Eduard Casajuana Urgell1,2, Laura Calsina Juscafresa3,4, Lluis Nieto Fernandez1, Lorena Romero Montaña1, Carme Llort Pont1, Albert Clarà Velasco1,5,6. 1. Department of Vascular and Endovascular Surgery, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain. 2. Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain. 3. Department of Vascular and Endovascular Surgery, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain. lcalsina@parcdesalutmar.cat. 4. Department of Medicine and Surgery, Universitat Pompeu Fabra, Barcelona, Spain. lcalsina@parcdesalutmar.cat. 5. Department of Medicine and Surgery, Universitat Pompeu Fabra, Barcelona, Spain. 6. CIBER Cardiovascular, Barcelona, Spain.
Abstract
BACKGROUND: As a result of the increasing life expectancy of the western population, the number of older patients with chronic limb-threatening ischemia (CLTI) seeking medical care is growing. Our objective was to describe the characteristics of a consecutive series of nonagenarian patients with CLTI and evaluate the outcomes of their management. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with CLTI attended at our institution between 2005 and 2019. Primary endpoints were 1-year limb salvage and survival rates. RESULTS: A total of 171 patients were included (mean age 92.7, 51.5% women), of which in 59 (34.5%) primary major amputation (n = 10) or palliative care (n = 49) was indicated at presentation because of severe dementia (n = 30, 50.8%), knee retraction (n = 17, 28.8%), terminal condition (n = 13, 22%) or a non-salvageable foot (n = 28, 47.4%). In the remaining 112 (65.5%), the need for a revascularization was further assessed finally performing A) conservative treatment/minor amputation (n = 57, 50.9%), B) revascularization (n = 50, 44.6%) or C) direct major amputation (n = 5, 4.4%), with 1-year limb salvage and survival rates of 93.1 and 57.4%, respectively. Predictive factors for lower survival included age >92 years (HR = 1,59, p = 0.041), hemoglobin <10.5 mg/dL (HR 2,34, p < 0.001), congestive heart failure (HR = 1.65, p = 0.036), non-severe dementia (HR 3,11, p < 0.001) and current mobility with wheelchair (HR 1,74, p = 0.014). CONCLUSION: Nearly one-third of nonagenarian patients with CLTI have a direct indication for amputation or palliative care at presentation. In the remaining, a judicious approach with conservative treatment, minor amputation or revascularization procedures yields excellent limb salvage rates. Survival is, however, the cornerstone of these patients. It can be predicted with certain clinical factors which may help decision-making.
BACKGROUND: As a result of the increasing life expectancy of the western population, the number of older patients with chronic limb-threatening ischemia (CLTI) seeking medical care is growing. Our objective was to describe the characteristics of a consecutive series of nonagenarian patients with CLTI and evaluate the outcomes of their management. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with CLTI attended at our institution between 2005 and 2019. Primary endpoints were 1-year limb salvage and survival rates. RESULTS: A total of 171 patients were included (mean age 92.7, 51.5% women), of which in 59 (34.5%) primary major amputation (n = 10) or palliative care (n = 49) was indicated at presentation because of severe dementia (n = 30, 50.8%), knee retraction (n = 17, 28.8%), terminal condition (n = 13, 22%) or a non-salvageable foot (n = 28, 47.4%). In the remaining 112 (65.5%), the need for a revascularization was further assessed finally performing A) conservative treatment/minor amputation (n = 57, 50.9%), B) revascularization (n = 50, 44.6%) or C) direct major amputation (n = 5, 4.4%), with 1-year limb salvage and survival rates of 93.1 and 57.4%, respectively. Predictive factors for lower survival included age >92 years (HR = 1,59, p = 0.041), hemoglobin <10.5 mg/dL (HR 2,34, p < 0.001), congestive heart failure (HR = 1.65, p = 0.036), non-severe dementia (HR 3,11, p < 0.001) and current mobility with wheelchair (HR 1,74, p = 0.014). CONCLUSION: Nearly one-third of nonagenarian patients with CLTI have a direct indication for amputation or palliative care at presentation. In the remaining, a judicious approach with conservative treatment, minor amputation or revascularization procedures yields excellent limb salvage rates. Survival is, however, the cornerstone of these patients. It can be predicted with certain clinical factors which may help decision-making.
Authors: Michael S Conte; Andrew W Bradbury; Philippe Kolh; John V White; Florian Dick; Robert Fitridge; Joseph L Mills; Jean-Baptiste Ricco; Kalkunte R Suresh; M Hassan Murad; Victor Aboyans; Murat Aksoy; Vlad-Adrian Alexandrescu; David Armstrong; Nobuyoshi Azuma; Jill Belch; Michel Bergoeing; Martin Bjorck; Nabil Chakfé; Stephen Cheng; Joseph Dawson; Eike S Debus; Andrew Dueck; Susan Duval; Hans H Eckstein; Roberto Ferraresi; Raghvinder Gambhir; Mauro Gargiulo; Patrick Geraghty; Steve Goode; Bruce Gray; Wei Guo; Prem C Gupta; Robert Hinchliffe; Prasad Jetty; Kimihiro Komori; Lawrence Lavery; Wei Liang; Robert Lookstein; Matthew Menard; Sanjay Misra; Tetsuro Miyata; Greg Moneta; Jose A Munoa Prado; Alberto Munoz; Juan E Paolini; Manesh Patel; Frank Pomposelli; Richard Powell; Peter Robless; Lee Rogers; Andres Schanzer; Peter Schneider; Spence Taylor; Melina V De Ceniga; Martin Veller; Frank Vermassen; Jinsong Wang; Shenming Wang Journal: Eur J Vasc Endovasc Surg Date: 2019-06-08 Impact factor: 7.069
Authors: Adriaan R Thomas; Jelle W Raats; Mare M A Lensvelt; Hans G W de Groot; Eelco J Veen; Lijckle van der Laan Journal: World J Surg Date: 2015-08 Impact factor: 3.352
Authors: Sanne Klaphake; Kevin de Leur; Paul G H Mulder; Gwan H Ho; Hans G W de Groot; Eelco J Veen; Lijckle van der Laan Journal: Ann Vasc Surg Date: 2017-07-06 Impact factor: 1.466
Authors: Stijn L Steunenberg; Matthijs J Faber; Jelle W Raats; Paul G H Mulder; Lijckle van der Laan Journal: Ann Vasc Surg Date: 2016-07-15 Impact factor: 1.466
Authors: Sanne Klaphake; Kevin de Leur; Paul Gh Mulder; Gwan H Ho; Hans G de Groot; Eelco J Veen; Hence Jm Verhagen; Lijckle van der Laan Journal: Clin Interv Aging Date: 2017-11-22 Impact factor: 4.458