Increased Mortality in Octogenarians Treated for Intermittent Claudication
Young Erben, MD1, Carlos I. Mena-Hurtado, MD1, Samuel M. Miller2, Raymond A. Jean, MD1, Brandon J. Sumpio1, Camilo A. Velasquez, MD1, Hamid Mojibian, MD1, John Aruny, MD1, Alan Dardik, MD, PhD1, Bauer E. Sumpio, MD, PhD1.
1Yale University Department of Vascular Surgery, New Haven, CT, USA, 2Warren Alpert Medical School of Brown University, Providence, RI, USA.
Treatment for intermittent claudication that is due to infra-inguinal peripheral artery disease relies on either bypass, angioplasty and/or stenting. Given the enthusiasm and shift towards more endovascular therapy for treatment of intermittent claudication in recent years, we sought to analyze whether octogenarians benefit from infra-inguinal interventions in the same manner as their younger counterparts.
We identified all patients admitted for elective treatment of intermittent claudication from the Nationwide Inpatient Sample from 2003-2012, who received open surgical or endovascular intervention for infra-inguinal peripheral arterial disease. These patients were divided into two groups including those between the ages 60-80 years (younger cohort) and those older than 80 years (octogenarians). Primary end-points included morbidity and mortality and the secondary end-points were length of hospital stay and disposition after dismissal.
Among 59,323 discharges identified in the dataset, 34,658 (58%) were males. There were 50,323 (85%) patients in the younger cohort and 9,000 (15%) octogenarians. The mean age was 69.9±5.7 years and 84.2±3.0 years for the younger cohort and octogenarians, respectively. The mean Charlson comorbidity index was higher in our younger cohort (2.1±1.1, p<0.001). Octogenarians mainly treated with open surgery prior to 2004 are now treated endovascularly and this trend has remained stable. The younger cohort’s treatment modality has fluctuated through the study period and most recently is treated mainly with open surgery. The rate of acute kidney injury, exacerbation of congestive heart failure and mortality was higher in octogenarians (p<0.001). The rate of infectious wound complications was higher in the younger cohort (p<0.05). Octogenarians have longer length of hospital stay and are dismissed in higher percentage to a skilled nursing facility (p<0.001). On binary logistic regression analysis, age over 80 years, female sex, higher Charlson comorbidity index, and having an open as opposed to an endovascular procedure are independent predictors of in-hospital mortality.
Although endovascular techniques seem to dominate the care for octogenarians with intermittent claudication, the overall morbidity and mortality rates are significantly higher in this patient population for a relatively benign disease process. Other options such as best medical management and/or supervised exercise therapy should be explored in this patient group.
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