(PC084) Critical Time, Critical Outcomes: The Role of Transfer for Lower Extremity Threatening Ischemia

Objectives: The Unites States is experiencing a nationwide shortage of vascular surgeons, especially in rural and urban areas. This shortage has resulted in fewer hospitals being equipped to manage vascular emergencies, thus necessitating the transfer of patients to higher-level facilities with vascular surgery expertise. These transfers introduce delays in treatment, which are particularly concerning for patients with ALI, given that revascularization is highly time-sensitive and delays increase the risk of irreversible tissue damage. The objective of this study is to compare outcomes of patients with ALI who undergo transfer versus no-transfer as part of their care.

Methods: We performed a retrospective cohort using survey-weighted data from the National Inpatient Sample database from 2019 to 2021. Adults >17 years old, admitted emergently with a primary diagnosis of ALI (ICD-10 codes) were included. Patients’ comorbidities, revascularization procedures, amputation, organ failure and mortality rates were compared between transferred and no-transfer patients. Population-level comparisons were made using the χ2 test with odds ratio (95% confidence interval) presented graphically.

Results: Out of 24,275 survey-weighed observations with ALI, 5,435 (22%) patients were transferred. More patients in micropolitan and rural areas were transferred than not (OR 1.59, 95% CI: 1.48-1.71 p< 0.001) (Fig 1). Transferred patients had a higher rate of amputation (3.96% vs. 1.67%, p< 0.001), amputation as a revascularization complication (3.3% vs. 1.3% p< 0.001), need for surgical thrombectomy (42.8% vs. 35.6%, p< 0.001), fasciotomies (2.67% vs. 1.17%, p< 0.001), and in hospital death (12.6% vs. 5.92%, p< 0.001) compared to non-transferred patients. Transferred patients also had higher rates of intubation (7.7% vs 4.2%, p< 0.001), and need for hemodialysis (2.5% vs. 1.5%, p< 0.001). OR (95% CI) are presented in a forest plot in Fig 2.

Conclusions: Patients undergoing transfer as part of ALI care experience a greater burden of mortality and morbidity, compared to patients who are not transferred. The reasons for this are likely multifactorial and include disease complexity, warm ischemic time duration and equity of access to definitive vascular care. Improving ALI outcomes will require a solution that tackles all these aspects, and the established time-sensitive guidelines for treatment as of acute stroke or myocardial infarction can serve as a framework for systematizing care in time-critical vascular pathologies.