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Revascularization viable for critical limb ischemia in certain nonagenarians
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Revascularization benefits nonagenarian patients with critical limb ischemia, yielding “acceptable” rates of mortality and limb salvage, if the patient is not in a fully dependent state before undergoing treatment, according to results from a recent retrospective study.
The researchers evaluated outcomes in nonagenarians with critical limb ischemia who underwent treatment via endovascular surgery (n = 116), open surgery (n = 73) or primary amputation (n = 54) at a single center between 2005 and 2014, during a mean follow-up of 10.38 months. Mortality and morbidity were assessed at 30 days, with follow-up including clinical and hemodynamic assessment at 1, 6 and 12 months, then annually.
During the study, endovascular procedures became increasingly common, from three in 2005 to 25 in 2014. Open procedures became less prevalent, declining from 14 in 2005 to three in 2014, whereas the number of amputations persisted at approximately six per year.
Mortality rates at 30 days were 2.6% in the endovascular group, 10.9% in the open group and 24.1% in the amputation group. Morbidity rates at 30 days were 5.1%, 21.9% and 11.1%, respectively. The researchers wrote that in both the endovascular and open surgery groups, 30-day mortality only occurred among patients who were in a fully dependent state, defined as requiring help to perform all daily life activities. Autonomy levels after surgery were stable in 88.5% of the endovascular group and 81.5% of the open group, improved in 11.5% and 13.9%, respectively, and declined in 4.6% of patients in the open-surgery group.
During follow-up, survival rates did not differ significantly according to treatment, with rates of 51.2% at 1 year and 38.9% at 2 years among patients who received endovascular surgery; 48.3% and 39.6%, respectively, in the open-surgery group; and 50.6% and 40.8%, respectively, in the amputation group (P = .58). The researchers also observed similar limb salvage rates between the endovascular (88.2% at 1 year and 77.8% at 2 years) and open-surgery groups (87.3% and 77.6%, respectively; P = .97).
Among patients in a fully dependent state, defined as requiring help to perform all daily life activities, the survival rate was 28.9% at 1 year and 20.6% at 2 years, and limb salvage rates were 61.2% and 44.5%, respectively. A fully dependent state was associated with mortality risk (P < .001) on multivariate analysis, as were CAD (P = .01) and undergoing major amputation (P < .001).
“Revascularization in nonagenarians is acceptable as long as the patients are not fully dependent,” the researchers concluded. “Age per se cannot be the only determinant to decide whether a patient can be a candidate for revascularization or not in the setting of [critical limb ischemia]. The cardiac assessment, the suitability of anatomy for revascularization and mostly the preoperative autonomy level should be taken into consideration to choose the best option for each patient.” – by Adam Taliercio
Disclosure: The researchers report no relevant financial disclosures.
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