Gender-related disparity in outcomes of lower extremities peripheral arterial disease continues: Study

Researchers from the Mount Sinai School of Medicine report that despite overall improvement, there is still gender-related disparity in outcomes of lower extremities peripheral arterial disease (PAD). Details of their study appear in the November issue of the Journal of Vascular Surgery®, published by the Society for Vascular Surgery®.

"Female gender continues to be an important risk factor that negatively influences the outcomes of vascular interventions; however these effects vary between different high risk groups and procedures," said Ageliki G. Vouyouka MD, a vascular surgeon at Mount Sinai. "The study - (completed with co-author Natalia Egorova, PhD also from the Mt. Sinai School of Medicine) reviewed the cases of 372,692 surgical hospitalizations from 1998-2007 in New Jersey, New York, and Florida (states with large populations at risk for PAD); of these 162,730 (43.66 percent) were women. When compared to men, the women were older (mean age 72 compared to 69 for men), more obese (11.86 percent vs. 4.89 percent), more likely to be black (18.81 percent vs. 12.66 percent), and had more critical limb ischemia (39.41 percent vs. 37.67 percent).

The study showed that women had higher mortality (5.26 percent vs. 4.21 percent). Even after adjusting for coexisting diseases it remained high. "The most pronounced difference was in cerebrovascular disease, where women had a 33 percent higher risk of mortality after adjustment for other relevant risk factors," added Dr. Vouyouka. "In patients with underlying coronary artery disease (CAD), the risk in women was 21 percent higher." The authors speculate that poor risk factor recognitions and suboptimal optimization of these high risk groups of women as compared to their male counterparts may account for this significant discrepancy in mortality.

However, differences in procedures affected mortality rates in the study. Researchers said that following endovascular procedures the rates were lower and showed only a marginal difference between women and men (2.87 percent vs. 2.11 percent). The difference was more pronounced after open revascularizations (5.05 percent for women vs. 4.00 percent for men) and amputations (9.82 percent for women vs. 8.82 percent for men). It also was noted that advanced age alone dissipates the negative effect of female gender on periprocedural mortality.

Complications also were higher in women (especially bleeding at 10.62 percent vs. 8.19 percent). The greatest variance between females and males in perioperative bleeding was seen when both open and endovascular procedures were done during the same hospitalizations; the lowest after major amputations.

After controlling for baseline comorbid conditions, patient age, type, and year of procedure, researchers found that female gender had an increased risk of bleeding of 33 percent. "Whether this is due to anatomic or technical factors in females, such as smaller arteries and use of relatively large devices during procedures, or excessive usage of blood thinners not adjusted to the women's weight and pharmacokinetics, further investigation using primary data collection is warranted on this subject," added Dr. Vouyouka.

The study found that being a female patient increased the odds of infection by 21 percent and the female overall perioperative infection rates were 3.23 percent vs. 2.88 percent for males. However, it should be noted that there was no significant difference between men and women in postoperative infection after endovascular procedures (1.21 percent vs 1.05 percent).

"One of the most interesting findings from our study might be that the female gender is associated with increased risk of mortality at variable intensity in different clinical subsets but not in octogenarians where, in fact, it has a protective effect. A better understanding, analysis, and consideration of these associations between gender and other risk factors may help to correct gender-related disparity in the outcomes of vascular procedures," said Dr. Vouyouka.