Analysis of gender-related differences in lower extremity peripheral arterial disease
Article Outline
- Abstract
- Methods
- Results
- Discussion
- Conclusions
- Author contributions
- Table I (online only)
- References
- Copyright
Introduction
Gender-related differences continue to challenge the management of lower extremity (LE) peripheral arterial disease (PAD) in women. We analyzed the time-trends in hospital care of such differences.
Methods
Data for patients with PAD from New York, New Jersey, and Florida state hospital inpatient discharge databases (1998-2007) were analyzed using univariate and multivariate regression analyses.
Results
The 2.4 million PAD-related inpatient discharge records analyzed showed a slight decrease of inpatient procedures for both genders. Compared with men, women had 18% to 27% fewer PAD and 33% to 49% fewer vascular procedural hospitalizations (P < .0001). They were persistently more likely than men to be admitted emergently (56% vs 51% in 1998 and 57% vs 53% in 2007) and discharged to a nursing home. During the study period, the amputation rate declined by 36% in women and 21% in men with PAD, and similarly, open procedures decreased by 36% and 30%. Endovascular procedures, however, increased by 150% in women and 144% in men. Procedural mortality was 4.95% vs 4.37% for men (P < .0001). Female mortality rates were persistently higher after amputations (9.89 % vs 8.90%, P < .0001), open (5.49% vs 4.00%, P < .0001), and endovascular procedures (2.87% vs 2.10%, P < .0001). Time trends showed improved mortality for men and women, with a stable difference between the two.
Conclusion
The analysis of representative state administrative databases of inpatient care records demonstrated improvements in mortality and amputation rates over time. However, a gender-related disparity in PAD outcomes remains that merits further investigation.
Advances in medical treatment and the incorporation of endovascular and other minimally invasive procedures have radically transformed the practice of vascular surgery over the last decade. These new techniques and strategies allow vascular surgeons to offer limb salvage procedures to patients that traditionally have been considered to be at prohibitive risk for open intervention.
These technologic advances coincide with demographic changes in the Western world, particularly in the United States. By 2007, the number of people aged >65 years increased by 21% and the number of people aged >85 increased by 80% compared with 1990.1 Women are the majority of this aging population, outnumbering men by a ratio 3:2 for those aged >75 and 2:1 for those aged >80.1
Contrary to common wisdom, elderly women do develop peripheral arterial disease (PAD).2 This misperception has, in part, led to under-diagnoses and presentation with more advanced disease in women.2, 3, 4, 5, 6, 7 According to older reports, women are also more likely to undergo amputation and are less likely to have an arterial reconstruction as a first-line procedure.4
The introduction of endovascular techniques as a valid alternative to open traditional surgery has improved the outcomes for women in other fields of vascular surgery. For example, endovascular techniques have decreased female mortality rates after abdominal aortic aneurysm repair.8, 9 Likewise, women undergoing carotid stenting have similar outcomes to men, contrary to the historical gender-related disparity previously seen with carotid endarterectomy.10, 11
The many advancements in the field of vascular surgery have led us to question their effect on the outcomes of lower extremity (LE) PAD in men and women over time. Specifically, have they affected the gender-related differences that historically have been observed in amputation rates, inpatient utilization of reconstructive procedures, and other periprocedural parameters such as in-hospital mortality and length of stay after inpatient procedures? In this study, we analyzed gender-related differences in PAD-related hospitalizations over time, with and without an open or endovascular revascularization, or amputation. We also studied admission and discharge status, diagnosis, procedurally related mortality, and length of stay (LOS) by gender.
Methods
Source of data and patient population
The New York, New Jersey, and Florida state inpatient discharge databases from 1998 through 2007 were used to identify all LE PAD hospitalizations and all PAD-related hospitalizations where open or endovascular revascularization, or major amputations were performed. We selected these states because of the size of their population and their administrative data sets report patient gender for all discharges.
The data were obtained from the following state agencies: New York State Health Department's Statewide Planning and Research Cooperative System (SPARCS); the New Jersey Department of Health and Senior Service; and the Florida State Department of Health. These data sets are based on the Uniform Billing form (UB92) and include primary and multiple secondary diagnoses, primary and secondary procedures (International Classification of Diseases, 9th Revision, Clinical Modification), age, gender, race, hospital identification, principal payer, length of stay and disposition. The data sets were obtained in deidentified form.
Patients with the diagnostic code (primary or secondary positions) 440.21 were categorized as having claudication, and those with diagnostic codes indicating rest pain (440.22), ulceration (440.23), or gangrene (440.24, 707.1, or 707.9) were categorized as having critical limb ischemia (CLI). Treatment groups were identified by cross-referencing relevant procedure codes with diagnostic codes.12 The following treatment groups were analyzed: open LE revascularization (ICD9 procedure codes 38.08, 38.18, 38.38, 38.48, or 39.29), endovascular LE revascularization (39.50 or 39.90), and major lower limb amputation (84.13-84.17). The diagnosis, procedure code groupings, and linkages were selected based on methodology from prior studies12 and are shown in Table I (online only). Because the prevalence of PAD in patients aged <40 years is very low, they were excluded from the analysis.
We conducted two analyses: First we analyzed hospitalizations with PAD as the primary diagnosis. Subsequently, we analyzed hospitalizations that included PAD as both primary and secondary diagnosis. Both analyses demonstrated similar gender-related differences over time. However, fewer vascular procedures were captured when the analysis was based on the primary diagnoses only (20% to 27% depending on the year). To maximize the evaluation of vascular procedures, we report results based on the analysis of all PAD-related hospitalizations (ie, where PAD is either primary or secondary diagnosis), unless otherwise stated. Annual state census information was obtained from the Centers for Disease Control and Prevention Wonder tool and was used for per capita calculations.1
Statistics
The t test was used for univariate analysis of continuous variables and the χ2 test for dichotomous variables. Poisson regression analysis was used to analyze trends in per capita hospitalizations by gender, and the χ2 test was used to analyze mortality and amputation trends. The association between mortality and gender was analyzed by multivariable logistic regression models controlling for age and year of procedure. Statistical significance was expressed as both P values and 95% confidence intervals (CI). Values of P < .05 were considered significant. Data were analyzed using SAS 9.1 software (SAS Institute, Cary, NC).
Results
We identified 2.4 million LE inpatient PAD-related hospitalizations from 1998 through 2007 in Florida, New Jersey, and New York; in 0.5 million of those hospitalizations, PAD was the primary diagnosis. The ratio of women to men was 46% vs 54% (P < .0001) in the overall group and in the subgroup. In the overall group, 16% of hospitalizations and 55% in the subgroup were associated with procedures. The rate of intervention was 56% for men vs 44% for women based on all PAD-related inpatient hospitalizations (P < .0001) and 56% for men vs 53% for women based on hospitalizations with PAD as the primary diagnosis (P < .0001). On average, women were older: mean age for all PAD-related hospitalizations was 73 years for women and 70 years for men (P < .0001); and 72 vs 70 years, respectively, for hospitalizations associated with procedures (P < .0001).
Trend analysis of hospitalizations
There was an increase in per capita hospitalizations for PAD (primary and secondary diagnoses) from 1998 through 2005. Admissions plateaued for the years 2006 through 2007. This trend was noted in both genders (Fig 1, A). A slight decrease occurred in per capita vascular inpatient procedures during this period (Fig 1, B).
Fig 1.
A, Trends in peripheral arterial disease (PAD) hospitalizations and (B) PAD hospitalizations associated with a vascular procedure. The solid lines show trends in hospitalizations based on primary and secondary diagnoses, and the dashed lines show trends in hospitalizations based on primary diagnoses only. C, The proportion of PAD hospitalizations with procedure for women (red) and men (blue) are shown from 1998 to 2007.
When trends were compared by gender, women had 18% to 27% fewer PAD hospitalizations per capita (P < .0001; Fig 1, A) and 33% to 49% fewer reported vascular procedures per capita than men (Fig 1, B) throughout the study period. Furthermore, women hospitalized for PAD were less likely than men to undergo a procedure (Fig 1, C). This gender-related difference in per capita hospitalizations and vascular procedures was also observed in each age group: 40 to 59, 60 to 69 and ≥80 (P < .0001 for each).
As age progressed, the gender difference diminished. Women aged 40 to 59 years had 42% fewer PAD-related hospitalizations than men, whereas women aged 60 to 69 and octogenarians had 38% and 29% fewer hospitalizations, respectively. The same trend was observed in procedural hospitalizations: the per capita difference between genders decreased from 46% to 42% and to 30% as ages progressed from 40 to 59, to 60 to 69, and to ≥80 years.
When we analyzed trends in the types of admissions and diagnoses, we found that although women were less likely to be admitted for LE PAD, they were persistently more likely to be hospitalized emergently. In fact, 56% of women vs 51% of men with primary PAD diagnoses were hospitalized emergently in 1998 and 57% vs 53% in 2007. The difference between these trends was constant throughout the decade (P < .0001; Fig 2).
Fig 2.
Rates of emergency peripheral arterial disease (PAD) hospitalizations where PAD is the primary diagnoses by gender from 1998 through 2007 in New York, New Jersey, and Florida.
During this period, women were more likely to have a more advanced disease: they were persistently less likely than men to have claudication (P = .0002; Fig 3, A), and until 2003, they were more likely to have critical limb ischemia (CLI; P < .0001). Beginning in 2005, the trend for women with CLI started to decline; and in 2007 the difference between men and women reversed, with 31.4% of women hospitalized with CLI vs 32.3% of men (P < .0001; Fig 3, B).
Fig 3.
Trends of peripheral arterial disease (PAD) hospitalizations by gender for (A) claudication and (B) critical limb ischemia (CLI) are shown from 1998 to 2007.
Trend analysis for the utilization of different vascular procedures
The management of PAD has changed dramatically in the last decade (Fig 4): the rate of endovascular revascularizations increased by 146%, the number of open revascularization dropped by 32%, and major amputation rates decreased substantially. Several observations were noted in comparing the genders:
Fig 4.
Trends in peripheral arterial disease (PAD)-related hospitalizations resulting in (A) open lower extremity revascularizations, (B) endovascular revascularizations, and (C) major amputations by gender are shown from 1998 to 2007.
Trends in mortality, LOS, and discharge status
There was an overall improvement in mortality rates for both genders (Fig 5) during the studied period. The mortality rate for hospitalizations associated with procedures was 6.47% in women vs 5.19% in men in 1998 (P < .0001) and 3.74% in women vs 2.87% in men in 2007 (P < .0001; Fig 5, A). The lowest mortality rates for women were seen after endovascular procedures (Fig 5, B), which also showed the smallest difference between men and women at nearly 0.6%, with mortality at 3.56% in women vs 2.86% in men in 1998 (P < .0001) and 2.32% in women vs 1.69% in men in 2007 (P = .0001).
Fig 5.
Mortality trends by gender in peripheral arterial disease hospitalizations associated with (A) all admissions with procedures and (B) after endovascular revascularizations, (C) open revascularizations, and (D) major amputations.
More pronounced gender differences and higher mortality rates were observed for open revascularization, at 6.02% for women vs 4.51% for men in 1998 (P < .0001) and 4.99% for women vs 3.09 for men in 2007 (P < .0001; Fig 5, C), and for major amputations, at 10.75% for women vs 9.71% for men in 1998 (P < .0001) and 7.56% in women vs 6.71% in men in 2007 (P < .0001; Fig 5, D).
The results of multivariable regression modeling to predict mortality, controlling for year of procedure and patient age, are reported in Table II. Results are reported in odds ratios of association between female gender (men are control) and death after different types of procedures. For patients aged 40 to 80 years, female gender was a strong predictor of periprocedural mortality, with a 15% to 33% odds ratio increase, depending on type of procedure. In contrast, among octogenarians, there were no sex-related differences in mortality for open or endovascular procedures. Female sex was actually protective of amputation-related mortality, that is, women were 12% less likely to die after amputation than men in this age group.
Table II. Female gender as a predictor of procedural major amputation and revascularization mortality after controlling for patient age and year of procedure
| Procedure | Age ≥80 yr | Age 40 to 80 yr | ||
|---|---|---|---|---|
| OR (95 % CI) | P | OR (95 % CI) | P | |
| Major amputation | 0.88 (0.82-0.96) | .003 | 1.14(1.08-1.21) | <.0001 |
| Open LER | 1.08(1.00-1.16) | .057 | 1.26(1.19-1.33) | <.0001 |
| Endo LER | 1.11(1.00-1.25) | .114 | 1.33(1.22-1.45) | <.0001 |
Trend analysis of length of stay (LOS) showed consistently longer LOS for women after all procedural PAD hospitalizations (P < .0001). However, the difference reduced over time from 1.4 days in 1998 (LOS was 11.5 days for men vs 12.9 days for women) to 0.3 days in 2007 (9.2 days for men vs 9.6 days for women).
Women were more likely to be discharged to a nursing home than men after a procedural hospitalization. In 1998, 24% of women who had a vascular procedure were discharged to a nursing home compared with 17% of men. In 2007, 25.0% of women and 20.2% of men with vascular procedures were discharged to nursing homes.
Discussion
Previous publications have reported a significant increase in LE PAD vascular procedures that had started in the early 1980s and plateaued at the beginning of the last decade.12 This initial rapid growth coincided with the introduction of endovascular procedures, which may have contributed to the increased volume of vascular interventions. However, other factors, including the growing proportion of the elderly population and the increasing awareness and treatment of vascular disease, have also added to the increased volume of procedures that was noted during that early period.
In contrast, our current analysis covered discharges from a later period (1998 to 2007) and demonstrated a decrease in the per capita rate of inpatient vascular procedures, regardless of gender. Similar observations were made by others who looked at national trends.13, 14 Although the reason for the decrease in vascular procedures is unclear, many speculations can be entertained. One possibility is a shift toward outpatient procedures, such as diagnostic angiography or endovascular interventions in freestanding or hospital-based ambulatory surgery settings, which are not included in “inpatient” data sets such as ones used here. Another possibility might be that an increased awareness of vascular disease resulted in early treatment of risk factors, which in turn might have reduced the number of PAD cases actually needing intervention. Finally, when open and endovascular procedures were analyzed together, we observed only a slight decrease in reconstructive inpatient procedures. Therefore, the observed decline in the number of vascular procedures is most probably associated with the significant reduction in amputation rates.
When analyzed by sex, women consistently had fewer PAD-related inpatient hospitalizations and procedures than men. It has been well established by other authors that PAD is less frequent in premenopausal and perimenopausal women because hormonal and metabolic factors create an atheroprotective environment, although the mechanisms are not well understood.15, 16 However, PAD in women increases significantly during the postmenopausal years, from 3% to 4.4% to 15.5% to 29%.17, 18 According to published reports from screening programs, the incidence of the disease in septuagenarian women and men is equal.19, 20 Our data do not reflect these observations. In fact, in our study we report fewer per capita PAD-related inpatient hospitalizations in women compared with men, regardless of age. Because these databases do not contain patient identification and longitudinal study is not possible, we cannot be certain that, when compared with women, men with PAD are more likely to have multiple interventions and hospitalizations and/or they are more likely to have bilateral disease or multiple lesions that could account for our observations. However, this warrants further investigation using different data sets. Another possible explanation is that PAD in women may go unrecognized until it reaches a critical stage. There are several reasons why PAD might be unrecognized in women compared with men:
Some of our findings suggest that women with PAD may not be diagnosed expeditiously. For instance, we observed that women were consistently less likely to be hospitalized for PAD but were more likely than men to be admitted emergently (Fig 1, Fig 2), and that until 2003, women had a higher frequency of CLI per PAD-related hospitalization (Fig 3). These trends suggest that compared with men, women are hospitalized for treatment at more advanced stages of their disease and require emergency and not elective medical attention, or they have a more complicated course during the management of their disease that causes clinical situations that cannot be treated electively. After 2003, the rate of hospitalizations that were related to CLI reached a plateau and, essentially, became similar in both men and women (Fig 3). From 2005 to 2007, the rate of hospitalizations related to CLI was significantly reduced in women, and the difference between genders was reversed (Fig 3). This event coincides with a dramatic increase in the volume of endovascular procedures in women (Fig 4, C). Whether this is a cause-and-effect relationship will require further investigation.
The significant decrease in amputation rates in patients hospitalized with PAD is, in fact, a very encouraging finding, attesting to the major improvements achieved in the management of arterial occlusive disease and limb salvage. According to Nowygrod et al,12 amputation was the most frequent procedure performed in the United States in 1979. In our study, amputation was the least frequently performed procedure in patients with PAD after endovascular and open reconstructive procedures (Fig 4).
Although women had lower rates of PAD-related hospitalization and vascular procedures at the beginning of our study, they had higher rates of amputation. This finding is consistent with older studies4 conducted in the urban communities of Northern Illinois from 1993 to 1997, which observed that 55% of the above-knee amputations were performed in women, despite a lower prevalence of diagnosed PAD, and that male sex was predictive of bypass surgery rather than amputation. In our study, however, this negative effect of female gender disappeared after 2000. On the other hand, the rates of open reconstructive procedures remained consistently higher in men compared with women for the entire period from 1998 to 2007, reaffirming results from previous publications using data from Maryland26 and California.27 Over time, rates for open procedures significantly decreased for both genders, but the difference between men and women persisted, unchanged.
Finally, we noticed a remarkable and continuous growth of endovascular procedures in the last 10 years distributed equally in both genders. The trends in Fig 4 show that endovascular procedures were the most frequently performed vascular interventions by the end of the decade in both genders, with comparable rates. The equal utilization of endovascular procedures in both sexes might have contributed to the diminished sex-related disparity in amputation rates that was observed in our study, but this warrants further confirmation.
Even though overall in-hospital mortality improved during the study period in both men and women, mortality remained higher in women after vascular interventions. Notably, mortality in women remained constantly higher after open procedures and amputations. However, female mortality was lowest, and the disparity between men and women was relatively less, after endovascular procedures (Fig 5). This finding is consistent with published abdominal aortic aneurysm (AAA) Medicare data and data using the national inpatient index, which revealed that despite advancements in AAA repair, women have higher mortality rates than men after elective open AAA surgery.8, 28 According to the same sources, the procedurally related mortality in women reached comparable levels with men (0% to 3.1%) when an endovascular approach was used.8, 29, 30
It is unclear why women have higher procedurally related mortality rates than men. One explanation may be more advanced age. In multivariable analysis, female gender did not increase the risk of death after open and endovascular reconstructions of octogenarians and had a protective effect for those undergoing amputations. Female gender increased the risk of periprocedural mortality of younger patients. Given that we do not understand risk factors for this latter group, it is possible that failure to manage these risk factors contributed to this observation. The gender effect on mortality is not seen in octogenarians because these patients are more homogeneous in terms of comorbidities and risk factors due to a natural selection that occurs in such advanced age.
Our data show that women were more likely to be discharged to a nursing home after procedural hospitalizations. They also had longer LOS. Although LOS was reduced for both genders, greater improvements were seen in women, and by 2007, we observed only a 0.3-day difference. Although this has yet to be proven, the implementation of minimally invasive procedures might have contributed significantly to the observed change. Medicare data showed similar results: women had higher LOS compared with men after AAA repair and were less likely to be discharged to home.8, 26 This persistent difference between male and female patients may imply different sociologic factors associated with elderly women hospitalized for PAD or AAA repair. According to American Association of Retired Persons (AARP) and population resource data, a larger proportion of these elderly women (48% vs 22% for men) live alone22, 31 and are often discharged to a nursing home for postoperative care because they would receive inadequate support had they been discharged home. Other factors contributing to gender-related differences in the discharge status of vascular patients, including different preoperative functional status and medical condition, warrant further investigation.
The current study has several limitations. Information derived from the state databases is subject to errors due to inaccurate or incomplete data recorded on discharge forms. Because there is no patient identification in this database, longitudinal follow-up of patients is not possible; each admission to the hospital counts as a separate encounter and cannot be related to a previous one as a readmission. Therefore, the reported in-hospital mortality rates do not reflect 30-day periprocedural events. Moreover, we cannot assess long-term patency or patient survival. The database does not include information on outpatient procedures, which might account for a significant percentage of overall interventions. Therefore, the large proportion of data on vascular procedures being performed on an ambulatory basis is missing from the analysis.
Finally, we used only regional databases from three large states instead of the Nationwide Inpatient Sample (NIS) database. Indeed, NIS represents 20% of hospitals from 37 states and 100% of discharges from those hospitals. Although it is a great tool for analysis and for the interpretation of national trends in medicine, not all of the states that are included in NIS record gender in the discharge data, which was crucial for our study. Our data, using information from the three most populous, gender-reporting states, show time trends in overall utilization of vascular procedures, similar to those from other published studies based on NIS.12, 13, 14 Therefore, we believe that our conclusions are by-in-large generalizable.
Conclusions
Our data show significant changes in treatment rates and treatment outcomes for LE PAD during the last 10 years. Endovascular procedures have supplanted open revascularization in the operative management of vascular disease in both genders, and outcomes have improved over time in both men and women. There are still significant gender-related disparities in the treatment and outcomes of PAD, although the differences have diminished. Women with PAD tend to be treated on a more emergent basis and have higher mortality rates, despite overall improvements. Endovascular procedures have decreased procedurally related mortality in both genders and have reduced the mortality gap between men and women. Continued progress of new technology is likely to transform the field of vascular surgery and equalize outcomes between men and women.
Author contributions
Table I (online only)
Table I (online only). International Classification of Diseases, 9th Revision, Clinical Modification diagnoses and procedure codes for selection of lower extremity peripheral arterial hospitalizations and associated vascular procedures
| DIAGNOSES CODES |
| 250.7 Diabetes with peripheral circulatory disorders |
| 440.2 Atherosclerosis of extremities |
| 440.30 Atherosclerosis of unspecified bypass graft of extremities |
| 440.31 Atherosclerosis—autologous vein/bypass graft/extremity |
| 440.32 Atherosclerosis—nonautologous vein/bypass graft/extremity |
| 440.9 Generalized and unspecified atherosclerosis. Arteriosclerotic vascular disease not otherwise specified |
| 442.3 Aneurysm of artery of lower extremity |
| 443.9 Peripheral vascular disease |
| 444.0 Arterial embolism and thrombosis |
| 444.22 Arterial embolism and thrombosis of arteries of lower extremity |
| 445.02 Atheroembolism, lower extremity |
| 447.1 Stricture of artery |
| 707.1 Ulcer of lower limbs, except decubitus |
| 785.4 Gangrene |
| 996.74 Complication—vascular device thrombosis |
| PROCEDURE CODES |
| Major amputation codes |
| 84.13 Disarticulation of ankle |
| 84.14 Amputation of tibia/fibula at ankle |
| 84.15 Other amputation, below knee |
| 84.16 Disarticulation of knee |
| 84.17 Amputation, above knee |
| Open procedure codes |
| 39.29 Other peripheral vascular shunt or bypass |
| 38.08 Embolectomy/thrombectomy lower limb arteries |
| 38.18 Endarterectomy of lower limb arteries |
| 38.38 Resection of blood vessel with primary anastomosis (lower limb arteries) |
| 38.48 Resection of blood vessel with replacement (lower limb arteries) |
| 38.88 Clamping/ligation/division/ occlusion of blood vessel (leg artery) |
| Endovascular procedure codes |
| 39.50 Angioplasty or atherectomy of noncoronary vessel |
| 39.90 Insertion of non-drug-eluting, noncoronary artery stent(s) |
References
- United States Department of Health and Human Services (US DHHS) CfDCaPC, National Center for Health Statistics (NCHS) Bridged-Race Population Estimates, United States July 1st resident population by state, county, age, sex, bridged-race, and Hispanic origin, compiled from 1990-1999 bridged-race intercensal population estimates and 2000-2007 (Vintage 2007) bridged-race postcensal population estimates. CDC WONDER On-line Database. 2007 ed; 2007.
- . Arterial vascular disease in women. J Vasc Surg. 2007;46:1295–1302
- Tissue loss, early primary graft occlusion, female gender, and a prohibitive failure rate of secondary infrainguinal arterial reconstruction. J Vasc Surg. 2002;35:902–909
- . Peripheral bypass surgery and amputation: northern Illinois demographics, 1993 to 1997. Arch Surg. 2000;135:75–80
- . Surgical treatment of infrainguinal arterial occlusive disease in women. J Vasc Surg. 1993;17:67–76discussion 76-8
- Women have increased risk of perioperative myocardial infarction and higher long-term mortality rates after lower extremity arterial bypass grafting. J Vasc Surg. 1999;29:807–812discussion 812-3
- . Risk factors associated with infection of lower extremity revascularization: analysis of 365 procedures performed at a teaching hospital. Ann Vasc Surg. 2003;17:91–96
- . The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004. J Vasc Surg. 2007;45:891–899
- . Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg. 2006;43:446–451discussion 451-2
- . Carotid artery stenting is safe and associated with comparable outcomes in men and women. J Vasc Surg. 2009;49:315–323discussion 323-4
- Does sex matter? (Thirty-day stroke and death rates after carotid artery stenting in women versus men: results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in phase). Stroke. 2009;40:1140–1147
- Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg. 2006;43:205–216
- . Patterns of treatment for peripheral arterial disease in the United States: 1996-2005. J Vasc Surg. 2009;49:910–917
- . National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. 2009;50:54–60
- . Inflammatory markers and cardiovascular risk in healthy polish women across the menopausal transition. Clin Chem. 2005;51:1893–1895
- . C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342:836–843
- . Epidemiology of peripheral arterial disease in women. J Epidemiol. 2003;13:1–14
- . Prevalence and correlates of lower extremity arterial disease in elderly women. Am J Epidemiol. 1993;137:559–568
- . Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation. 2004;110:738–743
- Lower extremity arterial disease assessed by ankle-brachial index in a middle-aged population of African Americans and whites: the Atherosclerosis Risk in Communities (ARIC) Study. Am J Prev Med. 2005;29(5 suppl 1):42–49
- . Women age 65 and older: their sources of income. Washington, DC: AARP Public Policy Institute; 2005;
- . Women & long-term care research report. Washington, DC: AARP Public Policy Institute; 2007;
- . An overview of nursing home facilities: data from the 1997 National Nursing Home Survey. http://www.cdc.gov/nchs/data/ad/ad311.pdfAccessed: Sept 17, 2009
- Vertebral fracture prevalence among women screened for the Fracture Intervention Trial and a simple clinical tool to screen for undiagnosed vertebral fractures (Fracture Intervention Trial Research Group). Mayo Clin Proc. 2000;75:888–896
- . Functional status and mobility among elderly women with lower extremity arterial disease: the Study of Osteoporotic Fractures. J Am Geriatr Soc. 1994;42:923–929
- . Variation in utilization of procedures for treatment of peripheral arterial disease (A look at patient characteristics). Arch Intern Med. 1993;153:991–998
- . Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994. J Vasc Surg. 1998;28:45–56discussion 56-8
- . A decade of change in abdominal aortic aneurysm repair in the United States: have we improved outcomes equally between men and women?. J Vasc Surg. 2006;43:230–238discussion 238
- . Gender differences in endovascular abdominal aortic aneurysm repair with the AneuRx stent graft. J Vasc Surg. 2002;35:882–886
- Endovascular aneurysm repair: gender-specific results. J Vasc Surg. 2003;38:93–98
- . Aging and the growth of long-term care. Cambridge, MA: National Bureau of Economic Research (NBER); 1999;
Competition of interest: Dr Marin is consulting for Medtronic.
Additional material for this article may be found online at www.jvascsurg.org.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.
PII: S0741-5214(09)01836-9
doi:10.1016/j.jvs.2009.09.006
© 2010 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
