Outcomes of Octogenarians in Lower Extremity Endovascular Revascularization

Abstract

Introduction - Endovascular surgery has evolved over the last decade to become a viable alternative for peripheral arterial disease (PAD) in high-risk patients due to medical comorbidities including advanced age. Efficacy trials continue to be done but high-risk patients are often preferentially offered endovascular interventions. The aim of this study was to compare outcomes between non-octogenarians and octogenarians following lower extremity endovascular revascularization (LEER). Methods - The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) LEER-targeted surgical cohort (2011-2014) was used to separately examine patients that underwent tibial (TB) or femoropopliteal (FP) angioplasty/stenting interventions. Disease, patient, clinical, and procedural characteristics were extracted (with data from 30 days of postsurgical follow-up), and evaluated using univariate/bivariate analyses (student t, χ2, and Fisher’s exact tests). Independent risk factors and trends were evaluated using multivariate logistic regression. Outcomes included 30-day mortality; readmission; loss of patency (LOP); as well as postoperative wound infection (WI), major amputation, and bleeding requiring intervention/transfusion. Results - The FP endovascular cohort consisted of 4193 patients. 30-day mortality was low (0.91%) and resulted in poor model-fit for both cohorts. Those 80+ years old had a slightly longer length of stay (LOS), higher physiological risk factors (PRF), similar elective vs emergent procedures, and a higher prevalence of CHF. The younger group exhibited more ESRD and HTN. 12.34% of patients were readmitted with age over 80 years, emergent procedures, PRF, ESRD, HTN, WI, and antiplatelet regimen as independent risk factors. Female gender was an independent risk factor for bleeding, as was smoking, emergent procedures, history of CHF, and WI. Major amputation was uncommon (2.55%); however, age, obesity, emergent procedures, bleeding, and WI were significant independent predictors. LOP (1.9%) was only independently predicted by emergent procedure. The TB endovascular cohort included 1105 patients. 30-day mortality was low (0.99%). There was no significant difference in LOS, CHF or hypertension between the older/younger groups. ESRD was more prevalent in the younger group, while the older group exhibited higher PRF. There were 19.5% of patients readmitted within 30 days, and was independently predicted by older age, and ESRD with 5.52% of patients undergoing a major amputation during follow-up. Obesity and bleeding were independent predictors. Bleeding was also examined as an outcome and was predicted by smoking, emergent admission, and ESRD. Conclusion - Following LEER involving the FP system, octogenarians were at a lower risk of major amputation and readmission but there was no difference in post-op WI or LOP. Following procedures involving the TB artery, octogenarians were at a lower risk of WI and readmission but a similar risk of amputation and bleeding. Considering the TB cohort had two-fold higher amputations and more readmissions than the FP cohort and that different risk factors impact the outcomes after each intervention, we must take this into account when discussing procedural options with patients. While sample size and selection bias may affect the results from databases such as ours, these results suggest that octogenarians may do just as well than non-octogenarians following LEER.