Contemporary Outcomes of Peripheral Bypass Compared to Amputation in Octogenarians
Cheryl Richie, MD, Daniel L. Davenport, PhD, Nathan T. Orr, MD.
University of Kentucky, Lexington, KY, USA.
OBJECTIVES:
Chronic limb threatening ischemia (CLTI) in octogenarians presents unique treatment challenges in patients with multiple comorbidities and variable functional status. Endovascular interventions offer a better risk profile; however, this is not always a feasible option for anatomic or disease specific reasons. This study compares outcomes of peripheral bypass versus amputation in octogenarians.
METHODS:
The ACS-NSQIP database was queried from 2013 to 2016 for patients >80 years-old undergoing femoral-popliteal (FPB), femoral-tibial (FTB), or popliteal-tibial (PTB) bypass with vein or prosthetic graft versus above-knee (AKA) or below-knee amputation (BKA). Patients presenting with SIRS, sepsis, septic shock, or a leukocytosis > 11,000 were excluded. Patient demographics, risk factors, and 30-day unadjusted outcomes were analyzed. Multivariate regression analysis was then performed to compare risk adjusted 30-day morbidity and mortality.
RESULTS:
The bypass group contained 2226 patients compared to 1253 patients in the amputation group. AKA represented 59.9% of the amputation group. The largest portion of bypasses were FPBs at 58.6%. Total pre-op functional dependence was 1.3% for bypass versus 18.2% for amputation (p-value, <0.01). Risk factors for amputation over bypass included age, minority race, ASA class IV-V, diabetes, CHF, dialysis, preoperative open wound, facility of origin, and functional dependence. Unadjusted 30-day mortality was 3.6% for bypasses and 7.7% for amputations (p-value, <0.01), with an in-hospital mortality of 2.0% v. 3.2% and a mortality after discharge of 1.6% v. 4.5%, respectively (p-value <0.01). Unadjusted morbidity was not significantly different between the two groups (18.7% bypass v. 17.8% amputation, p-value, 0.52). After multivariate risk adjustment, there was no statistically significant difference in mortality or morbidity between the groups.
CONCLUSIONS:
Contemporary risk-adjusted 30-day morbidity and mortality for bypass versus amputation in octogenarians shows no significant difference. This data demonstrates that aggressive surgical limb salvage when compared to amputation can be safe in well-selected patients in this age group.
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