Sex Disparities in Infra-inguinal Prosthetic Bypass for Peripheral Artery Disease

Although prior studies have demonstrated sex-based differences in peripheral arterial disease (PAD), contemporary surgical outcomes remain under-characterized for women compared with men. We aim to discern differences in perioperative outcomes between men and women with PAD who received infra-inguinal prosthetic bypasses. The Infra-Inguinal Bypass Vascular Quality Initiative registry was queried between 2010 and2020. We evaluated patients with infra-inguinal, prosthetic bypasses for occlusive disease, excluding patients with non-occlusive disease, asymptomatic disease, acute limb ischemia, and emergent procedures. Baseline demographics, comorbidities, prior medical and surgical management, and perioperative outcomes were compared between men and women using χ2 analysis and t test. Socioeconomic status was defined using distressed community index. Bypass patency at 1 year was compared between prosthetic bypasses of the same inflow and outflow targets, using Kaplan-Meier analysis. We identified 28,845 infra-inguinal prosthetic bypasses, 36.8% of which were performed in women. Women were older and had a higher proportion of Black race, non-ambulatory status, and chronic obstructive pulmonary disease, and were from socioeconomically “distressed” communities (Table I). Men had a higher rate of smoking, cardiac disease, and heart failure; they were also more often on aspirin and statin both prior to intervention and upon discharge. A higher proportion of females were on P2Y inhibitors with high rates of prior lower extremity percutaneous transluminal angioplasty/stenting compared with men. Additionally, more women had preoperative vein mapping, although there was no significant difference in prior bypass history (coronary or peripheral). Men presented more often with claudication, had more distal disease with tibial outflow targets, and received concurrent ipsilateral endarterectomy (Table II). Alternatively, women more often presented with rest pain or tissue loss and had proximal disease with a higher proportion of popliteal outflow targets. Women did have less perioperative antibiotic use and slightly more postoperative infections. Fewer women were returned home or were ambulatory on discharge. There was no significant difference in 5-year cumulative survival (89% vs 88.3%; P = .07) or 1-year patency between males and females in femoral-above knee (58.1% vs 61.2%; P = .069), femoral-below knee (59.4% vs 56.7%; P = .49), or femoral-tibial (59.4% vs 55.7%; P = .464) bypasses. Women present with a unique demographic, socioeconomic, and PAD disease pattern associated with diminished perioperative medical management and advanced disease severity at revascularization. With a history of higher rates of endovascular intervention, prior vein mapping without a cardiac or bypass history suggests that prosthetic is often used first in women potentially due to a more proximal target combined with inadequate conduit.