Lower extremity peripheral arterial disease affects approximately 7% of the United States population aged ≥ 40 years and approximately 10% of the worldwide population by age 70.[1, 2] It is the third leading cause of atherosclerotic morbidity following coronary artery disease and stroke. Patients with PAD experience functional limitations, reduced quality of life, and higher rates of adverse limb events including limb loss.[3-5] It also disproportionately prevalent in racial and ethnic minorities.[6] Black patients have been shown to have twice the amputation risk of White patients and Hispanic patients with diabetes have a 30% higher amputation risk compared to Whites.[7, 8] Low socioeconomic status (SES) is also associated with an increased prevalence of peripheral arterial disease and poor limb-related outcomes in population-based studies.[7, 9, 10]

Revascularization is a mainstay of therapy for symptomatic PAD; it is required to maximize limb salvage in chronic limb threatening ischemia and utilized to improve function and quality of life in patients with claudication. In order address disparities in outcomes in the Black, Hispanic, and low SES populations with PAD and/or diabetes, we must first understand the reported outcomes of revascularization in these populations. Unfortunately, it has been shown that underrepresented minorities, primarily Black and Hispanic patients, as well as some populations with low socioeconomic status, less often undergo revascularization.[11] Racial and ethnic minority populations are also generally underrepresented in investigations studying the clinical effectiveness of treatments aimed at ameliorating the impact peripheral arterial disease. Nevertheless, there is a small body of evidence which should be examined. These analyses have been conducted in a number of different populations including institutional patient cohorts, the National Surgical Quality Improvement Program database, and the Society for Vascular Surgery Vascular Quality Initiative database. As such, the studies reviewed in this section are retrospective analyses of either prospectively or retrospectively collected data. A limited number have been analyses performed as secondary analyses of data collected in a randomized controlled trial involving lower extremity revascularization. The goal of this article is to review the current data on the comparative outcomes after lower extremity revascularization in Black, Hispanic, and low SES patients. This article is intended as a narrative review and while a comprehensive search of the literature describing the relationship of Black race, Hispanic ethnicity, and low SES to outcomes after lower extremity revascularization was performed, it did not explicitly employ the methodology of systematic review.[12] The majority of the existing literature reports outcomes after any type of lower extremity revascularization, inclusive of both surgical and endovascular procedures, in a heterogeneous population of patients with symptomatic PAD. Where the existing literature allows, this article will examine the relationship of race and ethnicity and SES specifically on surgical revascularization as well as on endovascular therapy and within subgroups of patients presenting with claudication and chronic limb-threatening ischemia (CLTI).

A number of studies have specifically examined the outcomes of Black patients who underwent either endovascular or surgical lower extremity revascularization for CLTI. Rivero and colleagues compared outcomes in 107 Black men (137 limbs) to those in White men (925 limbs) at a single tertiary care center.[13] Black patients had higher rates of significant comorbidities and CLTI compared to White patients. Black patients more often required infrapopliteal intervention (62.6% vs 44.3%; P=0.004). Among patients with CLTI, the primary amputation rate was similar in Black and White patients (Black: 10.9% vs. White:7.2%; P = 0.209). The authors reported that patency rates as well as major adverse limb and cardiovascular events were similar in Black and White male patients. However, at a median follow-up of 39±29 months, the limb salvage rate was significantly lower in Black patients (Black: 73% ±6% vs. White: 83±2%; P = 0.048), which was mainly attributed to reduced limb salvage in patients treated with endovascular revascularization (5-year limb salvage, Black: 69±7% vs. White: 84±2% CA; P = 0.025). Outcomes did not differ in propensity matched cohorts and race was not independently associated with outcomes on multivariate analysis. The authors concluded that inferior limb salvage in Black patients after lower extremity bypass was likely due to advanced ischemia, infrapopliteal disease, and the increased prevalence of other prognostic factors independently associated with limb loss.

Kalbaugh et al also demonstrated inferior limb-related outcomes in non-Hispanic Black and Hispanic patients in comparison to White patients who underwent lower extremity revascularization within the Vascular Quality Initiative, a quality improvement registry which captures detailed clinical information and outcomes of vascular procedures from hundreds of participating community and academic centers across the United States.[14] This study compared 15,442 Black patients and 5,506 Hispanic patients to 88,599 White patients after lower extremity revascularization. The one-year risk of major adverse limb events (MALE; defined as major amputation or re-intervention on the re-vascularized limb) was 12.8% (95% CI, 12.5-13.0) in White patients, 16.5% (95% CI, 5.8-7.8) in Black patients, and 17.2% (95% CI, 5.6-6.9) in Hispanic patients. After adjusting for patient, treatment, and anatomic factors associated with disease severity, an overall increased hazard of poor limb outcomes was observed for both Black (MALE: 1.17; 95% CI, 1.12-1.22; amputation: 1.52; 95% CI 1.39-1.65) and Hispanic (MALE: 1.22; 95% CI, 1.14-1.31; amputation: 1.45; 95% CI, 1.28-1.64) patients (Figure 1).

In contradistinction to many other studies, the Kalbaugh study analyzed the impact of non-white race in cohorts of patients stratified by PAD severity at presentation. Amongst 55,451 limbs in 50,250 patients who underwent revascularization for CLTI, Hispanic and Black patients were approximately 25% more likely to have a major adverse limb event and 50% more likely to suffer leg amputation. Interestingly, after adjusting for confounders, Black and Hispanic patients had a lower risk of one-year mortality. Among 45,128 limbs in 38,349 patients who underwent revascularization for claudication, the one-year incidence of MALE did not differ by race and ethnicity. However, the one-year cumulative incidence of amputation was nearly double in Black patients compared to White patients (Black: 1.2% vs White: 0.6%), an outcome in Black patients with claudication which is worse than the presumed natural history of claudication untreated with intervention.[15] In adjusted analyses, Black race was independently associated with amputation after revascularization for claudication (HR 1.59, 95% CI, 1.17-2.15, Figure 1). The Use of VQI data source provides “real world” evidence of disparities in a large population of patients receiving care for PAD with strong generalizability due to variety of clinical providers contributing to VQI, representation across entire US and parts of Canada, and inclusion of tertiary and community hospitals. This analysis suggests that other factors, perhaps unmeasured to date, impact the increase in re-intervention and amputation seen in non-Hispanic Blacks and Hispanics and deserve further attention.

Other studies have specifically analyzed the outcomes of surgical revascularization and have identified that Black and Hispanic patients have worse outcomes after infrainguinal bypass compared to White patients. In an analysis of 16,276 patients undergoing infrainguinal bypass from the National Surgical Quality Improvement Program database between 2005 and 2011, 18% of bypasses were performed in black and 4.9% of bypasses performed in Hispanic patients.[16] Black and Hispanic patients were more likely to undergo distal bypass, with 34.7% of black patients and 38.6% of Hispanic patients requiring femoral tibial bypass in comparison to 31.4% of white patients. Likewise, popliteal-tibial bypass was required in 13.4 and 16.1% of Black and Hispanic patients respectively, but only in 8.9% of white patients. Autogenous conduit use was not different between groups. More Black patients than White patients developed early graft failure (6.7 versus 4.5%; P <0.001), while the difference in early graft failure between Hispanic and White patients was not statistically significant (6.0 versus 4.5%; P=0.057). On multivariable analysis, controlling for anatomic differences and the degree of peripheral arterial disease, Black race was independently associated with early graft failure (adjusted odds ratio=1.26, 95% CI 1.05 – 1.51; P = 0.011). The NSQIP database only captures 30-day outcomes and as a result this study only captures immediate postoperative graft outcome.

The relationship of race and the long-term success of surgical revascularization in more narrowly defined surgical cohorts has been the focus of other studies. Chew and colleagues compared the outcome of autogenous infrainguinal bypass in 89 Black patients to 1370 White patients in a single tertiary center.[17] Black patients were significantly younger and had a higher prevalence of medical comorbidities compared to White patients. Black patients also more often underwent bypass surgery for limb salvage compared to White patients (91% vs 81%, respectively; P = 0.01). 30-day morbidity and mortality were equivalent. The overall five-year primary graft patency was significantly worse in Black patients (Black, 52% ± 6%; White, 67% ± 2%; P = 0.009). In addition to young age, female gender, redo operations, tibial target, in the presence of CLTI, Black race was independently associated with primary graft failure. In addition, although the 5-year limb salvage rate was also significantly worse in Black patients (Black 81±5%; White, 90% ±%; P = 0.04), Black race was not an independent predictor of limb loss. In a subsequent larger analysis from the same institution, Robinson et al examined the comparative outcomes of autogenous infrainguinal bypass In Hispanic, non-Hispanic Black, and White patients.[18] Hispanic patients had a 5-year primary patency significantly lower than that in White patients and similar to that in Black patients (HI 54% ± 7% versus CA 69% ± 1%, P = 0.02; AA 50% ±4%, Figure 2), but Hispanic ethnicity was not an independent predictor of graft failure. Five-year limb salvage was also significantly lower in Hispanic patients compared to White patients (HI 80% ± 6% versus CA 91% ±1%, P = 0.004; AA 83±3%) and Hispanic ethnicity was an independent predictor of limb loss (HR 1.87, 95% CI 1.0-3.5, P=0.049).

These studies examine only bypasses performed only with autogenous conduit in a center with a uniform surveillance schedule (postoperative duplex at 1 month postoperatively, every three months for one year, and then yearly), which provides important information not available in studies performed from administrative data or large multi-institutional clinical registries. It is well-known that the choice of conduit is among the most important to the success of an infrainguinal bypass and that autogenous conduit provides optimal patency in comparison to prosthetic conduit. The inferior results seen in Black and Hispanic patients in these studies therefore cannot be ascribed to variability in surgeons’ choice of conduit in this particular study. However, larger multi-institutional studies, including one of 24,000 patients from the VQI, indicate that autogenous is less commonly used in Black and Hispanic patients compared to White patients.[19] This is an area for ongoing examination. The Robinson study also showed no differences in the utilization of important perioperative and postoperative medications (antiplatelet agents and statins) and postoperative duplex between groups. This finding stands in contrast to that of a number of larger studies of all patients with PAD which demonstrate much lower utilization of optimal medical therapy in minority, female, and low SES patients.[20, 21] On national level, these trends seen in the general PAD population would be expected in the smaller subset of patients undergoing revascularization. Achieving guideline-based optimal medical therapy for PAD is a major target for improvement.

Among patients with CLTI, the 3-year outcomes of infrainguinal bypass grafting from in Black and Hispanic patients have been reported by Anjorin et al in a study utilizing the Vascular Implant Surveillance and Interventional Outcomes Network (VISION), which includes data from the Vascular Quality Initiative linked to Medicare claims.[22] This study included 7,108 patients with CLTI, including 5599 (79% non-Hispanic White, 1053 (15%) Black and 408 (6%) Hispanic patients and demonstrates the persistence to the present day of the racial and ethnic disparities highlighted in the older reports reviewed thus far. Black patients had markedly higher rates of 3-year major amputation (Black vs. White, 32% vs. 9%; HR, 1.9; 95% CI 1.7-2.2), reintervention (Black vs. White, 61% vs. 57%; HR, 1.2; 95% CI 1.1-1.3) and 30-day MALE (Black vs. White, 8.1% vs.4.9%; HR, 1.3; 95% CI, 1.2-1.4) but lower mortality (Black vs. White, 30% vs. 42%; HR, 0.9; 95% CI 0.8-0.99) (Figure 2). Hispanic patients also had higher rates of amputation (Hispanic vs White, 27% vs. 19%; HR, 1.6; 95% CI 1.3 – 2.0), reintervention (Hispanic vs. White, 70% vs. 57%; HR, 1.4; 95% CI 1.2 – 1.6) and 30-day MALE, (Hispanic vs. White 8.7% vs. 4.9%; HR, 1.5; 95% CI, 1.3-1.7) (Figure 2). The analysis explored the potential factors contributing to these differences though multivariable Cox regression models including a large number of demographic factors, comorbidities, preoperative medical therapy, physician and center volume, disease severity, and operative factors. In adjusted analyses, the association between Black race and amputation was significantly attenuated by adjustment for such factors and the association between Hispanic ethnicity and amputation was no longer statistically significant. Similarly, after controlling for all covariates Black race was no longer significantly associated with re-intervention and the association between Hispanic ethnicity and re-intervention was attenuated. Black race and Hispanic ethnicity remain significantly associated with lower 3-year mortality after multivariable adjustment. The authors conclude that limb related outcomes after infrainguinal bypass are partly attributable to patient age and sex and the greater prevalence of comorbidities in Black and Hispanic patients with CLTI.

Important information regarding the outcomes of surgical revascularization for limb salvage in Black patients has also been derived from a large randomized trial. The Project of Ex Vivo Vein Graft Engineering via Transfection III (PREVENT III) included 1404 lower extremity vein graft operations performed exclusively for critical limb ischemia in 83 North American centers.[23] Trial design included intensive ultrasound surveillance of the bypass and clinical follow-up up to a year. 131 Black men and 118 Black women were enrolled in PREVENT III. Nguyen et al reported that Black men were at significantly higher risk for 30-day graft failure (HR, 2.83; 95% CI, 1.393– 5.76; P=0.0004), even when the analysis excluded high-risk venous conduits. Black patients also experienced reduced secondary patency (HR, 1.49; 95% CI 1.08 – 2.06; P = 0.016) and limb salvage (HR 2.02; 95% CI, 1.27 – 3.2 P= 0.003) at 1 year. Black women had the most disadvantaged outcomes, with increased risk for loss of graft secondary patency (HR, 2.02, 95% CI 1.27 – 3.20; P = 0.003) and major amputation (HR, 2.38; 95% CI, 1.18 – 4.83; P = 0.016) at 1 year. Perioperative mortality and 1-year mortality were similar between racial groups and genders. Given that all trial participants had protocolized clinical and graft surveillance, the Inferior outcomes observed in this particular study seem unlikely to be due to differences in access to postoperative care and surveillance. Like the retrospective analyses reviewed previously, this report confirms the significant disparities after revascularization in all Black patients but is unable to provide further insight into the underlying mechanisms. It calls attention to the particular need for improvement in Black women with CLTI, an at-risk group that unfortunately has not been the focus of significant additional investigation.

Data examining the impact of race and SES on outcomes of endovascular lower extremity revascularization is sparse. This is surprising to some extent given that there is significant variation in the utilization of peripheral vascular interventions for claudication with high rates of utilization in Black patients from low SES counties. Hicks et al, in an analysis of Medicare claims data from 2015 to 2017, reported a crude endovascular revascularization rate of 15.2 per 1000 claudicating Black patients, 12.5 per 1000 claudicating White patients, and 10.7 per 1000 claudicating Hispanic patients.[24] The crude peripheral vascular intervention (PVI) rate was also significantly higher for counties with low median household incomes in comparison to that in higher income populations. In addition, for Black patients, lower income counties had an almost 50% increased odds of undergoing endovascular revascularization (OR, 1.46; 95% CI, 1.31 – 1.64) in comparison to Black patients who resided in higher median income counties.

Loja and colleagues examined California's Office of Statewide Health Planning and Development Patient Discharge Data, a statewide all payer database with longitudinal follow-up, to identify all patients undergoing lower extremity arterial interventions from 2005 to 2009.[25] Over this time frame, 25,635 (62%) of a total of 41,507 interventions were endovascular, and included 17,433 (68%) non-Hispanic White patients, 4417 (17%) Hispanic patients, 1979 (8%) Black patients, and 1163 (4.5%) Asia/native Hawaiian patients. After adjustment for age, gender, insurance status and severity of PAD and comorbid conditions based upon ICD-9-CM, Hispanic and Black patients were found to have worse amputation-free survival and higher rates of lower extremity arterial reintervention in comparison to non-Hispanic White patients. The odds ratio for major amputation within 30 days of admission for an endovascular procedure was 1.5 in Hispanic patients (95% CI 1.23 – 1.83; P <0.0001) and 1.99 in Black patients (95% CI 1.56 – 2.55; P <0.001) compared to non-Hispanic White patients. The hazard ratio for amputation within 1 year after revascularization was 1.69 in Hispanic patients (95% CI 1.51 – 1.90; P<0.001) and 1.68 in Black patients (95% CI 1.44 – 1.96; P<0.001). In addition, Black and Hispanic patients were more likely to undergo arterial re-intervention within 12 months after adjustment for other measured variables.

Contrary to these findings, a study conducted in Medicare beneficiaries greater than 66 years of age between 2016 and 2018 did not identify black race as an independent predictor of death and major amputation within one year after femoropopliteal endovascular intervention.[26] Krawisz et el reported that Black adults who underwent femoropopliteal endovascular intervention were more likely to be female, and to have diabetes, chronic kidney disease, and heart failure in comparison to White adults who underwent intervention. They were also significantly more likely than White patients to undergo intervention for CLTI (61% versus 49.9%; P <0.01). While there was a strong association between Black race and a composite outcome of death or amputation death at 1 year (odds ratio, 1.21 [95% CI, 1.16 – 1.25]) and this association persisted after adjustment for SES, the association was eliminated after adjustment for comorbidities (odds ratio, 0.96 [95% CI, 0.92 – 1.01]). The authors concluded that adverse outcomes in this population of Black patients were driven by a higher burden of comorbidities.

While there is a body of evidence that that links low SES to decreased access to healthcare services valuable to the diagnosis and treatment of peripheral artery disease, there is limited evidence examining an association between SES and the outcomes of lower extremity revascularization. One limitation is difficulty in identifying and objectively defining low SES. Socioeconomic status is composed of a wide variety of factors including financial security, employment, housing, and education, but it can be difficult to measure and evaluate on a large scale. Durham et al, in an analysis of 187 patients undergoing open and endovascular revascularization divided into “low income” and “high income” cohorts, found that low income was associated with advanced presentation, increased age, and lack of pre-procedural statin use.[27] Although low income and high income patients had equivalent patency of their vascular reconstruction at one year, there was an increased “cost per day of patency” in low income patients after both endovascular and open intervention. On multivariate analysis, income >100% of the federal poverty line was protective against limb loss after revascularization (odds ratio 0.06, 95% CI 0.01-0.51, P <0.001). In addition, a single institution study by Bakshi et al demonstrated that low mean household income and per capita income increased the risk of postoperative femoral surgical site infection after lower extremity revascularization.[28]

Some authors have used a composite metric of SES called the Distressed Community Index (DCI), developed by the Economic Innovation Group (Washington DC) to identify and address economic challenges.[29] The DCI incorporates seven metrics at the ZIP Code level including unemployment, education level, poverty rate, medium income, business establishments, job growth, and housing vacancies. The composite score ranges from zero (no distress) to 100 (severe distress). Hawkins et al paired the Vascular Quality Initiative short and long term data sets for infrainguinal bypass with DCI scores at the patient level.[30] They then compared the outcomes of 9711 patients who came from severely distressed communities (DCI >75) who underwent infrainguinal bypass to outcomes in 30,398 patients from communities with a DCI ≤75. Patients captured in the vascular quality initiative came from a wide range of communities with considerable “between hospital” variation in patient DCI scores. A number of hospitals also have a broad range in DCI scores amongst the patients they treat. The authors found that patients from severely distressed communities were younger at the time of bypass, more likely to smoke, disproportionately African-American, and possessing more comorbidities. In addition, patients from more distressed communities had higher rates of CLTI (60% in DCI >75 versus 56% in DCI ≤ 75.[30] There was no difference in in-hospital mortality or major adverse cardiovascular events in the high DCI versus low DCI groups. However, patients from high DCI communities had higher rates of major adverse limb events (MALE; 14.4% versus 11.7%, P <0.001). After risk adjustment utilizing 22 demographic, baseline, and operative characteristics as covariates, DCI remained an independent predictor of both in-hospital MALE (OR, 1.05 per 25 DCI points; 95% CI 1.02 to 1.08; P = 0.001) and long-term MALE (HR 1.02; 95% CI 1.00 – 1.04; P = 0.045). DCI was also predictive of long-term graft occlusion (HR, 1.04; 95% CI 1.00–1.07; P = 0.0 2A) and amputation (HR, 1.09; 95% CI, 1.06–1.12; P< 0.001). Although the data captured in the VQI do not allow exact identification by which low SES negatively impacts outcomes, the authors hypothesize that it is related to the “resources available in monitoring and maintaining health” which is important to maintain graft patency and axis to medications and wound care that would be needed to avoid future amputation.

Analyses from national administrative data also suggests that SES influences outcomes after lower extremity arterial revascularization. Hughes et al analyzed 131,529 patients who underwent surgical between 2010 and 2014 from the Agency for Healthcare Research and Qualities Healthcare Cost and Utilization Project Nationwide readmission's database and looked at the impact of median household quartiles of the patient's residential ZIP Code on postoperative outcomes occurring in the same calendar year.[31] In comparison to patients in the lowest household income quartile, those in the highest quartile had lower risk of amputation (adjusted odds ratio, 0.70; 95% CI, 0.63 – 0.77) and 30-day readmission (adjusted odds ratio 0.91; 95% CI, 0.84 – 0.99). There was no difference between quartiles of household income for mortality having a subsequent revascularization procedure.

Not all existing studies support the assertion that low SES is negatively associated with revascularization. A small number of single-institution studies have found that associate economic disparities are not associated with outcomes after lower extremity revascularization procedures for symptomatic PAD, although none of these studies measured long-term limb-related outcomes. Mazzeffi et al estimated socioeconomic position (SEP) based upon data from the 2000 US census among 609 patients who underwent lower extremity bypass surgery between 2002 and 2007. SEP was not significantly associated with either 30-day or 1-year mortality in this cohort.[32] Similarly, in a single institution study of 94 patients undergoing either open or endovascular revascularization between 2020 and 2022, McElroy and colleagues reported that there was no significant difference in median income, distance live from hospital, and type of insurance between patients who experienced post procedural complications and those who did not.[33] On the balance, there is convincing evidence that low SES is association with poor outcomes after revascularization. Socio-economic deprivation has clearly been shown to increase the risk of major limb amputation in broader cohorts of patients with a diagnosis of PAD. [34, 35] It seems reasonable to assume that socioeconomic barriers would negatively impact limb outcomes in the narrower subset of PAD patients who undergo revascularization.

In summary, Black, Hispanic, and low SES patients have inferior limb-related outcomes after lower extremity revascularization for PAD, irrespective of the indication for revascularization or mode of revascularization. These adverse outcomes include higher rates of short-term and long-term graft failure and major adverse limb events including reintervention and major amputation. Interestingly, multiple studies also demonstrate that Black and Hispanic patients undergoing revascularization for PAD have improved overall survival in comparison to White patients following revascularization. This runs counter to general assumptions that a heavier burden of systemic disease in minority patients predisposes them to uniformly worse health outcomes. There is evidence from multiple studies that the high prevalence of comorbidities and risks factors known to be detrimental after lower extremity revascularization contribute to the inferior outcomes in Black and Hispanic patients. Black and Hispanic patients who present with either claudication or CLTI are more likely to have developed PAD related to diabetes and renal disease. This finding suggests that more intensive medical management of these conditions preoperatively and postoperatively may improve post-revascularization outcomes. Still, while comorbidities, and associated complex small vessel disease, may be partially driving the higher rate of major adverse limb events and amputation in patients who present with late-stage PAD, these factors do not necessarily explain the differences observed in patients presenting with claudication. Differences in comorbidities at presentation by race/ethnicity are unlikely to be solely responsible for driving such a dramatic difference in outcomes. Clinically, it would be helpful to better understand the specific mechanisms of failure.

Contextualization of the research studies and the data reviewed in this article is important to understanding the current status of disparities in the treatment of PAD in the United States. First and foremost, the construct of race itself is a social construct and is largely considered a surrogate for a variety of social determinants of health and the complex interplay between them. This article reviews a number of studies in which the patient's race, ethnicity, and SES (by whatever indirect method it can be ascertained) are treated as single and separate exposure variables. Importantly, these studies have helped us to identify, in broad terms, disparities and ongoing needs for improvement in the narrower cohorts of patients undergoing revascularization. As such, they are helpful to us as surgeons. However, a more nuanced approach to understanding and correcting disparities after revascularization is required. Important social determinants of health, and their interplay, which impact the delivery, recovery, and ongoing care in Black, Hispanic, and low SES patients are only recently being captured in broader patient populations and should be studied in patients undergoing revascularization.

The National Institute on Minority Health and Health Disparities Research (NIMHD) framework is a multi-dimensional tool that depicts a number of health determinants relevant to understanding and addressing minority health and health disparities (Figure 3).[36] The framework captures five domains of influence on health (biological, behavioral, physical/built environment, sociocultural environment, healthcare system) and also captures for levels of influence at which health can be measured (the individual, interpersonal, community, and societal). When one assesses the current literature relevant to outcomes in racial and ethnic minority and low SES patients after revascularization within the context of the NIMHD framework, it is apparent that the studies to date are largely descriptive in nature and do little to explore the majority of the domains of health influence at any of the levels proposed by framework. At best, the published studies to date have been limited explorations of determinants at individual and interpersonal levels within the domain of the healthcare system. Using the framework as a guide, one can see the need to explore a whole host of social determinants across domains and at different levels of influence. Unidentified system-level policies that negatively impact Black, Hispanic, and low SES patients may be revealed. There are a vast number of potential paths that could be explored as one looks to address the scope of social determinants identified across the framework and a cataloging would be beyond the scope of this article. A first step would be for researchers of disparities in the vascular surgery community as well as stakeholders influential in the national delivery of vascular care to develop a more granular and coordinated research and implementation plan which identifies and prioritizes the most important and potentially impactful social determinants according to the NIMHD model.

We can also address disparities as individuals and teams of physicians and healthcare providers in our current settings where we care for patients. Vascular surgeons are unique amongst surgical specialists in that we are responsible for the medical and procedural care of patients with PAD. We also follow our patients over lifetimes to help maximize not only procedural outcome but patient's quality of life. This presents us both a unique perspective and opportunity to identify patients at risk because of their race, ethnicity and/or socioeconomic status, reflect upon the multidimensional social determinants which could influence outcome, and then to act in coordination with other services in order to mitigate risks and improve outcomes in at-risk populations patients with PAD.