Outcomes After Endovascular Procedures For Critical Lower Limb Ischemia In Nonagenarians
Michael J. Paisley, MD, Tatyana Kopilova, MD, Arianne Johnson, PhD, Kevin M. Casey, MD.
Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.
Objectives: Acute and chronic limb threatening ischemia present a unique clinical challenge in nonagenarian patients, an often comorbid, high surgical risk population. Endovascular interventions are performed safely in younger populations. The safety and efficacy of endovascular intervention in nonagenarians is under examined.
Methods: A ten-year retrospective review was performed on all patients >90 years who underwent a lower extremity angiogram for acute or chronic limb ischemia at a single institution. Patient demographics, functional status, complications and target vessel revascularization were analyzed. Primary outcomes were thirty-day and one-year limb salvage and mortality rates.
Results: From 2009 - 2018, 47 patients with acute (n=11) and chronic (n=36) limb ischemia underwent endovascular procedures. The thirty-day hospital readmission rate was 27.1% and post-operative complications were rare, occurring in less than 9% of all patients. Thirty-day limb salvage and mortality rates were 87.1% and 8.3%. One-year limb salvage and mortality rates were 85.1% and 25.0% (Table 1). Patient demographics, preoperative functional status, and target lesion revascularization rates were similar between the patients who had early amputation (< 30 days) compared to those with limb salvage (Table 1). Patients with early amputation did have a significantly higher mortality rate at one year compared to those who did not (66.7% vs 19.5%, p=0.03).
| Table 1. Patient Demographics and Outcomes, N = 47 | |||
| n (% Yes) | n (% Yes) | ||
| Median Age (IQR) | 92 (91-94.3) | Outcomes: | |
| Sex - Male | 17 (35.4) | Target Vessel Reintervention within 1 year | 7 (14.6) |
| Comorbidities (%) | 30 day readmit | 13 (27.1) | |
| Diabetes | 14 (29.2) | Complications | |
| Pulmonary | 4 (8.3) | ||
| Coronary Artery Disease | 24 (50.0) | Cardiac | 3 (6.2) |
| History of Tobacco | 18 (37.5) | Groin | 1 (2.1) |
| COPD | 5 (10.4) | Limb Salvage - 30 days | 41 (87.2) |
| Pre op Functional Status: | Limb Salvage - 1 year | 40 (85.1) | |
| Ambulatory | 20 (42.6) | Mortality - 30 days | 4 (8.3) |
| Walk with Assistance | 20 (42.6) | Mortality - 1 year | 12 (25.0) |
| Non Ambulatory | 7 (14.9) | ||
| Indications: | |||
| Rest Pain | 24 (50) | ||
| Wound | 31 (64.6) | ||
| Acute/Chronic Limb Ischemia (% Chronic) | 36 (76.6) | ||
Conclusions: Minimally invasive procedures can be done safely in nonagenarian patients with similar mortality and limb salvage for acute and chronic limb ischemia. Patients with early amputation are at higher risk of mortality at one year. However, nonagenarians who do not undergo early amputation experience exceptional one-year limb salvage and mortality rates. Patients with early amputation should be considered high risk for one-year mortality and appropriately counseled.
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