Background Many believe that variation in vascular practice may affect limb salvage rates in patients with severe PAD. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown. Methods and Results Using Medicare 2003–2006, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year prior to amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the HRR undergoing vascular procedure in the year before amputation. Overall, 20,464 patients with CLI underwent major lower extremity amputations during the study period, and collectively underwent 25,800 vascular procedures in the year prior to undergoing amputation. However, these procedures were not distributed evenly − 54% of patients had no vascular procedures performed in the year prior to amputation, 14% underwent 1 vascular procedure, and 21% underwent more than one vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year prior to amputation (p<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high intensity regions were 2.4 times as likely to undergo revascularization in the year prior to amputation than patients in low intensity regions (adjusted OR=2.4, 95% CI 2.1–2.6, p<0.001). Conclusions Significant variation exists in the intensity of vascular care provided to patients in the year prior to major amputation. In some regions, patients receive intensive care, while in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and limb salvage.

Objective Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared to whites. Methods Using inpatient Medicare data for years 2003-2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. ‘Limb salvage care’ was defined as limb-related admissions and procedures that occurred during the two years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races. Results Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6 vs. 31.6%, p<0.0001), any limb-related admission (39.6 vs. 44.7%, p<0.0001), toe amputation (12.9 vs. 13.8%, p<0.0005) or wound debridement (11.6 vs. 14.2%, p<0.0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (OR 0.72 [95% confidence interval 0.68-0.76]), limb-related admission (OR 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions, and were not accounted for by regional differences in where black and white patients received care. Conclusion Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision-making.

Objective To examine the relationship between the intensity of vascular care and population-based rate of major lower extremity amputation (above-or below-knee) from vascular disease. Background Because patient-level differences do not fully explain the variation in amputation rate across the United States, we hypothesized that variation in intensity of vascular care may also affect regional rates of amputation. Methods Intensity of vascular care was defined as the proportion of Medicare patients who underwent any vascular procedure in the year prior to amputation, calculated at the regional level (2003–2006), using the 306 hospital referral regions in the Dartmouth Atlas of Healthcare. We examined relationship between intensity of vascular care and major amputation rate, at the regional level, between 2007–2009. Results Amputation rates varied widely by region, from 1 to 27 per 10,000 Medicare patients. Compared to regions in the lowest quintile of amputation rate, patients in the highest quintile were commonly African American (50% versus 13%) and diabetic (38% versus 31%). Intensity of vascular care also varied across regions: fewer than 35% of patients underwent revascularization in the lowest quintile of intensity, while nearly 60% of patients underwent revascularization in the highest quintile. Overall, there was an inverse correlation between intensity of vascular care and amputation rate ranging from R= −0.36 for outpatient diagnostic and therapeutic procedures, to R= −0.87 for inpatient surgical revascularizations. In analyses adjusting for patient characteristics and socioeconomic status, patients in high vascular care regions were significantly less likely to undergo amputation without an antecedent attempt at revascularization (OR 0.37, 95% CI 0.34–0.37, p<0.001). Conclusions The intensity of vascular care provided to patients at risk for amputation varies, and regions with the most intensive vascular care have the lowest amputation rate, although the observational nature of associations do not impart causality. High-risk patients, especially African-American diabetic patients residing in low-intensity vascular care regions, represent an important target for systematic efforts to reduce amputation risk.

trieval when the traditional snare technique fails. An 18-Fr sheath (85cm) is inserted over a stiff wire to the level of the filter. A wire and snare catheter are then maneuvered so that they pass through separate interstices of the filter. The wire is snared caudad to the filter legs and the resulting "lasso" is pulled up below the filter collar. The 18-Fr sheath is then advanced over the filter to collapse the filter legs. We have achieved technical success rates of 96% since adopting this technique 2 years ago with the single failed attempt occurring in a patient who refused further attempts at central venous catheterization following multiple unsuccessful attempts. With such high rates of technical success efforts should now be focused on methods to improve follow-up in patients with retrievable IVC filters.Objectives: While lower extremity revascularization is effective in preventing amputation, the relationship between intensity of vascular care and amputation rate remains unclear. Methods:We studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. We examined associations between patient characteristics, regional rates of revascularization, and amputation rate among the 307 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare.

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