Alcohol use disorder increases risk of major adverse limb events following lower-extremity revascularization for chronic limb-threatening ischemia

OBJECTIVE: One in four patients with chronic limb-threatening ischemia (CLTI) undergo major amputation. Despite an established pathophysiological link between excessive alcohol consumption and adverse cardiovascular outcomes, the prevalence and impact of alcohol use disorder (AUD) among adult patients with CLTI has not been investigated. To address this gap, we sought to evaluate the association between AUD and major adverse limb events (MALE) among adults undergoing lower extremity revascularization for CLTI. METHODS: Data were abstracted via Structured Query Language server queries of inpatient and outpatient electronic health records of the UPMC multi-hospital, unified health care system. We included index revascularization (endovascular or open) among adults with CLTI (2016-2024). Validated International Classification of Diseases, 10th Revision-Clinical Modification (ICD-10-CM) codes defined AUD. One-year outcomes of MALE (primary), major amputation, and major revascularization were compared with Fine-Gray regression risk-adjusted for competing mortality. Cumulative hazard curves and Cox modeling assessed these outcomes alongside 1-year mortality in sensitivity analyses. Multivariable regression was clustered by hospital and generated subdistribution (sHR) or adjusted (aHR) hazard ratios with 95% confidence intervals (CIs) for Fine-Gray or Cox modeling, respectively. RESULTS: Among 3744 patients with CLTI undergoing revascularization (mean age, 69.8 ± 11.7 years; 61.0% male), 183 (4.9%) had an AUD diagnosis. Patients with an AUD diagnosis were more frequently male (84.2% vs 59.8%; P < .001) and concurrent tobacco users (56.3% vs 26.4%; P < .001). AUD correlated with an increased risk of 1-year MALE (35.6% vs 27.2%; P = .002). In Fine-Gray competing-mortality risk regression, AUD was independently associated with increased risk MALE (sHR, 1.29; 95% CI, 1.03-1.63; P = .029). Although major revascularization failed to reach significance (sHR, 1.14; 95% CI, 0.89-1.47; P = .295), AUD conferred higher 1-year risk of major amputation (sHR, 1.94; 95% CI, 1.65-2.36; P < .001) and mortality (aHR, 1.51; 95% CI, 1.09-2.09; P = .013). CONCLUSIONS: An AUD diagnosis independently conferred greater risk of MALE and mortality among adults undergoing index lower extremity revascularization for CLTI. These findings underscore the potential value of preoperative identification of AUD to refine risk stratification in this vulnerable, understudied population.