Revascularization in Nonagenarians with Chronic Limb-Threatening Ischemia Can Be Effective.

Abstract

Purpose: The average age of patients with Chronic Limb-Threatening Ischemia (CLTI) who are being referred to vascular surgery units is increasing. This study aimed to evaluate clinical outcomes of revascularization (wound healing and cessation of rest pain) in nonagenarians with CLTI and the impact on their initial living status.

Methods: This retrospective, single centre study included patients aged 90 or more who presented with CLTI. Two groups were compared: "treated", who underwent revascularization (open, endovascular or hybrid), versus "not treated", who were treated conservatively. The latter included patients unfit for invasive treatment, with overriding active diseases, hip/knee ankylosis or refusing invasive treatment. Both groups were followed by dedicated wound care specialists. The primary outcomes were wound healing or cessation of rest pain and maintenance of initial living status after discharge. Secondary outcomes were overall mortality and major amputations at 1, 3, 6 and 12 months. Demographics, type of invasive treatment, access related complications and postoperative general complications were collected as well. Wound healing and mortality were assessed using cumulative outcome estimates according to Kaplan-Meier and comparisons using the log-rank test.

Results: Between 1st January 2018 and 31st July 2023, 123 patients with 131 chronic limb-threatening ischemic limbs were included. The "treated" group included 101 limbs with Rutherford 4 (n = 8,7.9%), 5 (n = 78, 77.2%) and 6 (n = 15, 14.9%) Peripheral Arterial Disease (PAD),. The "not treated" group included 30 limbs with Rutherford 5 (n = 22, 73.3%) and 6 (n = 8, 26.7%) PAD. Treatment consisted of eight open, 86 endovascular and seven hybrid procedures. No primary amputations were conducted. At 1 year, 64.6% (31/48) of the wounds in the "treated" group healed, while non healed in the "not treated" group (p < .001). Eighty-nine (94%) of the treated patients lived at home, and 72/89 (81%) were able to return home after discharge. One-year mortality rates for treated and not treated patients were 31.7% and 63.3%, respectively (p < .001). Access related complications were noted in 6.9% of the nonagenarians and 33.7% had a general adverse event.

Conclusions: Revascularization in nonagenarians with CLTI can be effective despite the advanced age. Wound healing is feasible without compromising the initial patient living autonomy and maintaining a low risk of major amputation and an acceptable mortality rate.