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Women with peripheral artery disease (PAD) of the lower extremities are being treated at an older age and when their disease is at a more advanced stage than men, according to research published online September 30, 2013, ahead of print in the Journal of Vascular Surgery. In addition, despite an overall decrease in in-hospital mortality and amputation rates, mortality rates remain higher for women than men.

Investigators led by Marc L. Schermerhorn, MD, of Beth Israel Deaconess Medical Center (Boston, MA), identified 1.8 million patients (56% male) with intermittent claudication (26%) or critical limb ischemia (CLI; 74%) from the Nationwide Inpatient Sample between 1998 and 2009. The patients underwent 1.9 million procedures, including open or endovascular revascularization, or amputation.

Among this sample of patients, men and women were compared with respect to presentation at time of intervention (intermittent claudication vs. CLI), procedure (open surgery vs. angioplasty or stenting vs. major amputation), and in-hospital mortality. To determine geographical trends, the investigators also compared data from the State Inpatient and Ambulatory Surgery Databases for California, Florida, Maryland, and New Jersey.

Women Older, Sicker

On average, female patients were 3.5 years older than male patients at the time of intervention and had more advanced disease. They were also more likely to present with CLI and to be treated with an endovascular procedure. While in-hospital mortality rates decreased for both sexes over time, they remained higher for women regardless of procedure or disease severity and adjustment for age and baseline comorbidities (table 1).

Table 1. Presentation, Treatment, and Outcome: Women vs. Men

^a P < 0.01 for all.
^b Adjusted for age and baseline comorbidities.

Female sex remained a predictor of in-hospital mortality after adjustment for age, disease severity, race, and other baseline demographics and comorbidities. The negative impact of female sex was greatest for endovascular procedures (OR 1.4; 95% CI 1.3-1.5; P < 0.001) and least for major amputation (OR 1.1; 95% CI 1.0-1.1; P < 0.001).

During the study period, the risk of amputation decreased for both sexes, from 18 to 11 per 100,000 in men and from 16 to 7 per 100,000 in women. This reduction predated the increase in total CLI revascularizations that occurred among both sexes starting in 2005.

Reasons for Endovascular Preference for Women

The authors suggest that because female PAD patients tend to be older and have more advanced disease than men, “there appears to be a preference to perform endovascular procedures in women and open procedures in men.”

Overall, endovascular procedures continue to increase, and many are now being performed in the outpatient setting, they note, adding that “amputation rates have declined steadily, and women now have lower rates than men.

“In-hospital mortality for both men and women also continues to decline,” Dr. Schermerhorn and colleagues continue. “These improvements do not necessarily correlate with the increased utilization of endovascular (or total number of) procedures and likely resulted from both continued improvements in medical management and risk factor reduction as well as advances in surgical technology.”

 

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Source:
Lo RC, Bensley RP, Dahlberg SE, et al. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg. 2013;Epub ahead of print.

 

 

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