title: An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety.
abstract: BACKGROUND
  Demographic and practice modality changes during the past decade have led to a substantial shift in the management of peripheral vascular disease. This study examined the effect of these changes using large national and regional data sets on procedure type, indications, morbidity, and on the primary target outcome: limb salvage.
  
  
  METHODS
  National Inpatient Sample (NIS) data sets and New York (NY) State inpatient hospitalizations and outpatient surgeries discharge databases from 1998 through 2007 were used to identify hospitalizations for lower extremity revascularization (LER) and major amputations. Patients were selected by cross-referencing diagnostic and procedural codes. Proportions were analyzed by chi(2) analysis, continuous variables by t test, and trends by the Poisson regression.
  
  
  RESULTS
  The national per capita (100,000 population, age >40 years) volume of major amputations decreased by 38%. The volume for national and regional use of endovascular LER doubled. The volume of open LER decreased by 67% from 1998 through 2007. Ambulatory endovascular LER grew in NY State from 7 per capita in 1998 to 22 in 2007. Interventions declined by 20% (93 to 75) for critical limb ischemia (CLI) but increased by nearly 50% for claudication. Outpatient data analysis revealed a fivefold increase in vascular interventions for CLI and claudication. Nationally, endovascular LER interventions quadrupled (8% to 32%) for CLI and doubled (26% to 61%) for claudication. A parallel reduction occurred in major amputations for patients with CLI (42% to 30%), for other PAD diagnoses (18% to 14%), and for claudication (0.9% to 0.3%). Although surgical interventions for CLI declined significantly for octogenarians from 317 to 240, outpatient interventions increased for CLI, claudication, and other diagnoses in all age groups. Comorbidities for patients treated in 2006 were substantially greater than those of a decade ago. For most procedures, cardiac and bleeding complications have significantly decreased during the last decade. Length of stay (LOS) declined from 9.5 to 7.6 days and the percentage of short (1-2 day) hospitalizations increased from 16% to 35%.
  
  
  CONCLUSIONS
  Although patients today, whether treated for claudication or CLI, have more comorbidities, the rates of amputation, the procedural morbidity and mortality, and LOS have all significantly decreased. Other variables, including changes in medical management and wound care, undoubtedly are important, but this change appears to be largely due to the widespread and successful use of endovascular LER or to earlier intervention, or both, driven by the safety of these techniques.
authors.affiliation: Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA.
authors.forename: Natalia N
authors.initials: NN
authors.lastname: Egorova
authors.forename: Stephanie
authors.initials: S
authors.lastname: Guillerme
authors.forename: Annetine
authors.initials: A
authors.lastname: Gelijns
authors.forename: Nicholas
authors.initials: N
authors.lastname: Morrissey
authors.forename: Rajeev
authors.initials: R
authors.lastname: Dayal
authors.forename: James F
authors.initials: JF
authors.lastname: McKinsey
authors.forename: Roman
authors.initials: R
authors.lastname: Nowygrod
mesh_terms: D000328:Adult; D017677:Age Distribution; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000556:Ambulatory Surgical Procedures; D000671:Amputation, Surgical / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data; D016009:Chi-Square Distribution; D015897:Comorbidity; D016638:Critical Illness; D019992:Databases as Topic; D019538:Health Care Surveys; D006295:Health Resources / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D007383:Intermittent Claudication / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D007511:Ischemia / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D007902:Length of Stay; D023821:Limb Salvage / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data; D035002:Lower Extremity / Q000098:blood supply*; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D016491:Peripheral Vascular Diseases / Q000150:complications / Q000401:mortality / Q000601:surgery*; D010818:Practice Patterns, Physicians'; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data