Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease
Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease
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DOI：
10.1016/j.jvs.2013.07.114
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发表时间：
2014-02-01
影响因子：
4.3
通讯作者：
Schermerhorn, Marc L.
中科院分区：
文献类型：
--
作者：
Lo, Ruby C.;Bensley, Rodney P.;Schermerhorn, Marc L.
目的：先前的研究表明，男性和女性之间的治疗和结果的差异下肢外周动脉疾病手术分流。鉴于最近转向血管内治疗，这已越来越多地用于治疗跛行，我们试图分析性别差异的介绍，血运重建，截肢，和住院mortality.Methods：我们确定了个人间歇性跛行和严重肢体缺血（CLI）使用国际疾病分类，第九次修订代码在全国范围内的住院病人样本从1998年至2009年。我们比较了男性和女性在介入治疗（间歇性跛行vs CLI）、手术（开放手术vs经皮腔内血管成形术或支架置入术vs大截肢术）时的表现以及住院死亡率。通过对来自四个地理位置不同的州（加州、佛罗里达、马里兰州和新泽西）的州住院和门诊手术数据库进行单独分析，评价了区域和门诊趋势。从全国住院患者样本中，我们确定了1，797，885名患者（56%男性），间歇性跛行（26%）和CLI（74%），接受了1，865，999例手术（41%开放手术，20%经皮腔内血管成形术或支架植入术，24%截肢）。女性在干预时平均年龄为3.5岁，更有可能出现CLI（75.9% vs 72.3%;比值比[OR]，1.21; 95%置信区间[CI]，1.21-1.23; P <0.01）。女性更可能接受间歇性跛行（47% vs 41%; OR，1.27; 95% CI，1.25-1.28; P <0.01）和CLI（21% vs 19%; OR，1.14; 95% CI，1.13-1.15; P <0.01）的血管内手术。从1998年到2009年，男性的大截肢率从每100 000人18例下降到11例，女性从每100 000人16例下降到7例，这比2005年开始的男性和女性的CLI血运重建手术总数增加要早。即使在调整了年龄和基线合并症后，无论疾病的严重程度或手术方式如何，（经皮腔内血管成形术或支架植入术治疗间歇性跛行后.5%对.2%，开放手术治疗间歇性跛行后1.0%对.7%，经皮腔内血管成形术或支架植入术治疗CLI后2.3%对1.6%，2.7% vs 2.2%开放手术后CLI;所有比较P <0.01）.结论：在年龄较大且疾病较晚期的女性中，似乎更倾向于进行血管内血运重建。经皮腔内血管成形术或支架植入术仍然很受欢迎，并且越来越多地在门诊进行。截肢率和住院死亡率一直在下降，现在妇女的截肢率低于男子，但死亡率高于男子。近期结局的改善可能是医疗管理改善和风险因素减少相结合的结果。
Objective: Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality.Methods: We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey.Results: From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons).Conclusions: There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.