patients would be treated with a given modality at 1 versus another randomly selected hospital. There were 15 896 (weighted n=79 480) hospitalizations identified where CLTI was the primary diagnosis. Medical therapy alone, endovascular revascularization ± amputation, surgical revascularization ± amputation, and amputation alone were used in 4057 (25%), 5390 (34%), 3733 (24%), and 2716 (17%) patients, respectively. After adjusting for both patient- and hospital-related factors, the median odds ratio (95% CI) for medical therapy alone, endovascular revascularization ± amputation, surgical revascularization ± amputation, any revascularization, and amputation alone were 1.28 (1.19-1.38), 1.86 (1.77-1.95), 1.65 (1.55-1.74), 1.37 (1.28-1.45), and 1.42 (1.27-1.55), respectively.

CONCLUSIONS

Significant variability in CLTI treatment exists across US hospitals and is not fully explained by patient or hospital characteristics.

A high burden of diabetes and ankle brachial index abnormalities exists in Mexican Americans in South Texas

Ethnic differences exist in the United States in the interrelated problems of diabetes (DM), peripheral arterial disease (PAD), and leg amputations. The purpose of this study was to determine the prevalence and risk factor associations for subclinical PAD in a population sample of Mexican Americans using the ankle brachial (ABI) index. The ABI-High (higher of the two ankle pressures/highest brachial pressure) and ABI-Low (lower of the two ankle pressures/highest brachial pressure) were calculated to define PAD. Toe brachial index (TBI) was also calculated. 746 participants were included with an age of 53.4 ± 0.9 years, 28.3 % had diabetes mellitus (DM), 12.6 % were smokers, and 51.2 % had hypertension (HTN). Using ABI-High ≤ 0.9, the prevalence of PAD was 2.7 %. This rose to 12.7 % when an ABI-Low ≤ 0.9 was used; 4.0 % of the population had an ABI-High > 1.4. The prevalence of TBI < 0.7 was 3.9 %. DM was a significant risk factor for ABI-High ≤ 0.9 and ABI-High > 1.4, and TBI < 0.7. Increased age, HTN, smoking was associated with ABI-High ≤ 0.9, while being male was associated with ABI-High > 1.4. Increased age, smoking, and lower education were all associated with abnormal TBI. Despite relatively younger mean age than other studied Hispanic cohorts, the present population has a high burden of ABI abnormalities. DM was a consistent risk factor for PAD. These abnormalities indicate an important underlying substrate of vascular and metabolic disease that may predispose this population to the development of symptomatic PAD and incident amputations.

A systematic review and meta-analysis on the influence of sociodemographic factors on amputation in patients with peripheral arterial disease

OBJECTIVE

To identify disparities in sociodemographic factors that are associated with major lower limb amputation in patients with peripheral arterial disease (PAD).

METHODS

A systematic review of the literature was performed to identify studies that reported major lower limb amputation rates in patients with PAD among different sociodemographic groups. Data that compared amputation rates on the basis of sex, race, ethnicity, income, insurance, geography, and hospital type were collected and described. Outcomes were then aggregated and standardized, and a meta-analysis was performed to synthesis data into single odds ratios (ORs).

RESULTS

Forty-one studies were included in the review. There was no association found between males and females (OR, 0.95; 95% confidence interval [CI], 0.90-1.00). Compared with Whites, higher rates of amputation were seen among Blacks/African Americans (OR, 2.02; 95% CI, 1.81-2.26) and Native Americans (OR, 1.22; 95% CI, 1.04-1.45). No significant association was found between Whites and Asians, Native Hawaiians, or Pacific Islanders (OR, 1.15; 95% CI, 1.00-1.33). Hispanics had higher rates of amputation compared with non-Hispanics (OR, 1.36; 95% CI, 1.22-1.52). Compared with private insurance, higher rates of amputation were seen among Medicare patients (OR, 1.38; 95% CI, 1.27-1.50), Medicaid patients (OR, 1.59; 95% CI, 1.44-1.76), and noninsured patients (OR, 1.41; 95% CI, 1.02-1.95). Compared with the richest income quartile, higher rates of amputation were seen among the second income quartile (OR, 1.10; 95% CI, 1.05-1.15), third income quartile (OR, 1.20; 95% CI, 1.07-1.35), and bottom income quartile (OR, 1.36; 95% CI, 1.24-1.49). There was no association found between rural and urban populations (OR, 1.35; 95% CI, 0.92-1.97) or between teaching and nonteaching hospitals (OR, 1.01; 95% CI, 0.91-1.12).

CONCLUSIONS

Our study has identified a number of disparities and quantified the influence of sociodemographic factors on major lower limb amputation rates owing to PAD between groups. We believe these findings can be used to better target interventions aimed at decreasing amputation rates, although further research is needed to better understand the mechanisms behind our findings.

Vascular surgeons are positioned to fight healthcare disparities

Comprehensively managing vascular disease in the United States can seem overwhelming. Vascular surgery providers encounter daily stress-inducing challenges, including caring for sick patients who often, because of healthcare barriers, struggle with access to care, socioeconomic challenges, and a complex medical system. These individuals can present with advanced disease and comorbidities, and many have limited treatment options. Subsequently, it could seem as if the vascular surgeon's efforts have little opportunity to make a difference. This review describes a method to counter this sentiment through directed action, hope, and community building. Vascular surgeons are passionate about what they do and are built to fight healthcare disparities. This review also outlines the reasoning for attempting to create change and one approach to begin making a difference.

Impact of Intensity of Vascular Care Preceding Major Amputation Among Patients With Chronic Limb-Threatening Ischemia

BACKGROUND

Lower-limb amputation rates in patients with chronic limb-threatening ischemia vary across the United States, with marked disparities in amputation rates by gender, race, and income status. We evaluated the association of patient, hospital, and geographic characteristics with the intensity of vascular care received the year before a major lower-limb amputation and how intensity of care associates with outcomes after amputation.

METHODS

Using Medicare claims data (2016-2019), beneficiaries diagnosed with chronic limb-threatening ischemia who underwent a major lower-limb amputation were identified. We examined patient, hospital, and geographic characteristics associated with the intensity of vascular care received the year before amputation. Secondary objectives evaluated all-cause mortality and adverse events following amputation.

RESULTS

Of 33 036 total Medicare beneficiaries undergoing major amputation, 7885 (23.9%) were due to chronic limb-threatening ischemia; of these, 4988 (63.3%) received low-intensity and 2897 (36.7%) received high-intensity vascular care. Mean age, 76.6 years; women, 38.9%; Black adults, 24.5%; and of low income, 35.2%. After multivariable adjustment, those of low income (odds ratio, 0.65 [95% CI, 0.58-0.72]; P<0.001), and to a lesser extent, men (odds ratio, 0.89 [95% CI, 0.81-0.98]; P=0.019), and those who received care at a safety-net hospital (odds ratio, 0.87 [95% CI, 0.78-0.97]; P=0.012) were most likely to receive low intensity of care before amputation. High-intensity care was associated with a lower risk of all-cause mortality 2 years following amputation (hazard ratio, 0.79 [95% CI, 0.74-0.85]; P<0.001).

CONCLUSIONS

Patients who were of low-income status, and to a lesser extent, men, or those cared for at safety-net hospitals were most likely to receive low-intensity vascular care. Low-intensity care was associated with worse long-term event-free survival. These data emphasize the continued disparities that exist in contemporary vascular practice.

Amputation Rates and Associated Social Determinants of Health in the Most Populous US Counties

Importance

Social Determinants of Health (SDOH) have been found to be associated with health outcome disparities in patients with peripheral artery disease (PAD). However, the association of specific components of SDOH and amputation has not been well described.

Objective

To evaluate whether individual components of SDOH and race are associated with amputation rates in the most populous counties of the US.

Design, Setting, and Participants

In this population-based cross-sectional study of the 100 most populous US counties, hospital discharge rates for lower extremity amputation in 2017 were assessed using the Healthcare Cost and Utilization Project State Inpatient Database. Those data were matched with publicly available demographic, hospital, and SDOH data. Data were analyzed July 3, 2022, to March 5, 2023.

Main outcome and Measures

Amputation rates were assessed across all counties. Counties were divided into quartiles based on amputation rates, and baseline characteristics were described. Unadjusted linear regression and multivariable regression analyses were performed to assess associations between county-level amputation and SDOH and demographic factors.

Results

Amputation discharge data were available for 76 of the 100 most populous counties in the United States. Within these counties, 15.3% were African American, 8.6% were Asian, 24.0% were Hispanic, and 49.6% were non-Hispanic White; 13.4% of patients were 65 years or older. Amputation rates varied widely, from 5.5 per 100 000 in quartile 1 to 14.5 per 100 000 in quartile 4. Residents of quartile 4 (vs 1) counties were more likely to be African American (27.0% vs 7.9%, P < .001), have diabetes (10.6% vs 7.9%, P < .001), smoke (16.5% vs 12.5%, P < .001), be unemployed (5.8% vs 4.6%, P = .01), be in poverty (15.8% vs 10.0%, P < .001), be in a single-parent household (41.9% vs 28.6%, P < .001), experience food insecurity (16.6% vs 12.9%, P = .04), or be physically inactive (23.1% vs 17.1%, P < .001). In unadjusted linear regression, higher amputation rates were associated with the prevalence of several health problems, including mental distress (β, 5.25 [95% CI, 3.66-6.85]; P < .001), diabetes (β, 1.73 [95% CI, 1.33-2.15], P < .001), and physical distress (β, 1.23 [95% CI, 0.86-1.61]; P < .001) and SDOHs, including unemployment (β, 1.16 [95% CI, 0.59-1.73]; P = .03), physical inactivity (β, 0.74 [95% CI, 0.57-0.90]; P < .001), smoking, (β, 0.69 [95% CI, 0.46-0.92]; P = .002), higher homicide rate (β, 0.61 [95% CI, 0.45-0.77]; P < .001), food insecurity (β, 0.51 [95% CI, 0.30-0.72]; P = .04), and poverty (β, 0.46 [95% CI, 0.32-0.60]; P < .001). Multivariable regression analysis found that county-level rates of physical distress (β, 0.84 [95% CI, 0.16-1.53]; P = .03), Black and White racial segregation (β, 0.12 [95% CI, 0.06-0.17]; P < .001), and population percentage of African American race (β, 0.06 [95% CI, 0.00-0.12]; P = .03) were associated with amputation rate.

Conclusions and Relevance

Social determinants of health provide a framework by which the associations of environmental factors with amputation rates can be quantified and potentially used to guide interventions at the local level.

Factors Associated With Early Amputation in Patients With Chronic Limb Threatening Ischemia

INTRODUCTION

Despite advancements in revascularization procedures, early amputation (EA) among patients with chronic limb threatening ischemia (CLTI) are still common. The present study evaluated clinical outcomes of patients with CLTI and factors associated with EA.

METHODS

The 2016-2019 Nationwide Readmission Database was queried to identify all adults (≥18 years) with CLTI of lower extremities undergoing limb salvage (LS) procedures. The primary outcome of the study was EA within 90 days of discharge. Secondary outcomes included infectious complication, length of stay (LOS), cumulative hospitalization cost and non-home discharge.

RESULTS

Of 103,703 patients who initially underwent surgical or endovascular revascularization, 10,439 (10.1%) subsequently underwent major amputation within 90 days of discharge. Following risk adjustment, factors associated with higher odds of EA were male sex, low-income quartile, tissue loss due to ulceration or gangrene, end-stage renal disease, and diabetes. Compared to those undergoing open revascularization, patients with endovascular limb salvage had a higher likelihood of having early amputation (AOR 1.41, 95% CI 1.31-1.51). Patients undergoing EA had greater odd of infectious complication, incremental LOS, incremental cost and non-home discharge.

CONCLUSIONS

We identified several risk factors to be associated with EA in patients with CLTI. These findings may supplement the objective performance goals for limb-related outcomes and facilitate institutional limb salvage programs.

Limb Salvage and Survival in Chronic Limb-Threatening Ischemia: The Need for a Fast-Track Team-Based Approach

Chronic limb-threatening ischemia (CLTI) represents the end-stage form of peripheral arterial disease (PAD) and is associated with a very poor prognosis and high risk of limb loss and mortality. It can be considered very similar to a terminal cancer disease, reflecting a large impact on quality of life and healthcare costs. The aim of this study is to offer an overview of the relationship between CLTI, limb salvage, and mortality, with a focus on the need of a fast-track team-based management that is a driver to achieve better survival results. This review can be useful to improve management of this growing impact disease, and to promote the standardisation of care and communication between specialist and non-specialist healthcare professionals.

Focused Ultrasound, an Emerging Tool for Atherosclerosis Treatment: A Comprehensive Review

Focused ultrasound (FUS) has emerged as a promising noninvasive therapeutic modality for treating atherosclerotic arterial disease. High-intensity focused ultrasound (HIFU), a noninvasive and precise modality that generates high temperatures at specific target sites within tissues, has shown promising results in reducing plaque burden and improving vascular function. While low-intensity focused ultrasound (LIFU) operates at lower energy levels, promoting mild hyperthermia and stimulating tissue repair processes. This review article provides an overview of the current state of HIFU and LIFU in treating atherosclerosis. It focuses primarily on the therapeutic potential of HIFU due to its higher penetration and ability to achieve atheroma disruption. The review summarizes findings from animal models and human trials, covering the effects of FUS on arterial plaque and arterial wall thrombolysis in carotid, coronary and peripheral arteries. This review also highlights the potential benefits of focused ultrasound, including its noninvasiveness, precise targeting, and real-time monitoring capabilities, making it an attractive approach for the treatment of atherosclerosis and emphasizes the need for further investigations to optimize FUS parameters and advance its clinical application in managing atherosclerotic arterial disease.

Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study

BACKGROUND

Patients with diabetes and peripheral arterial disease are at increased risk of minor amputation. The aim of study was to assess the rate of re-amputations and death after an initial minor amputation, and to identify associated risk factors.

METHODS

Data on all patients aged 40 years and over with diabetes and/or peripheral arterial disease, who underwent minor amputation between January 2014 and December 2018, were extracted from Hospital Episode Statistics. Patients who had bilateral index procedures or an amputation in the 3 years before the study were excluded. Primary outcomes were ipsilateral major amputation and death after the index minor amputation. Secondary outcomes were ipsilateral minor re-amputations, and contralateral minor and major amputations.

RESULTS

In this study of 22 118 patients, 16 808 (76.0 per cent) were men and 18 473 (83.5 per cent) had diabetes. At 1 year after minor amputation, the estimated ipsilateral major amputation rate was 10.7 (95 per cent c.i. 10.3 to 11.1) per cent. Factors associated with a higher risk of ipsilateral major amputation included male sex, severe frailty, diagnosis of gangrene, emergency admission, foot amputation (compared with toe amputation), and previous or concurrent revascularization. The estimated mortality rate was 17.2 (16.7 to 17.7) per cent at 1 year and 49.4 (48.6 to 50.1) per cent at 5 years after minor amputation. Older age, severe frailty, comorbidity, gangrene, and emergency admission were associated with a significantly higher mortality risk.

CONCLUSION

Minor amputations were associated with a high risk of major amputation and death. One in 10 patients had an ipsilateral major amputation within the first year after minor amputation and half had died by 5 years.

Development and Description of a National Cohort of Patients With Chronic Limb-Threatening Ischemia

Background

Chronic limb-threatening ischemia (CLTI) is a common condition with high rates of morbidity and mortality. Despite extensive literature documenting poor outcomes in patients with CLTI, as well as racial, ethnic, socioeconomic, and geographic disparities in these outcomes, process measures for high-quality CLTI care have not been developed. We developed the Chronic Limb threatening Ischemia Process PERformace (CLIPPER) cohort to develop and test the validity of CLTI care quality measures.

Methods

Using inpatient and outpatient claims data from patients with fee-for-service Medicare from 2010 to 2019, we created a coding algorithm to identify patients with CLTI. To qualify for a CLTI diagnosis, patients had to have either diagnostic codes for peripheral artery disease and for ulceration, infection, or gangrene on the same inpatient or outpatient claim or a CLTI-specific diagnostic code. Patients were also required to have a procedural code indicating arterial vascular testing within 6 months before or after the earliest qualifying CLTI diagnostic code(s). We describe baseline characteristics and long-term outcomes of this cohort.

Results

The final cohort comprised 1,130,065 patients diagnosed with CLTI between 2010 and 2019. Mean (±SD) age of the cohort was 75 ± 5.8 years; 48.4% were women, and 14.6% were Black. Within 30 days of CLTI diagnosis, 20.4% of patients underwent either percutaneous or surgical revascularization. Within 6 months, 3.3% of patients underwent major amputation; 16.7% of patients died within 1 year and 50.3% within 5 years.

Conclusions

We described the development of a cohort of fee-for-service Medicare patients with CLTI using inpatient and outpatient Medicare claims data. CLIPPER will be a resource for developing a set of process measures that can be captured from administrative claims data, with plans to describe their association with limb outcomes and corresponding racial, ethnic, socioeconomic, sex-based, and geographic variability.

Association of Health Care Utilization and Access to Care With Vascular Assessment Before Major Lower Extremity Amputation Among US Veterans

Importance

Patient-level characteristics alone do not account for variation in care among US veterans with peripheral artery disease (PAD). Presently, the extent to which health care utilization and regional practice variation are associated with veterans receiving vascular assessment prior to major lower extremity amputation (LEA) is unknown.

Objective

To assess whether demographics, comorbidities, distance to primary care, the number of ambulatory clinic visits (primary and medical specialty care), and geographic region are associated with receipt of vascular assessment prior to LEA.

Design, Setting, and Participants

This national cohort study used US Department of Veterans Affairs' Corporate Data Warehouse data from March 1, 2010, to February 28, 2020, for veterans aged 18 or older who underwent major LEA and who received care at Veterans Affairs facilities.

Exposures

The number of ambulatory clinic visits (primary and medical specialty care) in the year prior to LEA, geographic region of residence, and distance to primary care.

Main Outcomes and Measures

The main outcome was receipt of a vascular assessment (vascular imaging study or revascularization procedure) in the year prior to LEA.

Results

Among 19 396 veterans, the mean (SD) age was 66.78 (10.20) years and 98.5% were male. In the year prior to LEA, 8.0% had no primary care visits and 30.1% did not have a vascular assessment. Compared with veterans with 4 to 11 primary care clinic visits, those with fewer visits were less likely to receive vascular assessment in the year prior to LEA (1-3 visits: adjusted odds ratio [aOR], 0.90; 95% CI, 0.82-0.99). Compared with veterans who lived less than 13 miles from the closest primary care facility, those who lived 13 miles or more from the facility were less likely to receive vascular assessment (aOR, 0.88; 95% CI, 0.80-0.95). Veterans who resided in the Midwest were most likely to undergo vascular assessment in the year prior to LEA than were those living in other regions.

Conclusions and Relevance

In this cohort study, health care utilization, distance to primary care, and geographic region were associated with intensity of PAD treatment before LEA, suggesting that some veterans may be at greater risk of suboptimal PAD care practices. Development of clinical programs, such as remote patient monitoring and management, may represent potential opportunities to improve limb preservation rates and the overall quality of vascular care for veterans.

Racial Differences in Vascular Assessment Prior to Amputation in the Veterans Health Administration

Purpose

It is unclear whether disparities in the care provided before lower extremity amputation (LEA) is driven by differences in receipt of diagnostic work-up versus revascularization attempts.

Methods

We performed a national cohort study of Veterans who underwent LEA between March 2010 and February 2020 to assess receipt of vascular assessment with arterial imaging and/or revascularization in the year prior to LEA.

Results

Among 19,396 veterans (mean age 66.8 years; 26.6% Black), Black veterans had diagnostic procedures more often than White veterans (47.5% vs. 44.5%) and revascularization as often (25.8% vs. 24.5%).

Conclusion

We must identify patient and facility-level factors associated with LEA as disparities do not appear related to differences in attempted revascularization.

Regional variation in lower extremity revascularization and amputation for peripheral artery disease

OBJECTIVE

The aim of this study was to quantify the recent and historical extent of regional variation in revascularization and amputation for peripheral artery disease (PAD).

METHODS

This was a repeated cross-sectional analysis of all Ontarians aged 40 years or greater between 2002 and 2019. The co-primary outcomes were revascularization (endovascular or open) and major (above-ankle) amputation for PAD. For each of 14 health care administrative regions, rates per 100,000 person-years (PY) were calculated for 6-year time periods from the fiscal years 2002 to 2019. Rates were directly standardized for regional demographics (age, sex, income) and comorbidities (congestive heart failure, diabetes, chronic obstructive pulmonary disease, chronic kidney disease). The extent of regional variation in revascularization and major amputation rates for each time period was quantified by the ratio of 90th over the 10th percentile (PRR).

RESULTS

In 2014 to 2019, there were large differences across regions in demographics (rural living [range, 0%-39.4%], lowest neighborhood income quintile [range, 10.1%-25.5%]) and comorbidities (diabetes [range, 14.2%-22.0%], chronic obstructive pulmonary disease [range, 7.8%-17.9%]), and chronic kidney disease [range, 2.1%-4.0%]. Standardized revascularization rates ranged across regions from 52.6 to 132.6/100,000 PY and standardized major amputation rates ranged from 10.0 to 37.7/100,000 PY. The extent of regional variation was large (PRR ≥2.0) for both revascularization and major amputation. From 2002-2004 to 2017-2019, the extent of regional variation increased from moderate to large for revascularization (standardized PRR, 1.87 to 2.04) and major amputation (standardized PRR, 1.94 to 3.07).

CONCLUSIONS

Significant regional differences in revascularization and major amputation rates related to PAD remain after standardizing for regional differences in demographics and comorbidities. These differences have not improved over time.

Revascularizations and limb outcomes of hospitalized patients with diabetic peripheral arterial disease in the contemporary era

BACKGROUND

Concomitant diabetes mellitus and peripheral artery disease (PAD) is a complex disease process. This retrospective analysis of the National Inpatient Sample sought to understand trends in limb outcomes of this unique and prevalent cohort of patients.

METHODS

The National Inpatient Sample was queried between 2003 and 2017 for hospitalizations of patients with both type 2 diabetes mellitus and PAD. Trends in hospitalizations, limb outcomes, vascular interventions, and costs were analyzed.

RESULTS

There were 10,303,673 hospitalizations of patients with concomitant diabetes mellitus and PAD that were identified between 2003 and 2017. The prevalence of hospitalizations associated with this disease process increased from 1644 to 3228 per 100,000 hospitalizations, a 96.4% increase. This included an increase of 288 to 587 per 100,000 hospitalizations of patients aged 18 to 49 years old, which was accompanied by a 10.8% increase in minor amputations. Nontraumatic lower extremity amputations decreased overall. Black and Hispanic ethnicity were associated with an increased risk for amputation, along with Medicaid insurance and lower income quartile. Inpatient endovascular revascularization has increased over time with an associated decrease in open revascularization procedures. Amputation-related hospital costs significantly increased from $6.6 billion in 2003 to $14.8 billion in 2017.

CONCLUSIONS

An alarming increase of disease prevalence, negative in-hospital limb outcomes, and costs are seen in the current era in this analysis of patients with concurrent diabetes and PAD.

The use of telemedicine in peripheral artery disease and limb salvage

Chronic limb-threatening ischemia represents the morbid end stage of severe peripheral artery disease, with significant impact on patient quality of life. Early diagnosis of arterial insufficiency and referral for vascular intervention are essential for successful limb salvage. Disparate outcomes have been reported among patients residing in rural areas due to decreased access to care. Remote telemedicine outreach programs represent an opportunity to improve access to care in these rural communities. Establishment of a telehealth program requires identification of communities most in need of specialty care. After locating an ideal site, collaboration with local providers is necessary to develop a program that meets the specific needs of providers and patients. Surgeon guidance in development of screening and management algorithms ensures that patients obtain care reliably and with adjustments as needed to suit the referring provider, the patient, and the specialist. Telehealth evaluations can limit the financial burden associated with travel, while ensuring access to higher levels of care than are available in the patients' immediate area. Multiple barriers to telehealth exist. These include limited reimbursement, local provider resistance to new referral patterns, lack of in-person interaction and evaluation, and the inability to do a physical examination. Improved reimbursement models have made telehealth feasible, although care must be taken to ensure that practice patterns complement existing resources and are designed in a way that omits the need for in-person evaluation until the time of specialist intervention. Telemedicine is an underused tool in the arsenal of vascular surgeons. Targeted telehealth programs aid in increasing patient access to expert-level care, thereby improving health disparities that exist in rural populations.

Percutaneous Deep Venous Arterialization: Treatment of Patients with End-Stage Plantar Disease

Background

Percutaneous deep venous arterialization (pDVA) is a minimally invasive technique connecting the tibial arteries below the knee to the tibial venous system into plantar venous circulation to deliver oxygenated blood to otherwise nonperfused foot. This study demonstrated outcomes of pDVA with commercially available equipment and described single-center experience on pDVA for critical limb-threatening ischemia patients with small artery diseases and end-stage plantar disease (ESPD) who were deemed no-option cases.

Methods

A single-center retrospective review was performed on patients who underwent pDVA. Primary end points were successful establishment of tibial vein flow with venous pedal loop, rate of major amputation, and major adverse events over 6 months. Secondary end points were primary and secondary patency rates, minor amputation rates, and wound healing over 6 months.

Results

Forty-two patients with ESPD underwent pDVA. Risk factors identified were hypertension (92.8%), hyperlipidemia (85.7%), diabetes (78.6%), tobacco abuse (42.9%), and chronic kidney disease ≥ stage 3 (42.8%). Three patients were categorized as Rutherford Class 4, 14 patients Class 5, and 25 patients (59.5%) Class 6. Of 42 procedures, 33 (78.6%) were deemed successful. Amputation-free survival at 6 months was reported in 25 patients (60.9%); 16 patients (38.1%) reported minor amputations. Wound healing rate reported at 6 months was 23.8%.

Conclusions

This is one of the largest case series to date with real-world no-option patients undergoing pDVA. pDVA seems a reasonable option for limb salvage in patients with ESPD where traditional arterial revascularization is not feasible. Identifying criteria for patient selection and advanced wound care is important to ensure clinical success. Additional research is required to establish diagnostic guidelines for patients being evaluated for pDVA.

Racial and ethnic amputation level disparities in veterans undergoing incident dysvascular lower extremity amputation

BACKGROUND

The choice of incident amputation level can have a profound effect on clinical outcomes. Amputations at the transmetatarsal (TM) or transtibial (TT) levels result in greater preservation of function and mobility, whereas transfemoral (TF) amputations typically result in a greater adverse impact. Prior investigations have explored racial/ethnic and regional variation in incident amputation level. This study overcomes some of the methodological limitations seen in prior research through the use of a large national, multiyear veteran sample and by including only those who have undergone an incident amputation.

OBJECTIVES

(1) Determine if there are national/regional differences in the frequency of incident TF amputation compared with TM and TT amputation, (2) Determine if race/ethnicity and geographic region are associated with incident TF amputation level, and (3) Determine if racial/ethnic disparities of incident TF amputation differ by the presence of diabetes or prior revascularization.

DESIGN

Retrospective cohort study of veterans undergoing an incident dysvascular lower extremity amputation.

SETTING

One hundred ten Veterans Affairs (VA) Medical Centers.

PARTICIPANTS

Seven thousand two hundred ninety-six Veterans undergoing incident unilateral dysvascular lower extremity amputation identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database (2005-2014).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Incident amputation level.

RESULTS

The White, Black, and Hispanic risk for an incident TF amputation was 31% (n = 1356), 35% (n = 810), and 46% (n = 293), respectively. In the Continental region, Blacks who had not had a prior revascularization were more likely to undergo a TF amputation compared to Whites both with and without diabetes (odds ratio [OR] = 1.4; 95% confidence interval [CI], 1.1, 1.9 and OR = 1.5; 95% CI, 1.1, 2.1, respectively). In the Southeast region, Hispanics compared with Whites were at increased odds of undergoing a TF amputation, irrespective of a diabetes or a prior revascularization (ORs ≥ 2.9).

CONCLUSIONS

Racial and ethnic disparities exist in choice of proximal compared with distal amputation in specific VA geographic regions.

How to build a limb salvage program

Patients with chronic limb-threatening ischemia (CLTI) are medically complex and continue to experience high rates of amputation, despite improved diagnosis and treatment. Limb salvage programs and multidisciplinary teams provide comprehensive patient care and have been associated with reduced amputation rates. Recent societal guidelines suggest the adoption of limb salvage programs to improve care of patients with CLTI. In this article, we describe the critical components of a limb salvage program and outline the following steps to aid in their construction: community and institution assessment, formation of a multidisciplinary team, provision of patient care, and monitoring outcomes and processes refinement.

Variability in 30-day major amputation rates following endovascular peripheral vascular intervention for critical limb ischemia

Introduction: Patients with critical limb ischemia (CLI) can undergo endovascular peripheral vascular intervention (PVI) to restore blood flow and decrease risk of amputation. As a potential indicator of quality for CLI care, we sought to describe 30-day major amputation rates following PVI. We also examined rate variability, and patient-level and site-level factors predicting amputations, using a national electronic health record (EHR) database. Methods: Using the Cerner Health Facts de-identified EHR database, patients with CLI diagnosis codes undergoing PVI were identified. The rate of amputation within 30 days of PVI was calculated. Risk ratios predicting amputation were derived using a mixed effects Poisson regression model adjusting for 16 patient and clinical factors. Median risk ratios (MRRs) were calculated to quantify site-level variability in amputations. Results: A total of 20,204 PVI procedures for CLI from 179 healthcare sites were identified. Mean age at procedure was 69.0 ± 12.6 years, 58.0% were male, and 29.6% were persons of color. Amputation within 30 days of PVI occurred after 570 (2.8%) procedures. Malnutrition, previous amputation, diabetes, and being of Black race were predictors of amputation. Amputation rates across sites ranged from 0.0% to 10.0%. The unadjusted MRR was 1.40 (95% CI 1.35-1.46), which was attenuated after adjusting for patient-level factors (MRR 1.30, 95% CI 1.26-1.34) and site characteristics (MRR 1.11, 95% CI 1.09-1.13). Conclusions: Among PVI procedures for CLI treatment, 30-day amputation rates varied across institutions. Although patient-level factors explained some variability, site-level factors explained most variation in the rates of these outcomes.

Spatial analysis of factors impacting lower limb major amputation rates in Hungary

Summary: Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (β=−0.002, 95% CI: −0.05 – 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (β=−7.45, 95% CI: −10.50 – −4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.

Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review

BACKGROUND

The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible ("too late", "too sick", "no technical option"). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence.

METHODS

The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020.

RESULTS

If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life.

CONCLUSIONS

Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.

Team-Based Care in Patients with Chronic Limb-Threatening Ischemia

PURPOSE OF REVIEW

Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach.

RECENT FINDINGS

Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.

Early ABI Testing May Decrease Risk of Amputation for Patients With Lower Extremity Ulcers

BACKGROUND

Patients with lower extremity wounds from diabetes mellitus or peripheral artery disease (PAD) have a risk of amputation as high as 25%. In patients with arterial disease, revascularization decreases the risk of amputation. We aimed to determine if the early assessment of arterial perfusion correlates with the risk of amputation.

METHODS

We retrospectively reviewed patients referred to the vascular clinic over 18 months with Rutherford Grade 5 and 6 chronic limb-threatening ischemia to determine if patients had a pulse exam done at the time the wound was identified and when ankle brachial index (ABI) testing to evaluate perfusion was performed. Kaplan Meier analysis was used to determine if the timing of ABI testing affected the time to revascularization, wound healing, and risk of amputation.

RESULTS

Ninety-three patients with lower extremity wounds were identified. Of these, 59 patients (63%) did not have a pulse exam performed by their primary care provider when the wound was identified. Patients were classified by when they underwent ankle brachial index testing to assess arterial perfusion. Twenty-four had early ABI (<30 days) testing, with the remaining 69 patients having late ABI testing. Patients in the early ABI group were more likely to have a pulse exam done by their PCP than those in the late group, 12 (50%) vs. 22 (32%), P = 0.03. Early ABI patients had a quicker time to vascular referral (13 days vs. 91 days, P < 0.001). Early ABI patients also had quicker times to wound healing than those in the late group (117 days vs. 287 days, P < 0.001). Finally, patients that underwent early ABI were less likely to require amputation (Fig. 1), although this did not reach statistical significance (P = 0.07).

CONCLUSIONS

Early ABI testing expedites specialty referral and time to revascularization. It can decrease the time to wound healing. Larger cohort studies are needed to determine the overall effect of early ABI testing to decrease amputation rates.

Low Volume Hospitals Are Not Associated with Inferior Outcomes After Thoracic Endovascular Aortic Repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has been used increasingly to treat complex thoracic aortic pathology. This study aimed to assess hospital volume's impact on outcomes in patients undergoing TEVAR.

STUDY DESIGN

Patients undergoing TEVAR between January 2015 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The participating centers were grouped into either low-volume hospitals (LVH) or high-volume hospitals (HVH). We assessed the impact of hospital volume on 30-day mortality and major postoperative complications using a multivariable logistic regression analysis.

RESULTS

A total of 3,584 TEVAR patients (asymptomatic = 1,720; symptomatic/ruptured =1,864) were identified at 147 centers. The median average annual number of TEVAR cases at LVH and HVH was 6 and 17 cases, respectively. There was no significant difference in 30-day mortality between LVH and HVH (asymptomatic: 3.7% vs. 3.7%, p = 0.98; symptomatic/rupture: 9.3% vs. 7.3%, p = 0.13). After adjusting for multiple clinical and anatomical factors, being treated in LVH was not associated with increased 30-day mortality (asymptomatic: OR = 0.98, 95% CI: 0.52, 1.87, p = 0.96; symptomatic/rupture: OR = 1.15, 95%CI: 0.75, 1.77, p = 0.53) nor an increased risk of major complications, including renal, neurological, cardiac, pulmonary, and femoral artery access complication (all p > 0.05).

CONCLUSION

Using a large national database, we demonstrate that LVH is not associated with inferior TEVAR outcomes than HVH. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.

[Rehabilitation following the amputation of an extremity]

The rehabilitation of patients with an amputation is challenging and an example of an interdisciplinary team approach. Knowledge of the principal surgical techniques and the needs for a good prosthetic fitting is mandatory for the team members. According to the ideas of International Classification of Functioning, Disabilities and Handicaps the goal of the rehabilitation is to achieve the highest possible participation in private, work and social life of the patient. Within the team a clear definition of responsibilities is necessary, as well as an intensive communication structure. The patient himself plays a major role. This rehabilitation is complex, in terms of both personal and resource use. Depending on the level of amputation, the usual rehabilitation times range between 4 to 12 weeks for the lower extremity; for the arms, the time varies greatly from person to person. Longer rehabilitation times seem to ensure better treatment outcomes in the long term.

Racial disparities in surgical management and outcomes of acute limb ischemia in the United States

Background

Although significant racial disparities in the surgical management of lower extremity critical limb threatening ischemia have been previously reported, data on disparities in lower extremity acute limb ischemia are lacking.

Methods

The 2012–2018 National Inpatient Sample was queried for all adult hospitalizations for acute limb ischemia (N = 225,180). Hospital-specific observed-to-expected rates of major lower extremity amputation were tabulated. Multivariable logistic and linear models were developed to assess the impact of race on amputation and revascularization.

Results

Nonwhite race was associated with significantly increased odds of overall (adjusted odds ratio: 1.16, 95% confidence interval 1.06–1.28) and primary (adjusted odds ratio: 1.34, 95% confidence interval 1.17–1.53) major amputation, decreased odds of revascularization (adjusted odds ratio 0.79, 95% confidence interval 0.73–0.85), but decreased in-hospital mortality (adjusted odds ratio: 0.86, 95% confidence interval 0.74–0.99). The nonwhite group incurred increased adjusted index hospitalization costs (β: +$4,810, 95% confidence interval 3,280-6,350), length of stay (β: + 1.09 days, 95% confidence interval 0.70–1.48), and nonhome discharge (adjusted odds ratio: 1.15, 95% confidence interval 1.06–1.26).

Conclusion

Significant racial disparities exist in the management of and outcomes of lower extremity acute limb ischemia despite correction for variations in hospital amputation practices and other relevant hospital and patient characteristics. Whether the etiology lies primarily in patient, institution, or healthcare provider–specific factors has not yet been determined. Further studies of race-based disparities in management and outcomes of acute limb ischemia are warranted to provide effective and equitable care to all.

The association of healthcare disparities and patient-specific factors on clinical outcomes in peripheral artery disease

BACKGROUND

PAD increases the risk of cardiovascular mortality and limb loss, and disparities in treatment and outcomes have been described. However, the association of patient-specific characteristics with variation in outcomes is less well known.

METHODS

Patients with PAD from Duke University Health System (DUHS) between January 1, 2015 and March 31, 2016 were identified. PAD status was confirmed through ground truth adjudication and predictive modeling using diagnosis codes, procedure codes, and other administrative data. Symptom severity, lower extremity imaging, and ankle-brachial index (ABI) were manually abstracted from the electronic health record (EHR). Data was linked to Centers for Medicare and Medicaid Services data to provide longitudinal follow up. Primary outcome was major adverse vascular events (MAVE), a composite of all-cause mortality, myocardial infarction (MI), stroke, lower extremity revascularization and amputation.

RESULTS

Of 1,768 patients with PAD, 31.6% were asymptomatic, 41.2% had intermittent claudication (IC), and 27.3% had chronic limb-threatening ischemia (CLTI). At 1 year, patients with CLTI had higher rates of MAVE compared with asymptomatic or IC patients. CLTI and Medicaid dual eligibility were independent predictors of mortality. CLTI and Black race were associated with amputation.

CONCLUSIONS

Rates of MAVE were highest in patients with CLTI, but patients with IC or asymptomatic disease also had high rates of adverse events. Black and Medicaid dual-eligible patients were disproportionately present in the CLTI subgroup and were at higher risk of amputation and mortality, respectively. Future studies must focus on early identification of high-risk patient groups to improve outcomes in patients with PAD.

Moving forward: Recommendations to overcome existing structural racism

A critical need exists to address structural racism within academic and community medicine and surgery and determine methods that will serve to repair its long-standing effects and alleviate the associated negative consequences. Because of our broad skillset and the populations we serve, vascular surgeons are uniquely positioned to identify and address the effects of structural racism in our places of work and for the populations we treat. Our goal is to discuss the effects of racism on healthcare outcomes and provide recommendations on how to combat these through equitable practices such as the diversification of the vascular surgery workforce, inclusivity as partners and leaders, and the promotion of improved outcomes among our most vulnerable patients from racial and ethnic minority groups. It is imperative that we stand for antiracism within our field through our societies, journals, clinical trials, training programs, clinical practice groups, and leadership.

Racial and Ethnic Disparities in Peripheral Artery Disease

Peripheral artery disease is an obstructive, atherosclerotic disease of the lower extremities causing significant morbidity and mortality. Black Americans are disproportionately affected by this disease while they are also less likely to be diagnosed and promptly treated. The consequences of this disparity can be grim as Black Americans bear the burden of lower extremity amputation resulting from severe peripheral artery disease. The risk factors of peripheral artery disease and how they differentially affect certain groups are discussed in addition to a review of pharmacological and nonpharmacological treatment modalities. The purpose of this review is to highlight health care inequities and provide a review and resource of available recommendations for clinical management of all patients with peripheral artery disease.