Results from a new study highlighting that female patients are at increased risk of adverse outcomes after acute limb ischemia (ALI) lend weight to the possibility of underdiagnosis and management of vascular disease among women, the authors behind the research report.
Investigators from the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pennsylvania, found that females who presented with ALI were less likely to have had prior vascular interventions, less frequently on a preoperative statin or antiplatelet agent and more likely to be hypercoagulable. They had a higher rate of mortality after revascularization except when medically optimized, and female patients also had “notably higher amputation rates following endovascular interventions,” the UPMC research team found.
The results were delivered by Mikayla Lowenkamp, MD, a vascular surgery resident at UPMC, during a session dedicated to diversity, equity and inclusion (DEI) at the 2024 Eastern Vascular Society (EVS) annual meeting in Charleston, South Carolina (Sept. 19–22).
Lowenkamp set the scene for the study by pointing to the “underrepresentation of female patients” in key trials and a resultant “lack of sex-based guidelines regarding the evaluation, diagnosis and management” of vascular disease in women. “As a result, recent literature has found a difference in amputation and mortality rates following acute limb ischemia,” she said.
Lowenkamp and colleagues looked to identify sex-specific predictors of major amputation and mortality, as well as sex-specific differences in the presentation, management and outcomes in patients undergoing revascularization for ALI in a retrospective cohort study of cases from a multihospital system. All patients who underwent a revascularization procedure for ALI from 2016–2023 were included, with 548 meeting inclusion criteria. Female patients were older and made up 46% of the cohort. They were less likely to have a history of cardiovascular disease, specifically lower rates of coronary artery disease (CAD), Lowenkamp told EVS 2024.
Study data demonstrated that females report earlier after symptom onset and were more likely to go to the operating room within 24 hours in comparison to their male counterparts, despite no differences in Rutherford ALI classification on presentation.
There were no differences in either the initial surgical approach—endovascular vs. open—or in terms of endovascular strategy. But female patients were less likely to undergo thrombolysis or bypass. After intervention, female patients were less frequently discharged on an antiplatelet, and experienced an increased rate of mortality on both univariable and multivariable analyses. Increasing age, a cancer history and an advanced Rutherford classification were all predictors of an increased mortality risk, Lowenkamp added.
On subgroup analysis, the association between women and mortality did not differ except in the context of preoperative optimal medical therapy (OMT): “In female patients on optimal medical care, mortality risk after revascularization was equivalent to males,” she said. “In female patients not on OMT, their mortality risk was significantly increased in comparison to males.”
Furthermore, there were no differences in overall amputation rates between the sexes on univariable analysis, and sex was not a predictor of amputation on multivariable analysis, Lowenkamp continued. “And the association between females and amputation did not differ among the subgroups, except in patients who received an endovascular-first approach; they were 2.6 times as likely to undergo a major amputation.”
Concluding, Lowenkamp emphasized the data showing a higher rate of long-term morality alongside a higher rate of amputation following endovascular intervention, commenting that “one can speculate that may be due to smaller vessel size, differences in chronicity or distribution of the disease.”
Posing a question from the meeting floor, Alan M. Dietzek, MD, the chief of vascular surgery at Nuvance Health in Danbury, Connecticut, said the take-home message from the study results seemed to be women not being on OMT, and asked Lowenkamp whether, given the totality of the data, this prompted a preference for an endovascular or open surgical approach.
Lowenkamp said her takeaway was more centered on a need to ensure that female patients are medically optimized should they require a vascular intervention.
