VESS04 - Risk of 90-day Mortality After Limb Salvage Procedures - Who Stands to Benefit?

Objectives: Limb salvage is often the priority when performing revascularization for peripheral artery disease (PAD) in older adults. However, revascularization in these patients is associated with a nontrivial risk of short-term mortality. To date, risk factors for 90-day mortality after PAD interventions have been poorly characterized.

Methods: National cohort study of adults 65 years and older in a Vascular Quality Initiative (VQI) and Medicare linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD (emergent procedures and aneurysm repairs were excluded) between January 1, 2010 to December 31, 2018. The primary outcome was 90-day mortality. Multivariable cox regression was used to determine the association between patient- and facility-level characteristics and risk of death within 90-days post revascularization.

Results: Among 42,429 patients (median[IQR] 74(69-80), 58.9% male, 84.3% White), 71.3% of the revascularizations were endovascular, chronic limb threatening ischemia (CLTI) was the procedural indication in 56.4% of patients, and 42.8% of the procedures were completed in the outpatient setting. Age demonstrated a dose-response relationship with increased risk of death (ref – 65-69 years; 70-74, Hazard Ratio [HR] 1.27 [95% CI 1.07-1.51]; 75-79, HR 1.54 [95% CI 1.26-1.88]; 80-84, HR 2.04 [95% CI 1.66-2.52]; ≥85, HR 2.89 [95% CI 2.32-3.60]). Female birth sex (HR 0.89 [95% CI 0.82-0.97]) and non-White race (HR 0.79 [95% CI 0.71-0.89]) were associated with a lower risk of death. There were several preoperative factors associated with an increased risk of death: severity of PAD at presentation (ref – claudication; rest pain, HR 1.95 [95% CI 1.67-2.28]; tissue loss, HR 2.32 [95% CI 1.92-2.79]); preoperative functional status (ref – ambulatory without assistance; bedridden [HR 1.93 (95% CI 1.66-2.24)]; ambulatory with assist device [HR 1.52 (95% CI 1.37-1.70)]). The only facility-level factor associated with risk of death was care setting: (ref – inpatient; outpatient, HR 0.36 [95% CI 0.33-0.41]; office-based lab, HR 0.18, [95% CI 0.13-0.25]).

Conclusions: Among patients undergoing revascularization for PAD, patient-level factors associated with risk of death are largely non-modifiable. This indicates that efforts to improve limb salvage and treatment outcomes should likely focus on active disease surveillance and potentially earlier risk factor modifications.