Earlier Intervention for Peripheral Arterial Disease in Frail Patients is Associated with Improved Survival and Limb Salvage
Daniel J. Torrent, MD, John A. Crenshaw, Dean J. Yamaguchi, MD, Bryan A. Ehlert, MD.
East Carolina University, Greenville, NC, USA.
OBJECTIVES: Frailty is a risk factor that has been shown to negatively impact operative outcomes. Our objective was to ascertain the effects of frailty on post-operative mortality and amputation after intervention for peripheral arterial disease (PAD). METHODS: A retrospective cohort of all patients undergoing intervention for chronic PAD over a three year period was compiled from institutional Vascular Quality Initiative data and included procedural indication, demographic data, comorbid conditions, time to amputation and time to death. A modified frailty index (mFI) was calculated for each patient and the patients were divided into frail and non-frail cohorts, with frailty defined as mFI ≥4. Univariate associations between frailty and death within 12 months and amputation within 6 months were calculated. Univariate statistics for outcomes of amputation and death were further stratified to patients with claudication or critical limb ischemia (CLI). Logistic regression models were created using backward selection. RESULTS: There were 567 patients with a mean age of 65.1(±0.5) years with 60.8% male and 59.3% Caucasian. The frail cohort comprised 41.1% of the population. The indication for intervention was claudication for 49.6% and 50.4% for CLI. Endovascular revascularization accounted for 76.2% of interventions and infra-inguinal bypass the remaining 23.8%. Among the frail group, odds of death at 12 months were increased on a logistic model in the presence of CLI (OR 9.53; 95%CI 2.66,61.2) when controlling for significant confounders. In a logistic model for all CLI patients, frailty was associated with increased odds of death at 12 months (OR 10.1, 95%CI 3.22, 45.1). In a logistic model for claudicants, there was no association between frailty and death at 12 months (OR 0.3; 95%CI 0.06, 1.7). For the frailty group, there is increased association with amputation at 6 months for CLI (8.6%) compared to claudication (1.3%) (p=0.02) with no other significant factors by logistic regression. CONCLUSIONS: In frail patients, revascularization for CLI is associated with increased mortality and limb loss while intervention in claudicants does not correlate with poor outcomes. With increasing emphasis on cost-effective resource utilization, perhaps earlier intervention for frail patients before the development of CLI is warranted as it is associated with improved outcomes.
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