Improving 1-year Outcomes of Infrainguinal Limb Revascularisation: A Population-Based Cohort Study of 104 000 Patients in England

Abstract

Background—The availability and diversity of lower limb revascularisation procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes.

Methods—Individual-patient records from Hospital Episode Statistics (HES) were used to identify 103 934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty or bypass) lower limb revascularisation for infrainguinal peripheral artery disease (PAD) in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year following revascularisation were ascertained from HES and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score and indication for the intervention (intermittent claudication; severe limb ischaemia without tissue loss; severe limb ischaemia with ulceration; severe limb ischaemia with gangrene/osteomyelitis) and comorbid diabetes.

Results—The estimated 1-year risk of major amputation reduced from 5.7% (in 2006-07) to 3.9% (in 2014-15) following endovascular revascularisation, and from 11.2% (2006-07) to 6.6% (2014-5) following surgical procedures. The risk of death after both types of revascularisation also reduced. These trends were observed for all indications categories, with the largest reductions found in patients with severe limb ischaemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients were treated for the severe end of the PAD spectrum using less invasive procedures.

Conclusions—Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularisation. These observations suggest that patient outcomes after lower limb revascularisation have improved during a period of centralisation and specialisation of vascular services in the United Kingdom.