Racial/Ethnic Disparities in Revascularization for Limb Salvage

Hughes, Kakra; Boyd, Christopher S.; Oyetunji, Tolulope A.; Tran, Daniel; Chang, David C.; Rose, David; Siram, Suryanarayana M.; Cornwell, Edward E.; Obisesan, Thomas O.

doi:10.1177/1538574414543276

Cited by 55 publications

(21 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…9, 11, 14, 19 However, we demonstrate preoperative statin (OR 0.8, P=.04) and antiplatelet (OR 0.8, P=.049) therapy both independently reduce the risk of 30-day MALE. Similarly, preoperative antiplatelet therapy (OR 0.7, P=.049) independently reduces the risk of 30-day amputation.…”

Section: Discussionmentioning

confidence: 61%

“…Due to the theoretical procedural risk reduction with IEI, patients with higher surgical risk preferentially undergo IEI. 5, 14 Additionally, there is a growing body of literature supporting an “Endo First” approach suggesting CLI patients amenable to IEI should first undergo endovascular therapy before progressing to LEB. 15 For these reasons, a direct comparison of outcomes between IEI and LEB is difficult.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

Mehaffey

Hawkins

Fashandi

et al. 2017

Journal of Vascular Surgery

View full text Add to dashboard Cite

Objective Lower extremity bypass (LEB) has traditionally been the gold standard in the treatment of critical limb ischemia (CLI). Infrainguinal endovascular intervention (IEI) has become more commonly performed than LEB but comparative outcomes are limited. We sought to compare rates of Major Adverse Limb Events (MALE) and Major Adverse Cardiovascular Events (MACE) after LEB and EI in a propensity score matched, national cohort of patients with CLI. Methods The National Surgical Quality Improvement Program (NSQIP) Vascular Targeted Files (2011–2014) for LEB and IEI were merged. CLI patients were identified by ischemic rest pain and/or tissue loss. Patients were matched on a 1:1 basis for propensity to undergo LEB or IEI. Primary outcomes were 30-day MALE and MACE. Within the propensity matched cohort multivariate logistic regression was used to identify independent predictors of MALE and MACE. Results A total of 13,294 LEB and IEI were identified with 8,066 cases performed for CLI. Propensity matching identified 3,848 cases (1,924 per group). There were no differences in preoperative variables between the propensity matched LEB and IEI groups (all P>.05). At 30 days, rates of MALE were significantly lower in the LEB group (9.2% LEB vs IEI 12.2%, P=.003). On multivariate logistic regression, bypass with single segment saphenous vein vs IEI (OR 0.7 [0.54, 0.92], P=.01), and bypass with alternative conduit (prosthetic/spliced vein/composite) vs IEI (OR 0.7 [0.56, 0.98], P=.04), antiplatelet therapy (OR 0.8 [0.58, 1.00], P=.049), and statin therapy (OR 0.8 [0.62, 0.99], P=.04) were protective against MALE while infrageniculate intervention (OR 1.4 [1.09, 1.72], P=.01) and a history of prior bypass of the same arterial segment (OR 1.8 [1.41, 2.41], P<.0001) were predictive. Rates of 30-day MACE were not significantly different (4.9% LEB vs 3.7% IEI, P=.07) between the groups. Independent predictors of MACE included age (OR 1.02 [1.01, 1.04], P=.01), steroid use (OR 1.8 [1.08, 2.99], P=.03), congestive heart failure (OR 1.7 [1.00,1.96], P=.02), beta-blocker use (OR 1.6 [1.09, 1.43], P=.01), dialysis (OR 2.3 [1.55,3.45], P<.0001), totally dependent functional status (OR 3.1 [1.25, 7.58], P=.02), and suboptimal conduit for LEB compared to IEI (OR 1.6 [1.08, 2.36], P=.02). Conclusions Within this large, propensity-matched, national cohort, LEB predicted lower risk-adjusted 30-day MALE compared to IEI. Furthermore, there was no difference in 30-day MACE between the groups despite higher inherent risk with open surgical procedures. Therefore, the present study supports the effectiveness and primacy of LEB for revascularization in CLI.

show abstract

Section: Discussionmentioning

confidence: 61%

Section: Discussionmentioning

confidence: 99%

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

Mehaffey

Hawkins

Fashandi

et al. 2017

Journal of Vascular Surgery

View full text Add to dashboard Cite

show abstract

“…In previously published data, we also showed that African Americans have lower limb-salvage revascularization rates as compared with the Caucasians presenting with critical limb ischemia. 35, 36, Other investigators have also written about this disparity. 37-38 Directing additional resources to studying and correcting this healthcare disparity should prove valuable to our African American vascular patients.…”

Section: Discussionmentioning

confidence: 99%

Lower Extremity Arterial Reconstruction in Octogenarians and Older

Hamdi

Al-zubeidy

Obirieze

et al. 2016

Annals of Vascular Surgery

Self Cite

View full text Add to dashboard Cite

Background Despite previous single-institution studies showing that lower extremity arterial reconstruction (LEAR) in octogenarians and older may be undertaken with acceptable postoperative morbidity and mortality, there continues to be significant reluctance, in the vascular surgical community, to undertaking these complex revascularization procedures in this very elderly population. We undertook this study in an effort to determine the outcomes of LEAR in octogenarians and older on a national level. Methods The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) Database was queried to identify all patients who underwent LEAR between January 1, 2005 and December 31, 2009. Patient demographics and presenting comorbidities were recorded, and multivariate analyses were performed to compare outcomes in patients 80 and older to that in younger patients. Results There were 19,028 patients who underwent open infrainguinal LEAR during this time period. Patients ≥ 80 comprised 18% (3,486 patients); and patients < 80 years comprised 82% (15,542 patients). Multivariate analysis demonstrated that patients ≥ 80 years of age had an increased likelihood of mortality (OR 1.79, 95% CI 1.42-2.26), cardiovascular (OR 1.46, 95% CI 1.12-1.89), respiratory (OR 1.37, 95% CI 1.12-1.67) and renal (OR 1.57, 95% CI 1.27-1.95) complications. There was, however, no significant difference in the likelihood of graft failure (OR 1.04, 95% CI 0.86-1.27), wound infection (OR 0.92, 95% CI 0.79-1.06), or major amputation (OR 0.59, 95% CI 0.13-2.74) between these two groups. Conclusion LEAR in octogenarians is associated with an increased risk of postoperative morbidity and mortality, but no increased risk of wound infection, amputation or graft failure.

show abstract

“…Racial disparities in treatment are well established in people with lower extremity peripheral artery disease (PAD) and critical limb ischemia (1–6). Black patients with critical limb ischemia are less likely to undergo revascularization and more likely to have amputations than white patients with critical limb ischemia (1–6).…”

mentioning

confidence: 99%

“…Black patients with critical limb ischemia are less likely to undergo revascularization and more likely to have amputations than white patients with critical limb ischemia (1–6). …”

mentioning

confidence: 99%

Racial differences in functional decline in peripheral artery disease and associations with socioeconomic status and education

McDermott

Polonsky

Kibbe

et al. 2017

Journal of Vascular Surgery

View full text Add to dashboard Cite

OBJECTIVE To determine whether blacks with lower extremity peripheral artery disease (PAD) have faster functional decline than whites with PAD. METHODS Participants with ankle brachial index (ABI) < 0.90 were identified from Chicago medical centers and followed longitudinally. Mobility impairment and the six-minute walk were assessed at baseline and every 6 to 12 months. Mobility loss was defined as becoming unable to walk up and down a flight of stairs or walk ¼ mile without assistance. RESULTS Of 1,175 PAD participants, 310 (26%) were black. Median follow-up was 46.0 months. Among 727 PAD participants who walked six minutes continuously at baseline, black participants were more likely to become unable to walk six-minutes continuously during follow-up (68/178 (38.2%) vs. 157/549 (28.6%), log-rank P=0.002). Black race was associated with becoming unable to walk six minutes continuously, adjusting for age, sex, ABI, comorbidities, and other confounders (HR=1.51, 95% Confidence Interval (CI)=1.10,2.06, P=0.011). This association was attenuated after adjustment for income and education (P=0.150). Among 862 participants without baseline mobility impairment, black participants had a higher rate of mobility loss (67/212 (31.6%) vs. 169/650 (26.0%), log-rank P=0.004). Black race was associated with increased mobility loss, adjusting for potential confounders (hazard ratio (HR)=1.44, 95% CI=1.06,1.96, P=0.021). This association was attenuated after additional adjustment for income and education (P=0.348) and physical activity (P=0.086). There were no differences in average annual declines in six-minute walk, usual-paced four-meter walking velocity, or fast paced four-meter walking velocity. CONCLUSION Black PAD patients have higher rates of mobility loss and becoming unable to walk for six-minutes continuously. These differences appear related to racial differences in socioeconomic status and physical activity.

show abstract

Racial/Ethnic Disparities in Revascularization for Limb Salvage

Cited by 55 publications

References 29 publications

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

Lower Extremity Arterial Reconstruction in Octogenarians and Older

Racial differences in functional decline in peripheral artery disease and associations with socioeconomic status and education

Contact Info

Product

Resources

About