Improving 1-Year Outcomes of Infrainguinal Limb Revascularization: Population-Based Cohort Study of 104 000 Patients in England
Improving 1-Year Outcomes of Infrainguinal Limb Revascularization: Population-Based Cohort Study of 104 000 Patients in England
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DOI：
10.1161/circulationaha.117.029834
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发表时间：
2018-05-01
期刊：
影响因子：
37.8
通讯作者：
Cromwell, David A.
中科院分区：
文献类型：
--
作者：
Heikkila, Katriina;Mitchell, David C.;Cromwell, David A.
背景：在过去的十年中，英国下肢血运重建手术的可用性和多样性有所增加。我们调查了这些发展在护理是否已转化为改善患者pathways and outcome.METHODS：从医院事件统计的个人患者记录被用来确定103934例患者接受血管内（血管成形术）或手术（动脉内膜切除术，深动脉成形术，或旁路）下肢血管重建腹股沟下外周动脉疾病在英格兰2006年1月至2015年12月。从医院事件统计和国家统计局死亡率记录中确定了血运重建后1年内的严重下肢截肢和死亡。竞争风险回归用于估计大截肢和死亡的累积发生率，调整患者年龄，性别，合并症评分，干预适应症（间歇性跛行、无组织损失记录的严重肢体缺血、有溃疡记录的严重肢体缺血、有坏疽/骨髓炎记录的严重肢体缺血）和共病糖尿病。血管内血运重建后估计的1年大截肢风险从5.7%（2006-2007年）降至3.9%（2014-2015年），外科手术后从11.2%（2006-2007年）降至6.6%（2014-2015年）。两种血运重建后的死亡风险也降低了。在所有适应症类别中均观察到这些趋势，其中重度肢体缺血伴溃疡或坏疽患者的降幅最大。总体而言，发病率增加了研究期间，和更大比例的患者接受治疗的严重结束外周动脉疾病谱使用微创processings.CONCLUSIONS：我们的研究结果表明，从2006年至2015年，总生存率增加，主要下肢截肢的风险降低血运重建。这些观察结果表明，在英国血管服务集中化和专业化期间，下肢血运重建后的患者结局有所改善。
BACKGROUND: The availability and diversity of lower limb revascularization procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes.METHODS: Individual-patient records from Hospital Episode Statistics were used to identify 103934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty, or bypass) lower limb revascularization for infrainguinal peripheral artery disease in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year after revascularization were ascertained from Hospital Episode Statistics and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score, indication for the intervention (intermittent claudication, severe limb ischemia without record of tissue loss, severe limb ischemia with a record of ulceration, severe limb ischemia with a record of gangrene/osteomyelitis), and comorbid diabetes mellitus.RESULTS: The estimated 1-year risk of major amputation decreased from 5.7% (in 2006-2007) to 3.9% (in 2014-2015) following endovascular revascularization, and from 11.2% (2006-2007) to 6.6% (2014-2015) following surgical procedures. The risk of death after both types of revascularization also decreased. These trends were observed for all indication categories, with the largest reductions found in patients with severe limb ischemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients was treated for the severe end of the peripheral artery disease spectrum using less invasive procedures.CONCLUSIONS: Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularization. These observations suggest that patient outcomes after lower limb revascularization have improved during a period of centralization and specialization of vascular services in the United Kingdom.