Female patients had fewer endovascular revascularizations for chronic limb-threatening ischemia (CLTI) compared to male patients but experienced lower risks of mortality and major amputation, according to recent data. However, the findings also showed female patients were more likely to experience a decline in ambulatory function following the procedure.
The study, published in the Journal of Vascular Surgery (JVS), sheds new light on sex-based differences in the most advanced stage of peripheral arterial disease (PAD). For the study, data was drawn from a 100% sample of Medicare fee-for-service claims spanning 2016 to 2023. Among the 333,173 patients undergoing revascularization for CLTI during the period, 146,644 were female. Females were older on average and were more likely to be Black and from socioeconomically distressed communities.
“Despite having higher social and demographic risk profiles, women underwent lower rates of endovascular revascularization throughout the study period,” said Katerina Dangas, BMBCh, first author on the study and resident physician in the Department of Internal Medicine at Massachusetts General Hospital. “The lower procedural rate may reflect differences in detection, referral patterns or treatment decision-making.”
The disparity in procedural access is not a new phenomenon, but the scale of the dataset used in the study provides a robust look at its scope. Investigators used population-level rates, Kaplan-Meier methods and multivariable Cox regression to analyze outcomes and adjusted for demographics, comorbidities, revascularization modality, disease severity, and other mediators.
“Longstanding perceptions that PAD is more common in men may contribute to under-recognition and potential undertreatment of women with CLTI, particularly among socially vulnerable populations,” said Eric Secemsky, MD, senior author on the study and director of vascular intervention at Beth Israel Deaconess Medical Center. “Women with PAD are more likely to present later or with atypical symptoms, which may delay diagnosis and referral.”
The findings showed female patients demonstrated a lower adjusted risk of the primary composite endpoint of mortality or major amputation, as well as lower independent risks of major amputation and mortality. Yet the same analysis found women were more likely to experience a meaningful restriction in ambulatory function after revascularization.
Female patients also demonstrated a lower risk of repeat revascularization following initial CLTI, a finding that adds further dimension to the overall outcomes picture. Taken together with the lower risks of major amputation and mortality, the data suggest that women who do access endovascular revascularization for CLTI tend to fare meaningfully better than men across the most clinically consequential hard endpoints, which adds significance to the ambulatory decline finding.
“Women in our cohort had modestly lower adjusted risks of mortality and major amputation, which may suggest that sex-based differences in endovascular revascularization outcomes may be less pronounced than historically reported,” said Dangas. “However, women had a higher likelihood of post-procedural ambulatory decline.”
The reasons behind ambulatory decline are likely multifactorial, said Dangas. The female patients in the cohort were older and carried higher rates of socioeconomic disadvantage, factors that may independently affect functional recovery. Biological differences may also play a role. “Women undergoing revascularization were older and may have lower baseline muscle mass and strength, which has been associated with greater functional impairment in PAD despite similar or better limb outcomes,” said Dangas.
The data bring into focus a broader question about how outcomes are measured and what endpoints matter most to patients. “These findings highlight the importance of evaluating outcomes not solely by limb salvage or survival,” said Secemsky. “Patient-centered outcomes such as functional recovery and mobility should be systematically assessed and addressed.”
Dangas and Secemsky identified two specific clinical priorities in response to the findings: maintaining a lower threshold for PAD evaluation in women — given their tendency to present later or with atypical symptoms — and building baseline mobility assessment and early rehabilitation planning into standard post-revascularization care pathways for female patients. Both represent actionable steps that vascular surgeons can begin to implement without waiting for further trial data.
According to Dangas, continued investigation into modifiable drivers of these differences is essential to not only understand them, but to act on them as well. “Evaluating the drivers of such differences is important to further improve vascular care delivery,” she said. “Closing these gaps will require looking beyond procedural success to ask whether our patients are truly recovering, and ensuring that women, who face distinct biological and social challenges, are not left behind in that effort.”
