Assistant Professor of Surgery Centre Hospitalier de l'Universite de Montreal Pointe-Claire, Quebec, Canada
Objectives: Studies have reported racial and ethnic disparities in patients with peripheral arterial disease (PAD), such as worse clinical outcomes following revascularisation. This systematic review and meta-analysis sought to describe the prognostic implications of racial and ethnic status on clinical outcomes in patients undergoing vascular interventions for claudication and critical limb threatening ischemia (CLTI).
Methods: Studies were systematically searched across 5 databases from inception to June 2021. Studies focusing on patients with claudication or CLTI undergoing open, endovascular, or hybrid procedures. Studies were included if racial and ethnic status was documented and associated with a clinical outcome. Two independent reviewers selected studies for inclusion, extracted data, and assessed risk of bias using ROBINS-I and Newcastle-Ottawa scales. Extracted data included study characteristics, demographics and clinical characteristics, interventions performed, outcome measured, and association of race or ethnicity with the clinical outcomes. Meta-analyses were performed using random effect models and reported pooled odds ratios with 95% confidence intervals.
Results: Ninety-two studies addressed the impact of race and ethnicity in patients undergoing interventions for PAD. The way race and ethnicity were captured and defined varied across the studies. Seventeen studies evaluated the impact of Black vs White patients undergoing amputation as a primary intervention and were subsequently pooled in a meta-analysis with Black patients significantly having amputation as a primary intervention compared to White patients (pooled OR 1.89, 95% CI 1.53-2.25) (Figure 1). A subsequent meta-analysis of 6 studies also demonstrated Black patients having significantly higher rates of amputation after revascularisation (pooled OR 1.50, 95% CI 1.23-1.77). Similar trends were seen in Hispanics and First Nations patients although the number of studies were less and with significant heterogeneity. A funnel plot suggested a low risk of bias. Furthermore, there were trends in racial disparities pertaining to graft patency, secondary interventions, post-operative complications, length of stay, re-admission, 30-day and overall mortality.
Conclusions: Our findings suggest that patients who are Black, Hispanic and First Nations undergo primary major amputation significantly more than White patients. Furthermore, Black patients are significantly more likely to undergo amputation following attempts at revascularisation compared to White patients. Reasons for these disparities should be explored to identify solutions for decreasing and eliminating these health inequities.