Gender does not impact infrainguinal vein bypass graft outcome

Outcomes of open and endovascular infra-inguinal revascularization are poor in young patients with atherosclerotic peripheral artery disease but do not differ between genders

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.

Indications for a "Surgery-First" Approach for the Treatment of Lower Extremity Arterial Disease

BACKGROUND

In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization.

METHODS

A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models.

RESULTS

We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis.

CONCLUSIONS

Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm.

Increased Reintervention After Infrainguinal Revascularization for Chronic Limb-Threatening Ischemia in Women

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.

Gender differences and long-term clinical outcomes in patients with chronic total occlusions of infrainguinal lower limb arteries treated from retrograde access with peripheral vascular interventions

PURPOSE

We sought to investigate gender-related differences in clinical outcomes after peripheral vascular interventions (PVIs) from retrograde access in patients with chronic total occlusions (CTOs) of the infrainguinal arteries.

PATIENTS AND METHODS

A total of 939 consecutive patients undergoing PVI were enrolled in the study. Patients with peripheral artery diseases (PAD) and CTOs were treated with PVI from retrograde access according to the local protocol. The participants were divided according to gender. Retrograde access included distal puncturing to reach the CTO. The mean follow-up lasted 1,144.9 ± 664.3 days. Baseline characteristics, procedural and long-term outcomes were compared according to gender.

RESULTS

Women represented 37.4% of the study population, and more frequently suffered from hypertension (92% vs. 86%, p = 0.001) and diabetes (54% vs. 46%, p = 0.02). Males more often presented with chronic obstructive pulmonary disease (14.8% vs. 6.8%, p = 0.0003), coronary artery disease (45.4% vs. 32.7%, p = 0.0001), smoking (60.4% vs. 45%, p = 0.007) and prior PVI (25% vs. 17%, p = 0.005). The Kaplan-Meier survival curves at 5 years did not reveal gender-related differences in mortality (p = 0.8), whereas men were at a significantly higher risk of re-PVI during the follow-up period (p = 0.047). Male gender was an independent predictor of re-PVI (Hazard ratio: 1.276; 95% confidence interval: 1.015-1.614, p = 0.03).

CONCLUSION

Males are at increased risk of re-PVI compared to females with PAD and CTOs of infrainguinal arteries treated with PVI from retrograde access.

Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume

Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10–707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83–0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17–0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69–0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09–1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.

Predictors for the Healing of Transmetatarsal Amputations: Retrospective Study of 91 Amputations

This retrospective study reviewed 80 consecutive patients (mean age 62 years; range 21–91 years) who underwent 91 transmetatarsal amputations (TMAs) between 1995 and 2003. The mean follow-up was 12 ± 1.36 months. Sixty-two TMAs healed initially (group 1), whereas 29 TMAs did not heal by 3 months (group 2). At the final examination, in groups 1 and 2, 63 of 91 (69%) limbs were healed. Of the 28 limbs that did not heal, 25 of 28 (89%) required further proximal amputation. Initial healing correlated significantly with the ability to ambulate ( p < .0001) and overall limb salvage ( p < .0001). In group 1, 20 of 27 (74%) limbs that were revascularized healed ( p = .0336). Nonhealing amputations were associated with end-stage renal disease (13 of 19; 68%) ( p = .0209) and leukocytosis (13 of 19; 68%) ( p = .0052).

The influence of gender on functional outcomes of lower extremity bypass

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.

Gender-Based Analysis of Perioperative Outcomes Associated with Lower Extremity Bypass

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.

Outcome of lower extremity revascularization for peripheral artery occlusive disease: is there a difference between men and women?

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.

Arterial vascular disease in women

BACKGROUND

Arterial disease in women will become a major issue in the near future.

METHODS

A systemic review of existing literature was retrospectively conducted to collect information on the three most common entities of vascular disease: carotid atherosclerotic, abdominal aortic aneurismal, and lower extremity arterial occlusive disease.

RESULTS

Vascular disease is either underdiagnosed or undertreated in women. Whether regarding cerebrovascular disease, aortic aneurysmal disease, or atherosclerosis affecting the lower extremities, natural history, clinical and physiologic patterns are different in women vs men. Current biomedical devices create challenges in endovascular procedures performed in women. Furthermore, indications for treatment of vascular disease are derived from large studies where women are often underrepresented; and, thus, may not be applicable in female vascular patients.

CONCLUSIONS

Better understanding of the gender differences in vascular disease with focused randomized trials, biomedical research, and identification of gender specific medical and social risk factors will improve the clinical outcomes in female patients.

[Preoperative factors influencing the early results of infrainguinal limb salvage procedures]

INTRODUCTION

The early results of 59 patients treated surgically for critical limb ischemia at the Institute of Cardiovascular Diseases were analyzed. Research was performed in a prospective manner, as an acute study, lasting for three months.

OBJECTIVE

Our focus was on primary and secondary patency rate, and graft efficacy (quality accomplished by graft patency, improvement of clinical status of the leg, and quality of life).

METHOD

The influence of each variable on the outcome was analyzed (descriptive: sex, comorbidity, risk factors, clinical stage of disease, angiographic verification of pedal arch, previous vascular procedures; and numerical: gender, preoperative Doppler index, angiographic score by Bollinger), as well as their predictive value. Inferential statistics was used for establishing the significance of influence, and univariate regression analysis for predictive values.

RESULTS

No influence of variables on the outcome was evident in the first three months, and their predictive value was not important considering the graft patency rates and efficacy (except for preoperative clinical status affecting the graft efficacy, presence of pedal arch, affecting both primary and secondary patency rates and graft efficacy, and finally Doppler index affecting the secondary patency rates).

CONCLUSION

When the surgeon needs to give an early prediction of graft destiny, he can rely on preoperative clinical status, earlier vascular operative procedures, presence of pedal arch, and values of Doppler index (in case of reintervention).

Gender Differences in Patients Treated for Critical Limb Ischemia

OBJECTIVE

To investigate, in patients treated for critical limb ischemia, how pre-operative conditions, localisation of lesions and outcome varied according to gender.

DESIGN

Retrospective cohort study.

METHODS

Medical records were analysed for all patients treated with vascular reconstruction or PTA for critical limb ischemia 1993-1994 (119 women, 115 men) at the Karolinska Hospital. All events such as secondary intervention, amputation and death occurring until 2003 were included in the analysis.

RESULTS

The preoperative conditions were similar between women and men apart from higher mean age (74 years in women vs 69 in men, p=0.0002), fewer subjects with a smoking history (63 vs 82%, p=0-005) and diabetic disease (22 vs 43%, p=0.0004) among females. More interventions were performed suprainguinally in women (44% in women vs 19% in men). Amputation and survival rates were similar in women and men, even after matching for age and diabetes.

CONCLUSION

Women were older, had a lower frequency of diabetes, smoked less and had more proximal lesions than treated men. Outcome was identical for both genders. Biological and anatomical differences could possibly explain several of the found gender differences. Gender differences in risk factors and possibly in the selection process also may have contributed to our findings.

Risk for stroke after elective noncarotid vascular surgery

INTRODUCTION

Patients undergoing operations to treat peripheral vascular disease have systemic atherosclerosis and are at risk for stroke. However, the incidence and effect of cerebrovascular events on noncarotid vascular surgical outcomes are not well-defined.

METHODS

Patients undergoing common operations for vascular disease from 1997 to 2000 were examined with data from the Veterans Affairs (VA) National Surgery Quality Improvement Project and the VA patient treatment files. Operations studied included abdominal aortic aneurysmectomy (n = 2551), aortobifemoral bypass (n = 2616), lower extremity bypass (n = 6866), and major lower extremity amputation (n = 7442). The incidence of perioperative stroke was determined, and logistic regression analysis was used to identify independent risk factors for stroke. Logistic and linear regression analyses were used to quantify the effect of postoperative stroke on adjusted mortality and length of stay. Odds ratio (OR) and 95% confidence interval (CI) were defined. P <.05 was considered significant.

RESULTS

Stroke was uncommon after noncarotid vascular procedures, occurring in only 0.4% to 0.6% of patients. Independent risk factors for stroke include preoperative ventilation (OR, 11; 95% CI, 5.0-22.3; P <.001), previous stroke or transient ischemic attack (OR, 4.2; 95% CI, 2.7-6.4; P <.001), postoperative myocardial infarction (OR, 3.3; 95% CI, 1.3-8.7; P =.009), and need to return to the operating room (OR, 2.2; 95% CI, 1.4-3.5; P =.001). Factors that did not appear to be associated with stroke risk included procedure type, diabetes, renal failure, dialysis dependence, number of transfused units of blood, and hypertension. After controlling for other postoperative complications and comorbid conditions, postoperative stroke significantly increased the risk for perioperative mortality (OR, 6.3; 95% CI, 3.4-11.4; P <.001), with similar magnitude as postoperative myocardial infarction (OR, 6.3; 95% CI, 3.9-10.1; P <.001). Stroke was also associated with a 48% increase in overall length of stay.

CONCLUSIONS

Stroke after noncarotid peripheral vascular surgery is uncommon, but results in markedly increased mortality and length of stay. Stroke risk is most strongly associated with previous stroke history and greater degree of illness. Patients with these associated conditions deserve particular attention to assessing and medically managing modifiable risk factors.

Redo infrainguinal bypass: factors predicting patency and limb salvage

The increased complexity of redo infrainguinal bypass procedures can result in prolonged operative time and increased morbidity. This review was undertaken to compare outcomes from primary and redo bypass procedures and to identify factors predictive of graft failure and limb loss after redo bypass. All infrainguinal bypasses ( n = 468) from 1995 to 1999 were reviewed. A total of 367 primary bypasses in 317 patients were compared to 101 redo grafts in 84 patients with previously failed bypasses. Risk factors and types of procedures were compared using Student's t-test and the chi(2) test. Patency and limb salvage were compared using life-table analysis. Patients requiring redo bypasses were less likely to have diabetes and end-stage renal disease. Two-year patency (66 +/- 4% primary vs. 55 +/- 7% redo, p = 0.13) and limb salvage (75 +/- 3% primary vs. 72 +/- 6% secondary, p = 0.43) were comparable between primary and redo bypass groups. Female gender was predictive of redo graft failure (2-year patency 73 +/- 8% male vs. 39 +/- 9% female, p = 0.01). Clinical indications that predicted failure of a redo bypass included thrombosis of an autologous graft (1-year patency 71 +/- 7% previous prosthetic vs. 49 +/- 10% previous autologous, p = 0.004), thrombosis of an infrageniculate bypass (2-year patency 65 +/- 10% suprageniculate vs. 46 +/- 9% infrageniculate, p = 0.044), and a limb salvage indication for the primary operation (2-year patency 86 +/- 9% claudication vs. 44 +/- 8% limb salvage, p = 0.008). When a primary bypass fails despite the use of optimal conduit (autologous vein) and an infrageniculate target vessel, the redo bypass has a higher risk of failure, particularly in female patients. Nonetheless, patency and limb salvage rates justify an attempt at revascularization after failed primary bypass.

Infrainguinal bypass graft patency and limb salvage rates in critical limb ischemia: influence of the mode of presentation

Rest pain, ulceration, and gangrene are often considered together in studies describing outcomes in patients with critical limb ischemia. A retrospective analysis of prospectively collected data of 152 infrainguinal bypass grafts performed on 128 patients with chronic critical limb ischemia over a 6-year period was carried out. Grafts were classified according to the mode of presentation and were followed up by regular clinical and duplex examinations. Mean follow-up period was 29 months (range 12 to 60 months). Patients' demographics, risk factors, and graft characteristics were not statistically different between the groups. The 5-year cumulative primary patency rates were 33%, 52%, and 51% for gangrene, ulceration, and rest pain, respectively (p = 0.04). The 5-year cumulative primary assisted patency rates were 46%, 70%, and 72% for gangrene, ulceration, and rest pain, respectively (p = 0.01). The 5-year cumulative secondary patency rates were 48%, 76%, and 75% for gangrene, ulceration, and rest pain, respectively (p = 0.003). The 5-year cumulative limb salvage rates were 59%, 87%, and 83%, for gangrene, ulceration, and rest pain, respectively (p = 0.01). Gangrene is a distinct subcategory of critical limb ischemia with a worse prognosis than ulceration and rest pain and should be classified as such when reporting results of infrainguinal bypass grafts.

Tissue loss, early primary graft occlusion, female gender, and a prohibitive failure rate of secondary infrainguinal arterial reconstruction

PURPOSE

This study tested the hypothesis that a subset of secondary infrainguinal arterial reconstructions show prohibitive failure rates.

METHODS

Records of 79 consecutive patients, 44 men and 35 women, with a mean age of 60 years, who underwent secondary infrainguinal bypass from 1992 to 2000 at the University of Michigan Hospital, were reviewed. Data were analyzed with life-table analysis, logistic regression, and descriptive statistics.

RESULTS

Secondary infrainguinal reconstructions were performed in patients who had undergone earlier ipsilateral bypasses once (n = 35) or twice (n = 44). Among the prior procedures, 68% (n = 54) were done at an institution other than the authors'. Comorbidities included coronary artery disease (72%), tobacco use (77%), and diabetes mellitus (34%), but no patient had hemodialysis-dependent renal failure. Disabling claudication, with average ankle brachial index of 0.48, had been the indication for the primary operation in 77% of cases. Femoral-popliteal bypass was the primary procedure in 67%, with a prosthetic graft used in 62%. The mean patency duration of these earlier bypasses was 25 months. The indication for the final bypass was rest pain or tissue loss in 51% of patients, with an average ankle brachial index of 0.37. The most common procedure was a femoral-distal bypass with autologous vein (63%). Mean patency duration of the secondary bypasses was 30 months. Graft failure within 30 days of operation occurred in 22 patients (28%), and amputation was necessitated in 86% of these patients. The presence of rest pain or tissue loss, when accompanied with a history of early prior graft thrombosis in female patients, correlated with worse mean patency rates, recurrent graft failure (P </=.05), and a 94% amputation rate. Men in a similar setting incurred a 57% amputation rate. No association of final patency existed with regard to age, number of prior bypasses, conduit types, tobacco use, or diabetes.

CONCLUSION

Secondary infrainguinal bypasses are associated with an increased rate of graft failure and significant limb loss, particularly in those with a history of rest pain or tissue loss, female gender, and early prior graft failure. More appropriate initial operations in carefully selected patients and aggressive postoperative graft surveillance is speculated to improve these outcomes.

Sex-related differences in outcome after vascular interventions for lower limb ischemia

OBJECTIVE

The purpose of this study was to investigate sex-related differences in outcome, defined as amputation rate and survival in patients treated for lower limb ischemia.

MATERIAL AND METHOD

Age, sex, and type of procedure for all patients undergoing vascular interventions for lower limb ischemia in Stockholm, Sweden, from 1970 to 1994, were obtained from the National Board of Health and Welfare. All patients who underwent amputation after treatment were analyzed separately. Data on deceased patients were extracted from the cause-of-death register.

RESULTS

Women had lower survival rates than men at 30 days and 1 and 5 years after operation (89% vs 92%, 75% vs 80%, and 50% vs 55%; P <.001). In the multivariate analysis of risk factors for death during the whole study period, increasing age, calendar year (1980 to 1989), and male sex were significant risk factors (P <.001). The percentage of women who underwent amputation after treatment was comparable with the percentage of men who underwent amputation (11.4% vs 10.2%, P =.075). The multivariate analysis identified increased age and calendar year (1985 to 1994) as important risk factors for amputation (P <.001). Female sex was not found to increase the risk for amputation. Patients who underwent amputation were older than patients with intact limbs (73 vs 68 years, P <.001). The highest percentage of patients who underwent amputation was found among those treated with femorodistal bypass (20%, P =.001).

CONCLUSIONS

Female sex is not an important risk factor for poor outcome after treatment for lower limb ischemia, when their increased age has been accounted for. These results imply that we should continue to consider age and type of procedure when estimating outcome, and women should not be refused an intervention on a sex-related basis. We should possibly be more selective toward men considering their higher mortality rates.

The influence of gender difference on the outcomes of infrainguinal bypass for critical limb ischaemia in Chinese patients

PURPOSE

to investigate the influence of gender difference on the outcomes of infrainguinal bypass operations performed in Chinese patients with critical limb ischaemia.

METHODS

we prospectively studied the results of 191 consecutive infrainguinal bypass operations (98 men, 93 women) for critical lower limb ischaemia in Chinese patients.

RESULTS

the women were older than men (median 75 vs 70 years, p=0.001) and cigarette smoking was commoner in men (83% vs 37% p<0.001). The calibre of run-off arteries at the level of distal anastomosis was smaller in women (median 2.5 mm vs 2.0 mm, p=0.03). The 30-day mortality was 3% (five men vs one woman, p=0.09) and early graft failure occurred in 19 patients (12 women vs seven men, p=0.28). At 3 months limb loss occurred in 16 (10 women vs six men, p=0.35) patients. Survival (38% vs 60% at 4 years, p=0.12) was similar in men and women. However, women suffered from poorer primary (33% vs 49% at 3 years, p=0.03) secondary graft patency rates (35% vs 64% at 3 years, p=0.02) than men. Limb survival rate in two groups (75% vs 85% at 4 years, p=0.18) was comparable.

CONCLUSION

following infrainguinal bypass for critical limb ischaemia, early results were similar in both gender groups. In the long-term, women patients suffered from significantly higher graft failure rate. However, their long-term survival and limb salvage rate remained comparable to those of men.