Open revascularization for infrainguinal peripheral arterial disease in elderly patients: A scoping review

Abstract

Peripheral arterial disease (PAD) is a prevalent and debilitating condition in elderly patients, often leading to critical limb threatening ischemia (CLTI) and major amputations. While endovascular interventions are usually preferred for their lower perioperative risk, open surgical revascularization should also be considered due to its durability and superior patency in complex disease patterns. Age alone does not determine suitability for surgery; rather, candidacy hinges on frailty, functional status, comorbidities, and anatomical considerations. Contemporary global guidelines endorse a patient-centered approach that integrates these multidimensional factors. This scoping review will evaluate the outcomes of open infrainguinal revascularization in patients over 70, compared to endovascular approaches, and discuss how these findings align with contemporary guidelines and clinical decision-making paradigms. A scoping review was performed using one independent reviewer who screened PubMed to identify peer-reviewed observational studies and randomized controlled trials (2004-2024) involving patients aged >70 undergoing open infrainguinal revascularization. Keywords included “infrainguinal PAD,” “open revascularization,” and “elderly.” Key data extracted included perioperative morbidity, mortality, graft patency, limb salvage, and comparative effectiveness against endovascular strategies. A total of 1,574 articles were identified through reference search. We then screened these articles and assessed 265 full-text articles for eligibility. After exclusion, 19 full-text articles were selected for final inclusion. Nineteen eligible studies were included. Open revascularization in the elderly demonstrated 30-day mortality rates of 2% to 5% and 80% to 90% limb salvage rates in patients. Compared to endovascular techniques, open bypass yielded lower reintervention rates and superior long-term patency, especially when an autologous vein was used. Endovascular procedures were favored in high-risk or frail patients for their favorable perioperative profile. Frailty, functional independence, and conduit availability emerged as key determinants of surgical success. Open infrainguinal revascularization remains a viable and often preferable option for select elderly PAD patients. Decision-making should prioritize biological age, anatomical suitability, and patient preferences over chronological age. A multidisciplinary, guideline-driven approach can optimize outcomes, minimize risk, and preserve limb function and quality of life in this growing population.