Premature peripheral arterial disease is associated with worse outcomes after endovascular peripheral vascular intervention.

Abstract

Premature peripheral arterial disease (PAD), defined as onset before the age of 50 years, is increasing in prevalence. The clinical characteristics, treatment patterns, and mid- and late-term outcomes of patients with premature PAD undergoing endovascular peripheral vascular intervention (PVI) are not well-defined. The linked Vascular Quality Initiative and Medicare dataset was used to examine those who underwent PVI for arterial occlusive disease from January 2017 to December 2018. The exclusion criteria were acute limb ischemia and concomitant open revascularization. Patient demographics, operative characteristics, and outcomes were analyzed by group: premature versus nonpremature PAD. The primary outcomes of interest included risk of major amputation and 30-day, 90-day, and 1-year mortality. Time-to-event analyses were employed to calculate the cumulative incidence and derive the risk between the groups for the primary outcomes. A total of 15,050 patients were identified: 14,699 with nonpremature PAD (97.7%) and 351 with premature (2.3%). The premature PAD group had a higher proportion of women (49.0% vs 41.2%; P = .003), higher proportion of minoritized group members, and higher comorbidity burden. The premature PAD group commonly presented with chronic limb-threatening ischemia (79.8% vs 60.3%; P < .001) and prior amputation, both minor (21.4% vs 8.4%; P < .001) and major (19.1% vs 8.7%; P < .001). Patients with premature PAD had a significantly higher cumulative incidence of major amputation at 30 days (4.6% vs 1.9%; P = .006), 90 days (13.7% vs 5.2%; P < .001), and 1 year (21.9% vs 8.9%; P < .001), with a significantly shorter mean time-to-amputation than that of their nonpremature PAD counterparts (14.6 [10.5] vs 17.3 [10.3] months; P < .001). Despite the significant difference in the mean age between the groups (28.3 [4.6] years), no significant difference was noted in 30-day, 90-day, or 1-year all-cause mortality, with a similar mean time-to-death, between the premature and nonpremature PAD groups (18.2 vs 18.6 months; P = .52). In multivariable analysis, premature PAD was not associated with mortality at 30 days (adjusted hazard ratio [aHR], 0.93; 95% confidence interval [CI], 0.49-1.75; P = .82), 90 days (aHR, 0.94; 95% CI, 0.63-1.40; P = .76), or 1 year (aHR, 0.83; 95% CI, 0.64-1.07; P = .15). However, premature PAD remained independently associated with 90-day (aHR, 1.62; 95% CI, 1.20-2.19; P < .001) and 1-year major amputation (aHR, 1.57; 95% CI, 1.24-1.99; P < .0001). Patients with premature PAD undergoing PVI represent a high-risk population characterized by higher comorbidity burden, advanced disease at presentation, significantly higher 1-year major amputation rates, and comparable mortality to patients with nonpremature PAD despite an almost 30-year difference in the mean age between the groups. Further work should focus on identifying the barriers to optimal medical therapy and developing targeted intervention strategies to mitigate limb loss in this vulnerable cohort.