Department of Vascular Surgery, University at Buffalo, Buffalo, NY.
Department of Vascular Surgery, University at Buffalo, Buffalo, NY.
J Vasc Surg. 2023 Aug;78(2):490-497. doi: 10.1016/j.jvs.2023.04.025. Epub 2023 May 6.
Optimizing medical management and risk factor modification are underused strategies in patients with chronic limb-threatening ischemia (CLTI), despite evidence of improved outcomes. The Vascular Quality Initiative (VQI) registry is a tool to improve quality of vascular care. In this study, we used the VQI to evaluate trends in medical management in patients with CLTI undergoing peripheral vascular interventions (PVI), and the impact of changes in management on overall survival (OS), amputation-free survival (AFS), and limb salvage (LS).
Patients undergoing index PVI for CLTI between 2012 and 2016, with ≥24 months of follow-up were identified from the national VQI registry. Patient details including smoking status and medication use, OS, LS, and AFS were analyzed with linear-by-linear association, t test, and logistic regression.
There were 12,370 PVI completed in 11,466 patients. There was a significant increase in infrapopliteal interventions (from 29.8% to 39.0%; P < .001) and PVI performed for tissue loss (from 59.1% to 66.5%; P < .001). The percentage of current smokers at time of PVI decreased (from 36.2% to 30.7%; P = .036). At discharge, statins were initiated in 25%, aspirin in 45%, and P2Y12 therapy in 58% of patients not receiving these medications before PVI. Over the course of follow-up, dual antiplatelet therapy (DAPT) (from 41.1% to 48.0%; P < .001), angiotensin-converting enzyme (ACE) inhibitor (from 46.2% to 51.3%; P < .001), and statin (from 70.4% to 77.5%; P < .001) use increased. Combined DAPT, ACE inhibitor and statin use increased from 33.6% to 39.6% (P ≤ .001). Significant improvement in 24-month OS and AFS was noted (OS, from 90.9% to 93.7% [P = .002]: AFS, from 81.2% to 83.1% [P = .046]), but not LS (from 89.6% to 89.0%; P = .83). Combined therapy with P2Y12 inhibitors, statins and ACE inhibitors was an independent predictor of improved OS (hazard ratio, 0.61; 95% confidence interval, 0.39-0.96; P = .034). DAPT was independent predictor of improved LS (hazard ratio, 0.83; 95% confidence interval, 0.79-0.87; P < .007).
Antiplatelet, ACE inhibitor, and statin use increased over the study period and was associated with improved OS and AFS. LS trends did not change significantly over time, possibly owing to the inclusion of patients with a greater disease burden or inadequate medical management. Medical management, although improved, remained far from optimal and represents an area for continued development.
尽管改善结局的证据确凿，但在患有慢性肢体威胁性缺血（CLTI）的患者中，优化医学管理和危险因素修正仍是未被充分利用的策略。血管质量倡议（VQI）登记处是提高血管护理质量的工具。在这项研究中，我们使用 VQI 来评估 CLTI 患者接受外周血管介入治疗（PVI）时的医学管理趋势，以及管理变化对总生存率（OS）、无截肢生存率（AFS）和保肢率（LS）的影响。
从全国 VQI 登记处中确定了 2012 年至 2016 年间接受 CLTI 索引 PVI 的患者，并至少随访 24 个月。使用线性线性关联、t 检验和逻辑回归分析患者详细信息，包括吸烟状况和药物使用、OS、LS 和 AFS。
共完成 11466 例患者的 12370 例 PVI。经腘动脉以下干预（从 29.8%增至 39.0%；P<.001）和为组织丢失而进行的 PVI（从 59.1%增至 66.5%；P<.001）显著增加。在 PVI 时的当前吸烟者比例下降（从 36.2%降至 30.7%；P=0.036）。出院时，25%的患者开始使用他汀类药物，45%的患者开始使用阿司匹林，58%的患者开始使用 P2Y12 抑制剂，而这些药物在 PVI 之前未被使用。在随访过程中，双联抗血小板治疗（DAPT）（从 41.1%增至 48.0%；P<.001）、血管紧张素转换酶（ACE）抑制剂（从 46.2%增至 51.3%；P<.001）和他汀类药物（从 70.4%增至 77.5%；P<.001）的使用增加。联合使用 DAPT、ACE 抑制剂和他汀类药物的比例从 33.6%增加到 39.6%（P≤.001）。24 个月的 OS 和 AFS 显著改善（OS，从 90.9%增加到 93.7%[P=.002]；AFS，从 81.2%增加到 83.1%[P=.046]），但 LS 没有显著改善（从 89.6%增加到 89.0%；P=.83）。P2Y12 抑制剂、他汀类药物和 ACE 抑制剂联合治疗是 OS 改善的独立预测因素（风险比，0.61；95%置信区间，0.39-0.96；P=.034）。DAPT 是 LS 改善的独立预测因素（风险比，0.83；95%置信区间，0.79-0.87；P<.007）。
抗血小板、ACE 抑制剂和他汀类药物的使用在研究期间增加，并与 OS 和 AFS 的改善相关。LS 趋势随时间变化没有明显变化，可能是由于纳入了疾病负担更大或医学管理不足的患者。尽管医学管理有所改善，但仍远未达到最佳水平，这是一个需要持续发展的领域。
