Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (Q.L., D.A.C.).
The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.).
Circulation. 2024 Jul 23;150(4):261-271. doi: 10.1161/CIRCULATIONAHA.123.067687. Epub 2024 Jul 22.
The aim of this study was to investigate the illness trajectories of patients with peripheral artery disease (PAD) after revascularization and estimate the independent risks of major amputation and death (from any cause) and their interaction.
Data from Hospital Episode Statistics Admitted Patient Care were used to identify patients (≥50 years of age) who underwent lower limb revascularization for PAD in England from April 2013 to March 2020. A Markov illness-death model was developed to describe patterns of survival after the initial lower limb revascularization, if and when patients experienced major amputation, and survival after amputation. The model was also used to investigate the association between patient characteristics and these illness trajectories. We also analyzed the relative contribution of deaths after amputation to overall mortality and how the risk of mortality after amputation was related to the time from the index revascularization to amputation.
The study analyzed 94 690 patients undergoing lower limb revascularization for PAD from 2013 to 2020. The majority were men (65.6%), and the median age was 72 years (interquartile range, 64-79). One-third (34.8%) of patients had nonelective revascularization, whereas others had elective procedures. For nonelective patients, the amputation rate was 15.2% (95% CI, 14.4-16.0) and 19.9% (19.0-20.8) at 1 and 5 years after revascularization, respectively. For elective patients, the corresponding amputation rate was 2.7% (95% CI, 2.4-3.1) and 5.3% (4.9-5.8). Overall, the risk of major amputation was higher among patients who were younger, had tissue loss, diabetes, greater frailty, nonelective revascularization, and more distal procedures. The mortality rate at 5 years after revascularization was 64.3% (95% CI, 63.2-65.5) for nonelective patients and 33.0% (32.0-34.1) for elective patients. After major amputation, patients were at an increased risk of mortality if they underwent major amputation within 6 months after the index revascularization.
The illness-death model provides an integrated framework to understand patient outcomes after lower limb revascularization for PAD. Although mortality increased with age, the study highlights patients <60 years of age were at increased risk of major amputation, particularly after nonelective revascularization.
本研究旨在探讨外周动脉疾病（PAD）患者血管重建后的疾病轨迹，并评估主要截肢和死亡（任何原因）的独立风险及其相互作用。
利用医院入院患者医疗数据，确定了 2013 年 4 月至 2020 年 3 月期间在英格兰因 PAD 进行下肢血管重建的患者（≥50 岁）。采用马尔可夫疾病-死亡模型描述初始下肢血管重建后、发生主要截肢时以及截肢后患者的生存模式。该模型还用于研究患者特征与这些疾病轨迹之间的关联。我们还分析了截肢后死亡对总死亡率的相对贡献，以及截肢后死亡率与从索引血管重建到截肢的时间之间的关系。
本研究分析了 2013 年至 2020 年间 94690 例因 PAD 进行下肢血管重建的患者。大多数患者为男性（65.6%），中位年龄为 72 岁（四分位间距，64-79）。三分之一（34.8%）的患者进行了非择期血管重建，而其余患者则进行了择期手术。对于非择期患者，血管重建后 1 年和 5 年的截肢率分别为 15.2%（95%CI，14.4-16.0）和 19.9%（19.0-20.8）。对于择期患者，相应的截肢率分别为 2.7%（95%CI，2.4-3.1）和 5.3%（4.9-5.8）。总体而言，年龄较小、组织缺失、糖尿病、衰弱程度更高、非择期血管重建和更远处的手术患者发生主要截肢的风险更高。非择期患者血管重建后 5 年的死亡率为 64.3%（95%CI，63.2-65.5），择期患者为 33.0%（32.0-34.1）。主要截肢后，如果患者在索引血管重建后 6 个月内进行主要截肢，其死亡风险会增加。
疾病-死亡模型为理解下肢血管重建后 PAD 患者的结局提供了一个综合框架。尽管死亡率随年龄增长而增加，但研究强调年龄<60 岁的患者发生主要截肢的风险增加，尤其是在非择期血管重建后。
