E. Elkins1,2, T. Coaston1, S. Sakowitz1, O. Kwon1, A. Vadlakonda1, S. Ali1, P. Benharash1,3 1David Geffen School Of Medicine, University Of California At Los Angeles, Cardiovascular Outcomes Research Laboratories, Los Angeles, CA, USA 2Columbia University in the City of New York, Columbia College, New York, NY, USA 3David Geffen School Of Medicine, University Of California At Los Angeles, Division Of Cardiac Surgery, Los Angeles, CA, USA
Introduction: Acute limb ischemia (ALI) is critical condition marked by sudden loss of peripheral perfusion. While the efficacy of endovascular versus open revascularization for chronic limb-threatening ischemia has been characterized in prior studies, few have examined the comparative efficacy of such modalities in the acute setting. We identified the association of endovascular versus open lower-extremity revascularization with in-hospital mortality, major lower extremity amputation (MLEA), and readmissions in a national cohort of ALI patients.
Methods: All non-elective adult (≥18 years) hospitalizations entailing revascularization for a diagnosis of ALI were identified in the 2012-2021 Nationwide Readmissions Database. Patients were grouped into endovascular (ENDO) and open (OPEN) revascularization cohorts while those receiving both modalities were excluded. Demographics including income, sex, and Elixhauser Comorbidity Index (ECI) were compared with the adjusted Mann-Whitney U and Χ2 tests. Multivariable regression models were developed to identify associations between operative approach and resultants including mortality, complications (infectious, thromboembolic, respiratory), non-home discharge, and readmission within 90 days.
Results: Of 270,000 hospitalizations, 45.3% and 54.7% received isolated ENDO and OPEN, respectively. Relative to OPEN, the ENDO cohort revealed no dissimilarity in demographics including female sex (19.0 vs 23.1%, p=0.07), private insurance status (8.0 vs 10.0%, p=0.06), and ECI (3.5 vs 3.6, p=0.13). At 90 days from index hospitalization, 6.7% of patients underwent MLEA (7.8% OPEN; 9.0% ENDO; p<0.01). Upon adjustment, operative approach did not define odds of amputation at index stay (OPEN: AOR 0.97, 95% Confidence Interval (CI) 0.9-1.03). At subsequent hospitalizations within 90 days, OPEN was correlated with a reduction in odds of MLEA (AOR 0.86, 95% CI 0.80-0.91). However, relative to ENDO, OPEN faced greater odds of in-hospital mortality (AOR 1.19, 95% CI 1.12-1.28) and non-home discharge (AOR 1.83, 95% CI 1.76-1.88). To this, OPEN was linked to greater odds of care fragmentation (AOR 1.17, 95% CI 1.11-1.23), as well as intraoperative (AOR 1.31, 95% CI 1.20-1.45), respiratory (AOR 1.42, 95% CI 1.24-1.39), and infectious complications (AOR 1.48, 95% CI 1.24-1.41; Figure 1).
Conclusion: While endovascular revascularization appears linked with reduced risk of in-hospital mortality and complication, it is dually associated with greater risk of amputation at 90 days post-discharge for ALI. Though these results may in part reflect selection bias, our study confers the notion that open revascularization may optimize potential for limb preservation in suitable candidates with lower extremity ALI.