Ochoa Chaar Cassius Iyad, Gholitabar Navid, Goodney Philip, Dardik Alan, Abougergi Marwan S
Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT.
Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT.
Ann Vasc Surg. 2019 Nov;61:25-32.e2. doi: 10.1016/j.avsg.2019.07.003. Epub 2019 Jul 31.
Lower extremity revascularization for critical limb ischemia (CLI) remains a subject of clinical equipoise. Readmissions and repeat lower extremity revascularization increase the cost of care and decrease the value of initial treatment. This study examines readmissions and repeat inpatient revascularization and major amputation up to 1 year after initial open and endovascular lower extremity revascularization.
The 2014 Nationwide Readmissions Database (NRD) was reviewed. The NRD provides all subsequent readmissions of any hospitalization for the calendar year. A cohort of patients undergoing lower extremity revascularization in January only was selected based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were divided into open and endovascular groups. Readmissions for repeat lower extremity revascularization (RFR) were identified based on procedural codes. Open and endovascular lower extremity revascularization were compared in terms of patient characteristics as well as readmissions, RFR, major amputation, and inpatient mortality at 1 year. Risk-adjusted outcomes accounting for differences in age, gender, income, and Charlson Comorbidity Index (CCI) were derived using regression analysis.
There were 1,668 open and 1,410 endovascular lower extremity revascularizations. Patients in the endovascular group were significantly older (P < 0.01), more likely to be women (P < 0.01), and had higher CCI (P < 0.01). Patients undergoing endovascular lower extremity revascularization had significantly higher readmission rate (49 vs. 33.7, P < 0.01) and higher mortality (10.4 vs. 5.3, P < 0.01). Readmitted patients after endovascular lower extremity revascularization had significantly higher mean number of repeat readmissions compared to open lower extremity revascularization (2.49 ± 0.12 vs. 2.13 ± 0.08, P = 0.01). There was no difference in RFR (P = 0.82) or major amputation (P = 0.19). Open revascularization was independently associated with decreased readmission (odds ratio = 0.55 [0.43-0.71]) compared to endovascular. However, there was no significant association between the type of lower extremity revascularization and major amputation or RFR.
Endovascular lower extremity revascularization for CLI is performed on older and sicker patients and seems to be associated with increased readmission at 1 year compared to open lower extremity revascularization. Regardless of the initial modality of treatment, patients are likely to undergo at least 1 revascularization during readmissions.
下肢严重肢体缺血（CLI）的血管重建仍然是临床 equipoise 的一个主题。再入院和重复下肢血管重建增加了护理成本并降低了初始治疗的价值。本研究调查了初次开放和血管腔内下肢血管重建术后长达 1 年的再入院、重复住院血管重建和大截肢情况。
回顾了 2014 年全国再入院数据库（NRD）。NRD 提供了该日历年任何住院治疗后的所有后续再入院情况。仅根据国际疾病分类第九版临床修订版代码，选择了 1 月份接受下肢血管重建的一组患者。患者分为开放手术组和血管腔内治疗组。根据手术代码确定重复下肢血管重建（RFR）的再入院情况。比较开放手术和血管腔内下肢血管重建在患者特征以及 1 年时的再入院、RFR、大截肢和住院死亡率方面的差异。使用回归分析得出考虑年龄、性别、收入和 Charlson 合并症指数（CCI）差异的风险调整后结果。
有 1668 例开放手术和 1410 例血管腔内下肢血管重建。血管腔内治疗组的患者年龄显著更大（P < 0.01），女性比例更高（P < 0.01），CCI 更高（P < 0.01）。接受血管腔内下肢血管重建的患者再入院率显著更高（49 对 33.7，P < 0.01），死亡率更高（10. The 4 对 5.3，P < 0.01）。与开放下肢血管重建相比，血管腔内下肢血管重建后再入院的患者重复再入院的平均次数显著更高（2.49 ± 0.12 对 2.13 ± 0.08，P = 0.01）。RFR（P = 0.82）或大截肢（P = 0.19）方面无差异。与血管腔内治疗相比，开放血管重建与再入院减少独立相关（优势比 = 0.55 [0.43 - 0.71]）。然而下肢血管重建类型与大截肢或 RFR 之间无显著关联。
与开放下肢血管重建相比，为 CLI 进行的血管腔内下肢血管重建手术针对的是年龄更大、病情更重的患者，并且在 1 年时似乎与再入院增加相关。无论初始治疗方式如何，患者在再入院期间可能至少接受 1 次血管重建。
