The Impact of Sex on Medical and Surgical Management of Peripheral Arterial Disease (PAD) Prior to Limb Loss in the Vascular Quality Initiative
Camila Villacreses, Tay Moore, Ravi Veeraswamy, Elizabeth A. Genovese
Medical University of South Carolina, Charleston, SC
INTRODUCTION: Studies demonstrate that PAD incidence is higher in women compared to men, despite lower traditional risk factors. There is a lack of studies comparing medical and surgical management of PAD between sexes prior to major limb loss. We aim to determine if sex is associated with differences in PAD treatment prior to major limb loss, level of amputation and long-term outcomes.
METHODS: Data was queried from the VQI for above-knee (AKA) and below-knee (BKA) amputations (2013-2021) due to chronic limb threatening ischemia. The Distressed Communities Index (DCI) was used to compare variables across similar socioeconomic environments. Comparison between sexes was performed using Chi-square and Kaplan Meier analyses. RESULTS: There was no significant difference limb salvage attempts prior to major amputation between sexes. Females had higher rates of AKA compared to males(52.1% vs 43.4%, p<0.001), this was consistent across all DCI categories. Prior to amputation, females had less ambulatory status (29.2% vs 33.5%, p<0.001) and lower use of Aspirin (63.7% vs 66.3%, p<0.001) and statins (68.7% vs 71.9%, p=0.003). After amputation, females were less likely to be started on Aspirin (69.2% versus 72.8%, p=0.005) or statins (71.5% versus 75.8%, p<0.001), and less likely to be discharged to a rehab facility, particularly in the distressed DCI patients (64.7% vs 74.9%, p<0.001). At long-term follow-up, females had worse ambulatory status (43.9% vs 53.9% ambulatory, p<0.001) and more likely to never have had a prosthesis, across both AKA and BKA operations (23.0% vs 19.5%, p<.001; % vs 18.6% vs 16.1%, p<0.005, respectively). Differences in ambulatory status and prosthetic use were shown across all DCI categories. Kaplan Meier mortality analysis at 1-year showed both increased mortality amongst female amputation patients compared to males, as well as earlier time to mortality in days (297 versus 305, p=0.015). CONCLUSIONS: Despite similar rates of limb salvage attempts to amputation, females have higher rates of AKA. Peri-operative medical management is inferior for females, moreover they have lower rates of discharge to rehab, decreased access to prosthetics, and worse long-term ambulatory status. Mortality analysis shows decreased survival and earlier days to mortality at 1-year for female amputees compared to males.
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