Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., A.Q., M.V.-S., S.G.).
Department of Veterans Affairs, Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center (K.M., M.V.-S., S.G.).
Circ Cardiovasc Interv. 2020 Feb;13(2):e008597. doi: 10.1161/CIRCINTERVENTIONS.119.008597. Epub 2020 Feb 13.
Contemporary patterns in management and outcomes of critical limb ischemia among United States veterans are unknown.
We used Veterans Health Administration data to identify patients admitted for critical limb ischemia between 2005 and 2014. We examined temporal trends in incidence, management, and outcomes.
A total of 20 938 veterans with critical limb ischemia were hospitalized between 2005 and 2014. Mean age was 67.8 years. Incidence decreased from 0.3 to 0.24 per 1000 persons from 2005 to 2013, <0.01. During the study period, there was a temporal increase in use of revascularization within 90 days of hospitalization-endovascular (11.2% in 2005 to 18.4% in 2014), surgical (23.8% in 2005 to 26.4% in 2014), and hybrid (6.2% in 2005 to 13.1% in 2014, value for trend <0.01). Statin prescriptions increased from 47.4% in 2005 to 60.9% in 2014 ( value for trend <0.01). There was a significant decline in risk-adjusted mortality (11.8% in 2005 to 9.7% in 2014) and major amputation (19.8% in 2005 to 12.9% in 2014; value for trend <0.01 for both) at 90 days. In adjusted analyses, revascularization was associated with a lower risk of mortality (RR, 0.45 [95% CI, 0.41-0.50]; <0.001) and major amputation at 90 days (RR, 0.23 [95% CI, 0.21-0.26]; <0.001). Nearly half of the patients who underwent amputation did not receive an invasive vascular procedure within the preceding 90 days. There was large site-level variation in the use of revascularization (median rate, 41.7% [interquartile range, 12.5%-53.2%]). Differences in patient case-mix explained only 8% of site-level variation in receipt of revascularization.
Over the past decade, use of revascularization increased among veterans with critical limb ischemia, which was accompanied by a reduction in mortality and major amputation. However, opportunities to further improve care in this high-risk population still remain.
目前尚不清楚美国退伍军人中严重肢体缺血的管理和结果的当代模式。
我们使用退伍军人健康管理局的数据来确定 2005 年至 2014 年间因严重肢体缺血住院的患者。我们检查了发病率、管理和结果的时间趋势。
在 2005 年至 2014 年期间，共有 20938 名患有严重肢体缺血的退伍军人住院。平均年龄为 67.8 岁。发病率从 2005 年的 0.3 降至 2013 年的 0.24/1000 人，<0.01。在研究期间，血管内治疗（2005 年为 11.2%，2014 年为 18.4%）、手术治疗（2005 年为 23.8%，2014 年为 26.4%）和混合治疗（2005 年为 6.2%，2014 年为 13.1%，趋势值<0.01）的 90 天内血运重建的使用率呈时间性增加。他汀类药物的处方从 2005 年的 47.4%增加到 2014 年的 60.9%（趋势值<0.01）。90 天的风险调整死亡率（2005 年为 11.8%，2014 年为 9.7%）和主要截肢（2005 年为 19.8%，2014 年为 12.9%；趋势值均<0.01）显著下降。在调整后的分析中，血运重建与较低的 90 天死亡率（RR，0.45 [95%CI，0.41-0.50]；<0.001）和主要截肢（RR，0.23 [95%CI，0.21-0.26]；<0.001）风险相关。近一半接受截肢的患者在过去 90 天内未接受有创血管手术。血管重建的使用率存在很大的站点间差异（中位数为 41.7%[四分位距，12.5%-53.2%]）。患者病例组合的差异仅解释了血管重建接受率站点间差异的 8%。
在过去十年中，严重肢体缺血退伍军人的血运重建使用率增加，死亡率和主要截肢率降低。然而，在这个高危人群中，进一步改善治疗的机会仍然存在。
