An analysis of vascular surgery in elderly patients to determine whether age affects treatment strategy

Abstract

The incidence of arterial disease increases with age. Increasing life expectancy in the western world will intensify demands on vascular surgeons with regard to increasing caseload, expanding patient selection criteria, and more complex and minimally-invasive treatment options. We analysed our arterial cases over the past 31 years (n = 6,144) and compared our methods of intervention and complication rates in the elderly population (>75) with the younger cohort, in order to determine whether age should influence our management strategies. Data were collected prospectively on all arterial cases from 1978 to 2009. Methods of intervention and corresponding complication rates in the over and under 75-year-old cohorts were analyzed utilizing Fisher's exact test to calculate two-sided p values, relative risks and 95% confidence intervals. Endovascular management has evolved to become the first line approach for all arterial cases (except carotid disease). Age was a significant risk factor for death and MI for the open procedures of AAA repair (p = 0.049 and p = 0.007, respectively), aorto-bifemoral reconstruction (p < 0.0001 and p = 0.006) and lower limb bypass (p = 0.01 and p < 0.001). For endovascular procedures, age did not impact on MI rate for EVAR (p = 0.78) or death rates for EVAR (p = 0.46), iliac angioplasty (p = 0.62) or lower limb angioplasty (p = 0.29). A paradigm shift has occurred towards endovascular management of aortic, iliac and femoral arterial disease. Whilst patient age >75 significantly impacts on complication rates from index open vascular procedures, age does not impact upon complication rates of corresponding endovascular procedures. We, therefore, recommend an endovascular approach be adopted as first line for all patients, regardless of patient age.