The Effect of Ambulatory Status on Outcomes of Percutaneous Vascular Interventions and Lower Extremity Bypass for Critical Limb Ischemia in the Vascular Quality Initiative
Kimberly Lu, Alik Farber, M.D., Marc L. Schermerhorn, M.D., Virendra I. Patel, M.D., Jeffrey A. Kalish, M.D., Denis Rybin, Ph.D., Gheorghe Doros, Ph.D., Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.
OBJECTIVES: Ambulatory status has been shown to be an important predictor of postoperative morbidity and mortality for a variety of surgical procedures. We sought to assess contemporary practice patterns in treating critical limb ischemia (CLI) and outcomes based on ambulatory status.
METHODS: The Vascular Quality Initiative (2010-2015) was queried for patients undergoing percutaneous endovascular interventions (PVIs) or lower extremity bypass (LEB) for CLI. Ambulatory status was classified as ambulatory, ambulatory with assistance, and non-ambulatory (composite wheelchair bound and bedridden). Perioperative and postoperative outcomes were recorded. Multivariable analyses were performed to identify the effect of ambulatory status.
RESULTS: There were 11522 ambulatory (PVI 63%, LEB 37%), 4443 ambulatory with assistance (PVI 67%, LEB 33%), and 1732 non-ambulatory (PVI 77%, LEB 23%) patients with CLI treated (P<.001 across ambulatory status groups). Perioperative mortality for ambulatory patients was PVI 1.5% and LEB 1.7% (P = .46), ambulatory with assistance was PVI 3.0% and LEB 3.1% (P = .87), and non-ambulatory was PVI 4.7% and LEB 4.9% (P = .92), (P < .001 across ambulatory status groups). Worsening status was associated with higher perioperative complications with PVI and LEB. Multivariable analysis showed that ambulatory with assist and non-ambulatory patients had a higher risk for mortality compared to ambulatory patients. When comparing PVI to LEB by ambulatory status, ambulatory patients had no differences in perioperative survival, long-term survival, or major amputation at one year comparing treatment type. For ambulatory with assistance patients, LEB had a higher odds of perioperative mortality (OR 1.75, 95% CI 1.1-2.77, P = .017), but no differences in long-term survival or major amputation. Non-ambulatory patients did not show any differences between LEB and PVI in outcomes.
CONCLUSIONS: As ambulatory status declines perioperative morbidity and mortality increase. Impaired ambulatory patients are more likely to receive PVI than LEB for the treatment of CLI, although even among non-ambulatory patients there are still a significant number who receive LEB. For ambulatory and non-ambulatory patients, PVI and LEB showed no differences in perioperative outcomes, long-term survival, or major amputation at one year. However, for ambulatory with assistance patients, perioperative survival appears to be better for PVI than for LEB.
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