An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety

Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 3.02). 04/2010; 51(4):878-85, 885.e1. DOI: 10.1016/j.jvs.2009.10.102
Source: PubMed


Demographic and practice modality changes during the past decade have led to a substantial shift in the management of peripheral vascular disease. This study examined the effect of these changes using large national and regional data sets on procedure type, indications, morbidity, and on the primary target outcome: limb salvage.
National Inpatient Sample (NIS) data sets and New York (NY) State inpatient hospitalizations and outpatient surgeries discharge databases from 1998 through 2007 were used to identify hospitalizations for lower extremity revascularization (LER) and major amputations. Patients were selected by cross-referencing diagnostic and procedural codes. Proportions were analyzed by chi(2) analysis, continuous variables by t test, and trends by the Poisson regression.
The national per capita (100,000 population, age >40 years) volume of major amputations decreased by 38%. The volume for national and regional use of endovascular LER doubled. The volume of open LER decreased by 67% from 1998 through 2007. Ambulatory endovascular LER grew in NY State from 7 per capita in 1998 to 22 in 2007. Interventions declined by 20% (93 to 75) for critical limb ischemia (CLI) but increased by nearly 50% for claudication. Outpatient data analysis revealed a fivefold increase in vascular interventions for CLI and claudication. Nationally, endovascular LER interventions quadrupled (8% to 32%) for CLI and doubled (26% to 61%) for claudication. A parallel reduction occurred in major amputations for patients with CLI (42% to 30%), for other PAD diagnoses (18% to 14%), and for claudication (0.9% to 0.3%). Although surgical interventions for CLI declined significantly for octogenarians from 317 to 240, outpatient interventions increased for CLI, claudication, and other diagnoses in all age groups. Comorbidities for patients treated in 2006 were substantially greater than those of a decade ago. For most procedures, cardiac and bleeding complications have significantly decreased during the last decade. Length of stay (LOS) declined from 9.5 to 7.6 days and the percentage of short (1-2 day) hospitalizations increased from 16% to 35%.
Although patients today, whether treated for claudication or CLI, have more comorbidities, the rates of amputation, the procedural morbidity and mortality, and LOS have all significantly decreased. Other variables, including changes in medical management and wound care, undoubtedly are important, but this change appears to be largely due to the widespread and successful use of endovascular LER or to earlier intervention, or both, driven by the safety of these techniques.

Download full-text


Available from: Nicholas J Morrissey, Dec 18, 2013
  • Source
    • "Invasive treatment of peripheral arterial disease (PAD) improves limb-salvage in critical limb ischemia [1] and potentially improves functional status in intermittent claudication (pain in the legs during walking exercise, due to reduced blood flow caused by atherosclerosis). Traditionally used clinical outcome measures for evaluating the impact of disease as well as the effects of invasive procedures in PAD include amputation-free survival, walking capacity (e.g. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Traditional outcome measures in peripheral arterial disease (PAD) provide insufficient information regarding patient benefit. It has therefore been suggested to add patient-reported outcome measures. The main aim of this study was to validate the Swedish Vascular Quality of Life questionnaire (VascuQoL) version, a patient-reported PAD-specific health-related quality of life (HRQoL) instrument. Two-hundred PAD patients were consecutively recruited from two university hospitals. Out of the 200 subjects, 129 had intermittent claudication and 71 had critical limb ischemia. Mean age was 70 ± 9 y and 57% of the participants were male. All patients completed SF-36 and VascuQoL at the vascular outpatient clinic, when evaluated for invasive treatment. Risk factors and physiological parameters were registered. Construct validity was tested by correlation analysis versus SF-36 and was also assessed with multitrait/multi-item scaling analysis (MTMI). Sensitivity analysis regarding disease severity identification was performed. Reliability was assessed with Cronbach's alpha and responsiveness by standardized response mean (SRM) calculations. Significant correlations were demonstrated between relevant subscales of VascuQoL and SF-36. MTMI showed acceptable construct validity, but some scaling-errors. VascuQoL significantly (p < 0.001) discriminated claudicants from critical limb ischemia patients. Cronbach's alpha was 0.94 and SRM 1.02 (sum score). The Swedish version of VascuQoL is valid and quantifies central aspects of HRQoL in PAD patients. Sensitivity analysis showed high ability to differentiate between disease severity and SRM illustrated excellent responsiveness. The relative abundance of items however makes use in the everyday clinical setting somewhat difficult.
    Full-text · Article · Apr 2012 · Health and Quality of Life Outcomes
  • Source

    Preview · Article ·
  • [Show abstract] [Hide abstract]
    ABSTRACT: The electrooptic effect has been used in conjunction with 100 fs optical pulses to sample electrical transients with an unprecedented resolution of .5 ps and sensitivity of 50-100 µV. The electrooptic material can be used in a traveling wave geometry or in an electrodeless manner. Applications of this technique to the characterization of electrical devices and to the study of short pulse propagation are described.
    No preview · Conference Paper · Feb 1983
Show more