Outcomes of Octogenarians in Open Lower Extremity Revascularization

Abstract

Introduction - Open vascular surgical outcomes in octogenarians are controversial. Octogenarian patients are often not considered suitable candidates for open revascularization due to their advanced cumulative risk factors of smoking, hypertension, hyperlipidemia, diabetes mellitus, and obesity increasing their perioperative and postoperative risks which may be associated with a higher mortality rate. The aim of this study was to examine the differences in outcomes between non-octogenarians and octogenarians following lower extremity bypass surgeries. Methods - The lower extremity open procedure-targeted American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried in this study using data from 2011-2014. Analyses were performed separately on patients undergoing lower extremity bypass surgery (femoral-distal, popliteal-distal, and femoral-popliteal bypass). Disease, patient, clinical, and procedural characteristics were evaluated using univariate and bivariate analyses (student t, χ2, and Fisher’s exact tests). Independent risk factors and trends of 30-day postoperative outcomes of interest (mortality, readmission, loss of patency [LOP], and wound infection) were assessed using multivariate logistic regression. Results - The analysis included 2359 femoral-distal bypass patients (19.8% ≥80 years of age); 763 popliteal-distal bypass patients (16.51% ≥80 years of age); and 4894 femoral-popliteal bypass patients (14.22% ≥80 years of age). Thirty-day mortality was low in all surgery types (1.02% femoral-popliteal; 1.97% popliteal-distal; and 1.31% femoral-distal). Age was not found to be a significant predictor of our outcomes of interest in either the femoral-distal or popliteal-distal bypass cohorts. In the femoral-popliteal bypass cohort however, age ≥80 years was an independent predictor of mortality (OR 3.93, 95% CI 2.22-6.98, p<0.001). Emergent procedures (OR 3.15, 95% CI 1.5-6.89, p=0.004) and pre-operative wound infection (OR 2.41, 95% CI 1.36-4.27, p=0.002) were also important predictors of mortality. Age was found to be an independent predictor of LOP (OR 2.2, 95% CI 1.33-3.65, p=0.002), readmission (OR 1.29, 95% CI 1.02-1.64, p=0.033), and postoperative wound infection (OR 1.74, 95% CI 1.45-2.07, p<0.001). A statistically significant trend was found for increasing BMI and risk of readmission (p<0.001). Conclusion - Age ≥80 years old is a significant independent predictor of mortality, loss of patency, readmission, and wound infection following femoral-popliteal bypass surgery. Smaller sample size and power restrictions limited our ability to analyze the femoral-distal and popliteal-distal subgroups. Given a mortality odds ratio of 3.93, yet also a low overall 30-day mortality, it may be useful to consider the benefit in quality of life of this procedure while also examining therapeutic alternatives for severe PAD in this older age group.