Alcohol use disorder (AUD) independently raises the risk of major adverse limb events (MALE) and mortality among patients undergoing lower-extremity revascularization for chronic limb-threatening ischemia (CLTI), according to a retrospective cohort study published in the Journal of Vascular Surgery (JVS). Investigators said AUD is likely more prevalent than current diagnosis codes capture.
The data, drawn from electronic health records across the University of Pittsburgh Medical Center multi-hospital health system, analyzed 3,744 patients with CLTI who underwent endovascular or open revascularization between 2016 and 2024. Among the patients, roughly 5% carried an AUD diagnosis. Those patients were more often male and concurrent tobacco users.
The findings showed that patients with AUD had worse outcomes across all measured endpoints. At one year, AUD was associated with a 29% higher risk of MALE and a 51% higher risk of mortality. The risk of major amputation was nearly double that of patients without AUD.
“The clinical cost of overlooking AUD in patients with CLTI is likely substantial,” said Katherine Reitz, MD, senior investigator on the study and an assistant professor of surgery at the University of Pittsburgh. “If AUD meaningfully increases the risk of amputation and mortality, failing to identify and address it represents a missed opportunity to improve outcomes. Patients cannot afford doctors to continue overlooking AUD when treating CLTI.”
Reitz and her colleagues note that the 5% prevalence of AUD likely undercounts the true burden. Because administrative data depend on ICD-10 codes, patients must first receive a formal diagnosis before they can be captured, but many are never screened. National survey data using DSM-5 criteria estimate that roughly 10% of adults over the age of 21 meet criteria for AUD.
“I expected to find that AUD in peripheral artery disease was understudied, but I was surprised by how little literature exists — ranging from the biological effects of alcohol on peripheral vascular disease to the clinical associations between alcohol exposure and outcomes,” said Reitz. “The prevalence of AUD among patients with CLTI is likely higher than what we observed.”
The study grew out of a collaboration between Reitz and first author Samantha Machinski, a medical student at the University of Pittsburgh School of Medicine, who underscored the urgency of improving AUD measurement prior to vascular surgery.
“The substantial underdiagnosis of AUD is likely multifactorial, driven by a combination of underreporting and limited screening and carrying important implications for clinical practice,” said Machinski. “The paucity of literature examining its impact on surgical outcomes, combined with my professional interest in vascular surgery, motivated this study. Improving how we identify and quantify alcohol exposure in surgical populations will be critical to better understand how AUD influences risk stratification and postoperative outcomes.”
Reitz said that preoperative optimization in CLTI has long centered on antithrombotic therapy, lipid-lowering agents, smoking cessation and glycemic control. “The importance of a holistic approach to preoperative optimization has become increasingly apparent and AUD with or without cirrhosis should be added to the list,” she said.
Because patients with AUD are vulnerable and understudied, Reitz said surgeons should consider incorporating routine screening to improve risk assessment. “Brief validated tools such as the Alcohol Use Disorders Identification Test can be administered quickly and easily in most clinical workflows,” she said. “Identifying AUD not only improves the accuracy of our research but may also provide an opportunity to directly improve patient outcomes through early intervention and treatment.”
