Study Compares Endovascular and Open Treatment for CLI in Octogenarians
August 3, 2009—In the Journal of Vascular Surgery, Hasan H. Dosluoglu, MD, et al published a study that sought to compare their results after open versus endovascular infrainguinal revascularizations in patients 80 years of age or older and those patients younger than 80 years of age presenting with critical limb ischemia (CLI) (2009;50:305-316). They also wanted to determine if limb salvage (LS) attempts were justified in patients 80 years of age or older with CLI, especially after endovascular interventions.
The investigators conducted a retrospective analysis of 344 consecutive patients (399 limbs) who presented with CLI and underwent infrainguinal open or endovascular revascularizations between June 2001 and December 2007. Patients 80 years of age or older (89 patients, 101 limbs) and younger than 80 years of age (255 patients, 298 limbs) were compared for demographics, characteristics, patency, limb salvage, sustained clinical success (preservation of limb, freedom from target extremity revascularization, and resolution of symptoms), secondary clinical success (preservation of limb and resolution of symptoms), overall improvement (preservation of limb and improvement of symptoms), and survival.
The investigators reported that patients 80 years of age or older were more likely to be nonambulatory and have coronary artery disease, whereas those younger than 80 years of age were more likely to have hypertension, hyperlipidemia, dialysis dependence, active tobacco abuse, and to be taking beta blockers. Primary amputation rates were similar between the two groups (patients younger than 80 vs patients 80 or older, 6.7% vs 8.1%; P = .53). Perioperative mortality was significantly worse in the 80-or-older patients in the open-treated group (16.2% vs 2.9%; P = .009), whereas it stayed similar in endovascular-treated patients (3.1% vs 0.6%; P = .197). The patency rates were similar between groups; however, limb salvage was significantly better in the 80-or-older endovascular-treated patients than in the younger-than-80 endovascular-treated group, and it remained similar between groups in open-treated patients.
Sustained clinical success, secondary clinical success, and overall improvement rates were similar between age groups. Endovascular-treated patients in the 80-or-older age group had significantly better overall improvement than those who were treated by open revascularization (24-month overall improvement was 83% ± 5% vs 61% ± 9%; P = .043).
According to the investigators, multivariate analysis showed diabetes, infrapopliteal intervention, presence of gangrene, nonambulatory status, dialysis dependence, and runoff status being associated with limb loss, whereas age being 80 or older or younger than 80 years was not. Age, coronary artery disease, chronic obstructive pulmonary disease, nonambulatory status, and dialysis dependence were found to be independently associated with decreased survival.
The investigators concluded that these results suggest that revascularization in patients 80 years of age or older with CLI is justified, especially when an endovascular intervention can be accomplished. Although limb salvage rates after endovascular interventions were better in the 80-or-older group, sustained clinical success and secondary clinical success rates were similar after open and endovascular interventions in both age groups. Open procedures carry a high perioperative mortality rate in the 80-or-older group and should be avoided if possible, advised the investigators.