Factors associated with delays in revascularization in patients with chronic limb-threatening ischaemia: population-based cohort study.

BACKGROUND: Prompt revascularization in patients with chronic limb-threatening ischaemia (CLTI) is important, and recent guidance has suggested that patients should undergo revascularization within 5 days of an emergency admission to hospital. The aim of this cohort study was to identify factors associated with the ability of UK vascular services to meet this standard of care. METHODS: Data on all patients admitted non-electively with CLTI who underwent open or endovascular revascularization between 2016 and 2019 were extracted from the National Vascular Registry. The primary outcome was interval between admission and procedure, analysed as a binary variable (5 days or less, over 5 days). Multivariable Poisson regression was used to examine the relationship between time to revascularization and patient and admission characteristics. RESULTS: The study analysed information on 11 398 patients (5973 open, 5425 endovascular), 50.6 per of whom underwent revascularization within 5 days. The median interval between admission and intervention was 5 (i.q.r. 2-9) days. Patient factors associated with increased risk of delayed revascularization were older age, greater burden of co-morbidity, non-smoking status, presentation with infection and tissue loss, and a Fontaine score of IV. Patients admitted later in the week were less likely undergo revascularization within 5 days than those admitted on Sundays and Mondays (P < 0.001). Delays were slightly worse among patients having open compared with endovascular procedures (P = 0.005) and in hospitals with lower procedure volumes (P < 0.001). CONCLUSION: Several factors were associated with delays in time to revascularization for patients with CLTI in the UK, most notably the weekday of admission, which reflects how services are organized. The results support arguments for vascular units providing revascularization to have the resources for a 7-day service.

Chronic limb-threatening ischaemia (CLTI) is a severe form of peripheral artery disease that reduces blood flow to the legs and can lead to amputation. Between 2016 and 2019, only 50.6 per cent of patients admitted to UK vascular units urgently with CLTI underwent revascularization within 5 days from admission. Several factors were associated with delays in time to revascularization, most notably the weekday of admission, which reflects how services are organized. The results support arguments for vascular units providing revascularization to have resources for a 7-day service.

Long-term survival after endovascular and open repair of unruptured abdominal aortic aneurysm.

BACKGROUND: The aim of this study was to examine patterns of 10-year survival after elective repair of unruptured abdominal aortic aneurysms (AAAs) in different patient groups. METHODS: Patients having open repair or endovascular aneurysm repair (EVAR) in the English National Health Service between January 2006 and December 2015 were identified from Hospital Episode Statistics data. Postoperative survival among patients of different age and Royal College of Surgeons of England (RCS) modified Charlson co-morbidity score profiles were analysed using flexible parametric survival models. The relationship between patient characteristics and risk of rupture after repair was also analysed. RESULTS: Some 37 138 patients underwent elective AAA repair, of which 15 523 were open and 21 615 were endovascular. The 10-year mortality rate was 38·1 per cent for patients aged under 70 years, and the survival trajectories for open repair and EVAR were similar when patients had no RCS-modified Charlson co-morbidity. Among older patients or those with co-morbidity, the 10-year mortality rate rose, exceeding 70 per cent for patients aged 80 years. Mean survival times over 10 years for open repair and EVAR were often similar in subgroups of older and more co-morbid patients, but their survival trajectories became increasingly dissimilar, with open repair showing greater short-term risk within 6 months but lower 10-year mortality rates. The risk of rupture over 9 years was 3·4 per cent for EVAR and 0·9 per cent for open repair, and was weakly associated with patient factors. CONCLUSION: Long-term survival patterns after elective open repair and EVAR for unruptured AAA vary markedly across patients with different age and co-morbidity profiles.

ANTECEDENTES: El objetivo de este artículo fue examinar los patrones de supervivencia a 10 aáos tras reparación electiva de aneurismas de la aorta abdominal sin rotura (abdominal aortic aneurysms, AAA) en diferentes grupos de pacientes. MÉTODOS: Se identificaron pacientes sometidos a reparación abierta (open repair, OR) o reparación endovascular (endovascular aneurysm repair, EVAR) del aneurisma en el Sistema Nacional de Salud Inglés entre enero de 2006 y diciembre de 2015, a partir de los datos del Hospital Episode Statistics. Se analizaron la supervivencia postoperatoria entre los pacientes de diferentes edades y los perfiles de comorbilidad con la puntuación de Charlson modificada del Royal College of Surgeons of England (RCS) utilizando modelos de supervivencia paramétricos flexibles. También se analizó la relación entre las características de los pacientes y el riesgo de rotura tras la reparación. RESULTADOS: Un total de 37.138 pacientes fueron sometidos a reparaciones electivas de AAA, de las cuales 15.523 fueron reparaciones abiertas y 21.615 endovasculares. La mortalidad a los 10 aáos fue del 38% para los pacientes de edad inferior a los 70 aáos, y las curvas de supervivencia de la OR y EVAR fueron similares cuando los pacientes no tenían comorbilidad con el Charlson modificado del RCS. Entre los pacientes de edad avanzada y aquellos pacientes con comorbilidad, la mortalidad a los 10 aáos aumentó, excediendo el 70% para los pacientes de más de 80 aáos de edad. La media de los tiempos de supervivencia superior a 10 aáos para OR y EVAR fueron similares dentro de los subgrupos de pacientes de edad avanzada y más comorbilidad, pero las curvas de supervivencia se hicieron cada vez más diferentes, con la OR mostrando un mayor riesgo a corto plazo en los primeros 6 meses pero tasas de mortalidad a los 10 aáos más bajas. El riesgo de rotura mas allá de los 9 aáos fue 3,4% para EVAR y 0,9% para la reparación abierta, con una débil asociación con los factores inherentes a los pacientes. CONCLUSIÓN: Los patrones de supervivencia a largo plazo tras OR y EVAR electivas para AAA sin rotura varían notablemente entre pacientes con perfiles de edad y comorbilidad diferentes.

Population-based study of mortality and major amputation following lower limb revascularization.

BACKGROUND: The aim of this study was to estimate separate risks of major lower limb amputation and death following revascularization for peripheral artery disease (PAD) using competing risks analysis. METHODS: Routinely collected data from Hospital Episode Statistics (HES) were used to identify patients who underwent endovascular or open lower limb revascularization for PAD in England from 2005 to 2015. The primary outcomes were major lower limb amputation and death within 5 years of revascularization. Cox proportional hazards and Fine-Gray competing risks regression were used to examine the competing risks of these outcomes. RESULTS: Some 164 845 patients underwent their first lower limb revascularization for PAD during the study interval. Most were men (64·6 per cent) and the median age was 71 (i.q.r. 62-78) years. Following endovascular revascularization, the 5-year cumulative incidence of amputation was 4·2 per cent in patients with intermittent claudication and 18·0 per cent in those with a record of tissue loss. The corresponding rates were 10·8 and 25·3 per cent respectively after open revascularization, and 8·1 and 25·0 per cent after combined procedures. The 5-year cumulative incidence of death varied from 24·5 to 39·8 per cent, depending on procedure type. Competing risks methods consistently produced lower estimates than standard methods. CONCLUSION: The 5-year risk of major amputation following lower limb revascularization for PAD appears lower than estimated previously. Patients undergoing revascularization for tissue loss and those who require an open procedure are at highest risk of limb loss.

Editor's Choice - Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry.

OBJECTIVE: Guidelines recommend that patients suffering an ischaemic transient ischaemic attack (TIA) or stroke caused by carotid artery stenosis should undergo carotid endarterectomy (CEA) within 14 days. METHOD: The degree to which UK vascular units met this standard was examined and whether rapid interventions were associated with procedural risks. The study analysed patients undergoing CEA between January 2009 and December 2014 from 100 UK NHS hospitals. Data were collected on patient characteristics, intervals of time from symptoms to surgery, and 30-day postoperative outcomes. The relationship between outcomes and time from symptom to surgery was evaluated using multilevel multivariable logistic regression. RESULTS: In 23,235 patients, the median time from TIA/stroke to CEA decreased over time, from 22 days (IQR 10-56) in 2009 to 12 days (IQR 7-26) in 2014. The proportion of patients treated within 14 days increased from 37% to 58%. This improvement was produced by shorter times across the care pathway: symptoms to referral, from medical review to being seen by a vascular surgeon, and then to surgery. The spread of the median time from symptom to surgery among NHS hospitals shrank between 2009 and 2013 but then grew slightly. Low-, medium-, and high-volume NHS hospitals all improved their performance similarly. Performing CEA within 48 h of symptom onset was associated with a small increase in the 30-day stroke and death rate: 3.1% (0-2 days) compared with 2.0% (3-7 days); adjusted odds ratio 1.64 (95% CI 1.04-2.59) but not with longer delays. CONCLUSIONS: The delay from symptom to CEA in symptomatic patients with ipsilateral 50-99% carotid stenoses has reduced substantially, although 42% of patients underwent CEA after the recommended 14 days. The risk of stroke after CEA was low, but there may be a small increase in risk during the first 48 h after symptoms.

Current practice of carotid endarterectomy in the UK.

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid stenosis of 50-99 per cent. This study assessed national surgical practice through audit of CEA procedures and outcomes. METHODS: This was a prospective cohort study of UK surgeons performing CEA, using clinical audit data collected continuously and reported in two rounds, covering operations from December 2005 to December 2007, and January 2008 to September 2009. RESULTS: Some 352 (92·6 per cent) of 380 eligible surgeons contributed data. Of 19,935 CEAs recorded by Hospital Episode Statistics, 12,496 (62·7 per cent) were submitted to the audit. A total of 10,452 operations (83·6 per cent) were performed for symptomatic carotid stenosis; among these patients, the presenting symptoms were transient ischaemic attack in 4507 (43·1 per cent), stroke in 3572 (34·2 per cent) and amaurosis fugax in 1965 (18·8 per cent). The 30-day mortality rate was 1·0 per cent (48 of 4944) in round 1 and 0·8 per cent (50 of 6151) in round 2; the most common cause of death was stroke, followed by myocardial infarction. The rate of death or stroke within 30 days of surgery was 2·5 per cent (124 of 4918) in round 1 and 1·8 per cent (112 of 6135) in round 2. CONCLUSION: CEA is performed less commonly in the UK than in other European countries and probably remains underutilized in the prevention of stroke. Increasing the number of CEAs done in the UK, together with reducing surgical waiting times, could prevent more strokes.