Young Patients with Claudication and Chronic Limb-threatening Ischemia Have Worse Limb-specific Outcomes After Infrainguinal Bypasses

Abstract

Although the prevalence of claudication and chronic limb-threating ischemia (CLTI) has increased in younger patients, less is known about the age-based differences in treatment and outcomes. This study compares the differences in limb-specific outcomes and predictors of complications in younger patients who undergo open operative intervention. The American College of Surgeons National Surgical Quality Improvement Project targeted lower extremity bypass database was used from 2012 to 2021. Bypasses for claudication and CLTI were analyzed separately. A histogram of limb-specific outcomes vs age showed adverse events markedly dropped around 65 years old. Thus, we stratified cases into younger patients (≤65 years old) and older patients (>65 years old). Primary outcomes included 30-day mortality, major organ dysfunction, and major amputations. To supplement the lack of long-term data and angiographic details in the National Surgical Quality Improvement Project, institutional data from 2017 to 2022 with 6-month follow-up was also analyzed. There were 5789 patients with claudication (2526 younger vs 3263 older) and 16,675 patients with CLTI (5948 younger vs 10,205 older). In both cohorts, younger patients were more likely to be obese and smokers but have independent function. Younger patients were less likely to have significant comorbidities including hypertension, chronic obstructive pulmonary disorders, and high-risk physiologic factors. Although younger age was independently associated with lower mortality in both claudication and CLTI (aOR, 0.32; P = .013; aOR, 0.40; P ≤ .001, respectively), patients had significantly worse limb-specific outcomes. Younger age was associated with increased untreated loss of patency (aOR, 2.68; P ≤ .001) and reoperation (aOR, 1.35; P = .045) in the claudication cohort and increased wound complications (aOR, 1.11; P = .038) and major amputation (aOR, 1.47; P ≤ .001) in the CLTI cohort (Table). A total of 96 institutional patients with CLTI were reviewed, of which 58 (60.4%) were younger than 65. There was no difference in graft material, orientation, or preoperative wounds, ischemia, and foot Infection score among age groups. Young patients, however, had significantly worse Global Limb Anatomic Staging System pedal scores. Although young patients have lower 30-day mortality after infrainguinal bypass, they have higher risk of limb-specific complications. Worse pedal Global Limb Anatomic Staging System scores may suggest the presence of more aggressive disease. Bypass for young patients with claudication should be done with extreme caution whereas bypass for CLTI may require more diligent postoperative follow-up.TableYounger patients are more likely to have limb-specific complications after infrainguinal open bypass than older patientsClaudicationCLTIYounger (n = 2526) vs older (n = 3263) patientsYounger (n = 5948) vs older (n = 10205) patientsAdjusted odds ratio95% Confidence intervalP valueAdjusted odds ratio95% Confidence intervalP valueMortality0.320.130.78.0120.500.310.54<.001MACE0.911.350.61.6130.800.670.79.009Pulmonary complications0.981.682.69.9420.860.951.05.130Wound complications1.040.871.23.6811.111.001.23.038Untreated loss of patency2.681.594.55<.0011.050.831.32.686Major amputation1.580.773.27.2161.481.231.76<.001Reoperation1.361.011.83.0461.150.991.32.052MACE, Major adverse cardiac events, including myocardial infarction, stroke, and cardiac arrest.Boldface entries indicate statistical significance. Open table in a new tab