Arterial Embolectomy in the Brazilian Unified Health System: Temporal Trends, In-Hospital Mortality and Healthcare Disparities in a Time-Series Study (2016-2025)ABSTRACT
Introduction: Acute Arterial Occlusions are vascular emergencies associated with substantial morbidity and mortality. In Brazil, the role of arterial embolectomy within the Brazilian Unified Health System (SUS) remains incompletely characterized, particularly in the context of the expansion of endovascular therapies and the impact of the COVID-19 pandemic.
Methods: This ecological time-series study used secondary data from the Hospital Information System (SIH-SUS), including hospitalizations for arterial embolism and thrombosis (ICD-10: I74.*) between 2016 and 2025. Arterial embolectomies were identified using procedure codes. Temporal trends were assessed using Prais-Winsten regression, with estimation of the annual percent change (APC).
Results: A total of 240,350 hospitalizations were identified, of which 46,439 (19.3%) involved arterial embolectomy. Patients were predominantly older adults, male, and admitted on an emergency basis. The overall in-hospital mortality rate was 10.3%. Procedures were concentrated in the Southeast region, whereas the highest mortality rates were observed in the North. A significant downward temporal trend was identified (APC: −5.4%), with a 25.8% reduction over the study period and an inflection after 2022, consistent with changes in disease management patterns and possible repercussions of the COVID-19 pandemic.
Conclusion: Arterial embolectomy remains relevant in emergency vascular care within the Brazilian Unified Health System, despite the temporal decline in the number of procedures, possibly related to multiple factors, including advances in cardiovascular prevention and changes in therapeutic strategies. High mortality and regional disparities highlight inequalities in access to specialized care, reinforcing the need for strategies aimed at strengthening the vascular care network.
Keywords:
Arterial Occlusive Diseases; Embolectomy; Hospital Mortality; Time Series Studies; Health Status Disparities
RESUMO
Introdução: As oclusões arteriais agudas são emergências vasculares associadas a elevada morbidade e mortalidade. No Brasil, o papel da embolectomia arterial no Sistema Único de Saúde (SUS) permanece pouco caracterizado, especialmente diante da expansão das terapias endovasculares e das repercussões da pandemia de COVID-19.
Métodos: Estudo ecológico de série temporal com dados secundários do Sistema de Informações Hospitalares (SIH-SUS), incluindo internações por embolia e trombose arteriais (CID-10: I74.*) entre 2016 e 2025. As embolectomias arteriais foram identificadas por código de procedimento. As tendências foram analisadas por regressão de Prais-Winsten, com estimativa da variação percentual anual (APC).
Resultados: Foram registradas 240.350 internações, das quais 46.439 (19,3%) incluíram embolectomia arterial. Predominaram pacientes idosos, do sexo masculino e atendimentos em caráter de urgência. A mortalidade hospitalar foi de 10,3%. Observou-se concentração de procedimentos na região Sudeste, enquanto as maiores taxas de mortalidade ocorreram na região Norte. Houve tendência temporal decrescente significativa (APC: −5,4%), com redução de 25,8% no período e inflexão após 2022, compatível com mudanças no padrão de manejo da doença e possíveis repercussões da pandemia de COVID-19.
Conclusão: A embolectomia arterial permanece relevante no atendimento vascular de urgência no SUS, apesar da tendência temporal de redução dos procedimentos, possivelmente relacionada a múltiplos fatores, incluindo avanços na prevenção cardiovascular e mudanças nas estratégias terapêuticas. A elevada mortalidade e as disparidades regionais evidenciam desigualdades no acesso à assistência especializada, reforçando a necessidade de estratégias para qualificação da rede de atenção vascular.
Palavras-chave:
Arteriopatias Oclusivas; Embolectomia; Mortalidade Hospitalar; Estudos de Séries Temporais; Disparidades em Saúde
INTRODUCTION
Acute Arterial Occlusions resulting from embolic or thrombotic events are vascular emergencies marked by the abrupt interruption of blood flow to a limb or arterial territory. These conditions carry a substantial clinical and epidemiologic burden and can lead to high morbidity and mortality, including major amputations, in-hospital death, permanent functional disability, and increased healthcare costs within Brazil’s Unified Health System (Sistema Único de Saúde)1,2. In this context, early diagnosis and prompt initiation of appropriate treatment are critical determinants of patient outcomes.
Arterial embolectomy using a Fogarty catheter remains a widely used surgical strategy for the management of acute arterial ischemia, particularly in emergency settings. Although endovascular techniques have expanded over the past several decades, open surgery remains an important treatment option in many SUS facilities, particularly in regions with limited infrastructure and reduced availability of advanced technology and specialized teams2,3.
In Brazil, Acute Arterial Occlusions predominantly affect older adults, who frequently have multiple cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, and peripheral arterial disease2,4,5. Population aging, combined with the high prevalence of these chronic conditions, has contributed to a progressive increase in the demand for emergency vascular care, underscoring the importance of monitoring the epidemiology of these events over time.
The main etiologic mechanisms include embolic events of cardiac origin, frequently associated with atrial fibrillation, previous ischemic events, or valvular heart disease, as well as thrombotic events resulting from the progression of established atherosclerotic plaques3,6,7. The rapid progression of these conditions to severe forms of ischemia underscores the need for timely intervention to reduce the risk of limb loss and mortality.
In recent years, changes in the care patterns of these hospitalizations have been discussed in the literature, including potential indirect effects of the COVID-19 pandemic on both the prothrombotic state of hospitalized patients and the organization of care pathways in specialized services8. In addition, substantial regional disparities persist in access to endovascular technologies and higher-complexity vascular care in Brazil, factors that may influence the indication for and performance of arterial embolectomy across the country.
Despite the clinical relevance of acute arterial occlusions, national evidence regarding temporal trends and regional disparities in the performance of arterial embolectomy within the Brazilian Unified Health System (SUS) remains limited. Accordingly, this study aimed to evaluate temporal trends, hospital outcomes, and regional disparities in arterial embolectomies performed within the SUS between 2016 and 2025.
METHODS
A descriptive ecological time-series study was conducted using a quantitative approach based on secondary, aggregated, and anonymized data. Data were obtained from the Hospital Information System of the Unified Health System (SIH-SUS), available through the TabNet platform of the Department of Informatics of the Unified Health System (DATASUS), an agency of the Brazilian Ministry of Health9.
The study population comprised all hospital admissions within the SUS with a primary or secondary diagnosis of arterial embolism and thrombosis (ICD-10: I74.*) recorded in Brazil’s 27 federative units - including 26 states and the Federal District - from January 2016 through December 2025. This period represented the most recent interval with consolidated data available at the time of data collection, which was performed in March 2026. Because this was a population-based study using secondary census data, all available records from the study period were included, and no a priori sample size calculation was performed.
To identify the surgical procedures of interest, only records containing procedure code 04.06.02.012-4 (arterial embolectomy), according to the current version of the SUS Management System for the Table of Procedures, Medications, and OPMs (SIGTAP), were selected9. Hospitalizations without a record of this procedure were included only in analyses concerning the overall profile of hospitalizations for arterial embolism and thrombosis.
The variables collected included the annual number of hospitalizations, distribution by federative unit and geographic region, sex, age group, race/skin color, type of admission (elective or emergency), number of in-hospital deaths, total expenditures, and mean cost per hospitalization. For arterial embolectomies specifically, the analyses included regional distribution of procedures, type of admission, level of care complexity, total expenditures, mean cost per procedure, associated in-hospital mortality, and mean length of hospital stay in days.
The level-of-care complexity variable was included to characterize the organizational profile of surgical services within the public healthcare system. Records classified as “unknown” or “undetermined” were retained in the descriptive analysis and presented as separate categories to preserve the completeness of the available information.
To minimize information bias, standardized codes were used to identify diagnoses and procedures in accordance with the International Classification of Diseases, 10th Revision (ICD-10), and the official table of the SUS Management System for Procedures, Medications, and OPMs (SIGTAP). Nevertheless, potential inconsistencies inherent to the use of secondary administrative databases were acknowledged.
In-hospital mortality was reported as absolute numbers and percentages, calculated relative to the total number of hospitalizations or procedures analyzed. Mean length of hospital stay corresponded to the arithmetic mean reported by the SIH-SUS through the TabNet platform.
Initially, a descriptive analysis of the variables was performed, including absolute and relative frequencies, percentages, and measures of central tendency, such as means and medians.
Hospitalization rates and arterial embolectomy rates were estimated per 100,000 inhabitants by dividing the number of observed events by the estimated resident population of the corresponding federative unit or the country and multiplying the result by 100,000. Population estimates provided by DATASUS in conjunction with the Brazilian Institute of Geography and Statistics (IBGE) were used for these calculations9.
The calculated rates were subsequently log10-transformed, and Prais-Winsten regression was used to assess temporal trends, according to the methodology proposed by Antunes and Cardoso10. The magnitude of the trends was estimated using the Annual Percent Change (APC), calculated as APC = (10^β − 1) × 100, with 95% confidence intervals and a 5% significance level. Trends were classified as increasing when the APC was positive and statistically significant, decreasing when the APC was negative and statistically significant, and stationary when no statistical significance was observed.
Additionally, a complementary descriptive analysis was performed to examine the behavior of the time series during the COVID-19 pandemic period (2020-2022) and in subsequent years, to identify potential inflection points in the trends previously observed. This analysis was exploratory and interpretive in nature and was not included as an independent variable in the regression models; rather, it was considered in the contextualization of the findings.
Federative units with fewer than five consecutive years of complete data during the study period would have been excluded from the temporal trend analyses to reduce potential distortions while remaining eligible for all other descriptive analyses. However, all federative units had sufficient data for inclusion in the analyses throughout the study period.
The data were organized using Microsoft Excel® and analyzed with Stata® version 17.0 (StataCorp, College Station, TX, USA).
Because this study was based exclusively on aggregated, publicly available secondary data without individual-level identification, submission to a Research Ethics Committee was not required, in accordance with Resolutions No. 466/2012 and No. 510/2017 of the Brazilian National Health Council11,12.
The study was conducted in accordance with the STROBE guidelines.
RESULTS
Between 2016 and 2025, 240,350 hospitalizations for arterial embolism and thrombosis were recorded in the Brazilian Unified Health System (SUS), of which 46,439 involved arterial embolectomy, corresponding to approximately 19.3%. Table 1 presents the distribution of these hospitalizations according to sociodemographic, healthcare-related, and economic characteristics.
Distribution of hospitalizations for arterial embolism and thrombosis according to sociodemographic, healthcare-related, and economic characteristics. Unified Health System, Brazil, 2016-2025.
Hospitalizations were more common among males, who accounted for 56.97% of the total. Regarding race/skin color, White patients were the most frequently represented group (43.51%), followed by Brown/mixed-race patients (36.12%). With respect to age, there was a marked concentration among individuals aged 60 years or older, who accounted for 69.4% of hospitalizations and 83.46% of deaths recorded during the study period.
Regarding admission type, emergency hospitalizations predominated substantially, accounting for 90.6% of cases and 94.16% of in-hospital deaths. Total expenditures for these hospitalizations amounted to BRL 607,356,431.00 over the study period, with a mean cost of BRL 2,526.97 per hospitalization.
Regionally, the largest concentration of hospitalizations occurred in the Southeast region, which accounted for 45.23% of cases and 48.42% of deaths, followed by the South (25.45%) and Northeast (21.09%) regions. The North and Central-West regions accounted for smaller proportions of hospitalizations.
Specifically regarding arterial embolectomies, the largest concentration of procedures was also observed in the Southeast region, with 22,105 procedures (47.6%), followed by the Northeast (9,931; 21.4%) and South (9,856; 21.2%) regions. The Central-West and North regions accounted for smaller proportions, with 3,432 (7.4%) and 1,115 (2.4%) procedures, respectively. The vast majority of procedures were performed as emergency interventions (43,819), whereas only 2,601 were performed electively.
All procedures were classified as intermediate-complexity procedures throughout the study period. Total expenditures for arterial embolectomies amounted to BRL 152,362,429.78, with a mean cost of BRL 3,280.92 per procedure. A total of 4,793 deaths were recorded among hospitalizations involving arterial embolectomy, corresponding to an in-hospital mortality rate of 10.3%.
The regional distribution of procedures, deaths, mortality rates, and mean length of hospital stay is presented in Table 2.
Healthcare utilization indicators and hospital outcomes of arterial embolectomies by geographic region. Brazil, 2016-2025.
Regional analysis of in-hospital mortality showed the highest rate in the North region (13.6%), followed by the Southeast (11.1%), Central-West (10.6%), and South (10.2%) regions, whereas the Northeast region had the lowest rate (8.2%).
The national mean length of hospital stay following arterial embolectomy was 7.3 days, with substantial regional differences. The longest mean length of stay was observed in the Northeast region (9.0 days), followed by the North (7.7 days) and Southeast (7.5 days) regions. The Central-West region had an intermediate mean length of stay (6.0 days), whereas the South region had the shortest (5.7 days).
Table 3 presents the analysis of temporal trends in arterial embolectomies performed within the SUS. Overall, Brazil showed a decreasing temporal trend throughout the study period, with an estimated average annual reduction of −5.4%. Comparing the first and last years of the time series, the annual number of procedures decreased by approximately 25.8%.
Temporal trends in arterial embolectomies performed within the Brazilian Unified Health System among hospitalizations for arterial embolism and thrombosis in Brazilian federative units. Brazil, 2016-2025.
The number of arterial embolectomies increased progressively between 2017 and 2022, reaching a national peak of 5,241 procedures in 2022. Beginning in 2023, the number of procedures declined continuously through 2025, when 3,731 cases were recorded, representing an approximately 28.8% decrease from the peak of the time series.
However, heterogeneous patterns were observed across geographic regions. The Southeast and Northeast regions showed steeper declines after 2022, whereas the South region demonstrated a fluctuating pattern. The states in the North region showed a predominantly increasing pattern over the time series, although most were classified as having stationary trends. The Central-West region maintained a relatively stable pattern.
Regarding mean length of hospital stay, a progressive reduction was observed in Brazil, from 7.8 days in 2016 to 6.2 days in 2025. During the pandemic period, a temporary reduction in mean length of stay was observed in some regions between 2020 and 2022, followed by stabilization in subsequent years.
DISCUSSION
The findings of the present study demonstrate that arterial embolectomy remains relevant to the provision of care within Brazil’s Unified Health System (SUS), accounting for approximately one-fifth of hospitalizations for arterial embolism and thrombosis. This finding reinforces the continued central role of open surgical management in the treatment of acute limb ischemia within the Brazilian public healthcare system.
These findings should be interpreted in the context of the increasing global burden of peripheral arterial disease over the past several decades. International epidemiologic studies have demonstrated a consistent increase in the prevalence of this condition, driven primarily by population aging and greater exposure to modifiable cardiovascular risk factors, including diabetes mellitus, hypertension, dyslipidemia, and smoking4. Consequently, the demand for revascularization procedures has increased, placing growing pressure on healthcare systems, particularly in middle-income countries undergoing rapid demographic transitions while facing limitations in the availability of specialized services5.
Given this context, acute limb ischemia represents a critical clinical condition that is frequently associated with poor outcomes even when managed in the hospital setting. The in-hospital mortality rate observed among patients undergoing arterial embolectomy, exceeding 10%, underscores the clinical severity of acute limb ischemia and the complexity of patients undergoing this procedure.
This finding is consistent with studies conducted within the Brazilian public healthcare system showing substantial mortality among patients undergoing revascularization for acute limb ischemia, particularly among older individuals with multiple cardiovascular comorbidities13. Comorbid conditions such as heart failure, chronic kidney disease, and diffuse atherosclerotic disease contribute to poorer prognosis and an increased risk of perioperative complications.
The high concentration of deaths among patients aged 60 years or older further highlights the influence of population aging on the healthcare burden of acute limb ischemia, given the greater prevalence and impact of peripheral arterial disease in this age group5.
From an international perspective, evidence indicates that acute limb ischemia remains associated with high rates of mortality and amputation, even in healthcare systems with greater technological resources. Recent studies have shown that delays in diagnosis and initiation of definitive treatment are key determinants of poor outcomes in these patients14,15. The time-sensitive nature of the condition partly explains these outcomes, as the rapid progression of tissue compromise creates a limited therapeutic window in which early intervention is critical for limb preservation and reduction of mortality14.
Regional analysis of the data revealed substantial heterogeneity in the distribution of procedures and hospital outcomes. A marked concentration of embolectomies was observed in the Southeast region, which also had the highest absolute number of deaths, partly reflecting its larger population and greater availability of high-complexity healthcare services. However, the highest proportional mortality rate was observed in the North region, which may be related to structural factors affecting the organization of the healthcare network, such as limited availability of specialized centers, logistical challenges in patient transfer, and longer times to access definitive treatment. Evidence indicates that delays in referral and revascularization are associated with poorer outcomes in patients with acute limb ischemia, underscoring the importance of well-organized care pathways and timely access to specialized treatment14,15. Conversely, the lower mortality observed in the Northeast region should be interpreted with caution, as it may reflect differences in patients’ clinical profiles, healthcare organization, or aspects related to the quality of administrative records.
The high proportion of emergency admissions observed in this study further supports the interpretation that some of the regional disparities identified may be related to difficulties in obtaining timely access to specialized diagnosis and treatment. Evidence indicates that delays in seeking care are associated with greater clinical severity at admission, with direct implications for amputation and mortality rates. In this context, time to revascularization is a critical prognostic factor14,15. Recent studies have shown that patients undergoing interhospital transfer have higher mortality and a greater risk of major amputation, particularly when access to definitive treatment is delayed15.
These findings underscore the need to strengthen the organization of care pathways, with an emphasis on regionalization of care, improved prehospital care, and training of lower-complexity facilities to recognize acute limb ischemia early.
A decreasing temporal trend was also observed in the number of arterial embolectomies performed nationwide over the study period, with a reduction of more than 25% between the beginning and end of the period, suggesting changes in the pattern of disease management.
The observed reduction is therefore likely to result from multiple factors acting concurrently, including changes in patients’ epidemiologic profiles, advances in cardiovascular prevention, and changes in therapeutic strategies used in contemporary vascular practice.
Another factor that may have contributed to the observed reduction in arterial embolectomies is improved medical management of cardiovascular diseases, particularly atrial fibrillation, an important source of arterial embolic events. Over the past several decades, advances in screening, diagnosis, and treatment of atrial fibrillation, together with the broader use of oral anticoagulant therapy, have contributed to reducing the risk of systemic thromboembolic events16,17.
Supporting this hypothesis, a recent population-based study conducted in Denmark demonstrated a temporal reduction in the risk of complications associated with atrial fibrillation over the past two decades despite an increasing prevalence of the condition, suggesting a positive impact of contemporary cardiovascular prevention strategies18. Although the present study lacks individual-level clinical information to directly assess this association, it is plausible that part of the observed decreasing trend reflects improvements in primary and secondary prevention of embolic events among patients at higher cardiovascular risk.
An additional possible explanation for this trend is the progressive expansion of endovascular techniques for the treatment of acute limb ischemia. The development of percutaneous thrombectomy devices and the growing experience with minimally invasive procedures have changed clinical practice in several settings and have been associated with lower perioperative morbidity and shorter hospital stays. However, the availability of these technologies remains heterogeneous across Brazil19,20.
Despite these advances, the choice between open surgical and endovascular approaches for acute limb ischemia remains strongly dependent on the clinical and structural context in which the patient is treated. Although the adoption of these technologies has expanded the use of minimally invasive techniques, evidence indicates that the effectiveness of these strategies is directly related to resource availability, operator expertise, and appropriate patient selection19,20.
In settings with limited infrastructure or delayed access to treatment, surgical embolectomy remains a definitive and often more accessible option, particularly in emergency situations, extensive occlusions, or regions with limited access to endovascular resources3. Thus, the continued use of this procedure within the SUS should not be interpreted solely as a reflection of technological lag, but also as an adaptation to the real-world conditions under which the healthcare system operates. This reinforces the need for strategies that reconcile technological innovation with equitable access to specialized vascular care.
Additionally, the potential impact of the COVID-19 pandemic period on this trend should be considered. The reorganization of healthcare services, with prioritization of care for patients with COVID-19 and reductions in procedures at various centers, has been associated with decreased volumes of vascular interventions and increased severity among patients receiving care8.
Furthermore, delays in seeking care and difficulties accessing specialized services during this period may have contributed to this scenario, affecting both clinical outcomes and the number of procedures performed15.
Taken together, these findings suggest a transition in the management of acute limb ischemia in Brazil, although this transition has occurred heterogeneously across regions.
Beyond clinical outcomes, the economic impact of hospitalizations for arterial embolism and thrombosis is also noteworthy. A substantial volume of financial resources was allocated to these hospitalizations over the study period. Moreover, evidence indicates that hospital costs vary according to the therapeutic strategy used, with relevant differences between open and endovascular approaches21. These findings underscore the importance of evaluating the cost-effectiveness of different therapeutic strategies within the public healthcare system.
International studies indicate that patients with peripheral arterial disease are more likely to require reinterventions, intensive care, and hospital readmissions, contributing to increased healthcare costs22.
From the perspective of clinical and economic decision-making, recent reviews suggest that open and endovascular approaches may yield similar outcomes in terms of limb salvage and mortality in selected settings23. However, the choice between these strategies should consider not only clinical effectiveness but also the structural context, technological availability, and economic impact, particularly within the SUS.
Therefore, understanding the epidemiologic patterns of arterial embolectomy within the Brazilian public healthcare system is essential to inform health planning strategies and reduce disparities in access to specialized vascular treatment.
From a health-system management perspective, the findings highlight the need to optimize the vascular care network in Brazil by expanding access to specialized services, improving care pathways, and ensuring equitable adoption of new technologies.
Several limitations should be acknowledged. The study relied on aggregated secondary data, which are subject to inconsistencies and lack detailed clinical variables. The inability to perform individual-level analyses limited the assessment of important prognostic factors, such as Rutherford classification, time to revascularization, and postoperative complications.
In addition, it was not possible to distinguish embolic cases from those predominantly caused by thrombosis or to assess individual-level changes in the use of anticoagulant therapies over the study period.
Despite these limitations, the main strength of this study lies in its nationwide scope and large number of observations, allowing the epidemiologic profile, patterns of care, and impact of arterial embolectomy in Brazil to be characterized on a national scale and contributing to the improvement of strategies for organizing vascular care within the Unified Health System.
CONCLUSION
Arterial embolectomy remains an important component of care within Brazil’s Unified Health System (SUS) and is associated with high in-hospital mortality and a predominance of emergency admissions. A decreasing temporal trend in the number of procedures was observed over the study period, potentially reflecting multiple factors, including advances in cardiovascular prevention and the management of atrial fibrillation, changes in therapeutic strategies, and the indirect effects of the COVID-19 pandemic on the organization of healthcare services. Substantial regional disparities persist in the distribution of cases, clinical outcomes, and length of hospital stay, highlighting inequities in access to specialized vascular care. These findings underscore the need to strengthen the organization of the healthcare network, with emphasis on timely access to vascular treatment, reduction of regional disparities, and improvement of clinical outcomes within the Unified Health System.
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