Limb salvage and survival rates among elderly patients with advanced limb ischemia

Limb salvage in octogenarians with critical limb ischemia after lower extremity bypass surgery

OBJECTIVES

Peripheral artery disease is a worldwide epidemic that affects millions of patients, especially the elderly. It has a prevalence of 20% in individuals >80 years old. Although peripheral artery disease affects >20% of octogenarians, information about limb salvage rates in this patient population is limited. Therefore, this study aims to understand the impact of bypass surgery on limb salvage in patients aged >80 years with critical limb ischemia.

METHODS

We conducted a retrospective analysis by querying the electronic medical records at a single institution from 2016 through 2022 to identify the population of interest and analyzed their outcomes after lower extremity bypass. The primary outcomes were limb salvage and primary patency, with hospital length of stay and 1-year mortality as secondary outcomes.

RESULTS

We identified 137 patients who met the inclusion criteria. The lower extremity bypass population was divided into two cohorts: <80 years old (n = 111) with a mean age of 66 or ≥80 years old (n = 26) with a mean age of 84 years. The gender distribution was similar (P = .163). No significant difference was found in the two cohorts when it came to coronary artery disease, chronic kidney disease, or diabetes mellitus. However, when current and former smokers were grouped together, they were significantly more common in the younger cohort when compared with nonsmokers (P = .028). The primary end point of limb salvage was not significantly different between the two cohorts. Hospital length of stay was not significantly different between the two cohorts with 4.13 days vs 4.17 days in the younger vs octogenarian cohorts, respectively (P = .95). The 30-day all-cause readmissions were also not found to be significantly different between the two groups. The primary patency at 1 year was 75% and 77% (P = .16) for the <80-year-old and ≥80-year-old cohorts, respectively. Mortality was low in both cohorts, with two and three for the younger and octogenarian populations, respectively; thus, no analysis was performed.

CONCLUSIONS

Our study shows that octogenarians who undergo the same preoperative risk assessment as younger populations have similar outcomes when it comes to primary patency, hospital length of stay, and limb salvage when comorbidities were considered. Further studies need to be done to determine the statistical impact on mortality in this population with a larger cohort.

Diabetes effect on Quality of Life in the long-term after Limb salvage with Infrageniculate Bypasses accompanied with minor amputations

Objective : To evaluate the quality of life in patients, who had their limbs salvaged with an infrageniculate bypass and minor amputation in the long term and to see if diabetics are prone to worse results.

METHODS

The patients with limb salvage following an infrageniculate bypass and minor amputation were asked to complete Short Form 36 at the last follow-up visit. The mean scores in diabetic and non-diabetic population were compared to each other .The mean follow-up period was 58±8 months. Results : Of 142 patients, 40 patients were eligible to be included in the study. 33 (82.5%) patients were male and 7 (17.5%) patients were female. The mean age at the time of intervention was 57±14 (33-83) years. The mean scores for eight domains of SF-36 evaluation ranged from 44 to 67 out of 100. There were no significant differences concerning the mean scores of any dimension between the diabetic and non-diabetic group. Conclusion : Despite a minor amputation, the functional outcome of limb salvage with an infrageniculate bypass is favorable and diabetes does not seem to have negative effect on the functional outcome and Quality of Life.

Popliteal versus tibial retrograde access for subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique

OBJECTIVE

This study aimed to ascertain differences in benefit and effectiveness of popliteal versus tibial retrograde access in subintimal arterial flossing with the antegrade-retrograde intervention (SAFARI) technique.

METHODS

This was a retrospective study of SAFARI-assisted stenting for long chronic total occlusion (CTO) of TASC C and D superficial femoral lesions. 38 cases had superficial femoral artery lesions (23 TASC C and 15 TASC D). All 38 cases underwent SAFARI-assisted stenting. The ipsilateral popliteal artery was retrogradely punctured in 17 patients. A distal posterior tibial (PT) or dorsalis pedis (DP) artery was retrogradely punctured in 21 patients, and 16 of them were punctured after open surgical exposure.

RESULTS

SAFARI technical success was achieved in all cases. There was no significant difference in 1-year primary patency (75% vs. 78.9%, p = .86), secondary patency (81.2% vs. 84.2%, p = .91) and access complications (p = 1.00) between popliteal and tibial retrograde access. There was statistical difference in operation time between popliteal (140.1 ± 28.4 min) and tibial retrograde access with PT/DP punctures after surgical vessel exposure (120.4 ± 23.0 min, p = .04).

CONCLUSION

The SAFARI technique is a safe and feasible option for patients with infrainguinal CTO (TASC II C and D). The PT or DP as the retrograde access after surgical vessel exposure is a good choice when using the SAFARI technique.

Long-term results of open and endovascular revascularization of superficial femoral artery occlusive disease

BACKGROUND

First-line treatment for patients with superficial femoral arterial (SFA) occlusive disease has yet to be determined. This study compared long-term outcomes between primary SFA stent placement and primary femoral-popliteal bypass. Periprocedural patient factors were examined to determine their effect on these results.

METHODS

All femoral-popliteal bypasses and SFA interventions performed in consecutive patients with symptoms Rutherford 3 to 6 between 2001 and 2008 were reviewed. Time-dependent outcomes were analyzed using the Kaplan-Meier method and log-rank test. Cox proportional hazards were performed to determine predictors of graft patency. Multivariate analysis was completed to identify patient covariates most often associated with the primary therapy.

RESULTS

A total of 152 limbs in 141 patients (66% male; mean age, 66 ± 22 years) underwent femoral-popliteal bypass, and 233 limbs in 204 patients (49% male; mean age, 70 ± 11 years) underwent SFA interventions. Four-year primary, primary-assisted, and secondary patency rates were 69%, 78%, and 83%, respectively, for bypass patients and 66%, 91%, and 95%, respectively, for SFA interventions. Six-year limb salvage was 80% for bypass vs 92% for stenting (P = .04). Critical limb ischemia (CLI) and renal insufficiency were predictors of bypass failure. Claudication was a predictor of success for SFA stenting. Three-year limb salvage rates for CLI patients undergoing surgery and SFA stenting were 83%. Amputation-free survival at 3 years for CLI patients was 55% for bypass and 59% for SFA interventions. Multivariate predictors (odds ratios and 95% confidence intervals) of covariates most frequently associated with first-line SFA stenting were TransAtlantic Inter-Society Consensus II A and B lesions (5.9 [3.4-9.1], P < .001), age >70 years (2.1 [1.4-3.1], P < .001), and claudication (1.7 [1.1-2.7], P = .01). Regarding bypass as first-line therapy, claudicant patients were more likely to have nondiabetic status (5.6 [3.3-9.4], P < .001), creatinine <1.8 mg/dL (4.6 [1.5-14.9], P = .01), age <70 years (2.7 [CI, 1.6-8.3], P < .001), and presence of an above-knee popliteal artery target vessel (1.9 [CI, 1.1-3.4] P = .02).

CONCLUSION

Indication, patient-specific covariates, and anatomic lesion classification have significant association when determining surgeon selection of SFA stenting or femoral-popliteal bypass as first-line therapy. Patients with SFA disease can have comparable long-term results when treatment options are well matched to patient-specific and anatomic characteristics.

Aging causes collateral rarefaction and increased severity of ischemic injury in multiple tissues

OBJECTIVE

Aging is a major risk factor for increased ischemic tissue injury. Whether collateral rarefaction and impaired remodeling contribute to this is unknown. We quantified the number and diameter of native collaterals and their remodeling in 3-, 16-, 24-, and 31-month-old mice.

METHODS AND RESULTS

Aging caused an "age-dose-dependent" greater drop in perfusion immediately after femoral artery ligation, followed by a diminished recovery of flow and increase in tissue injury. These effects were associated with a decline in collateral number, diameter, and remodeling. Angiogenesis was also impaired. Mechanistically, these changes were not accompanied by reduced recruitment of T cells or macrophages to remodeling collaterals. However, endothelial nitric oxide synthase signaling was dysfunctional, as indicated by increased protein nitrosylation and less phosphorylated endothelial nitric oxide synthase and vasodilator-stimulated phosphoprotein in collateral wall cells. The cerebral circulation exhibited a similar age-dose-dependent loss of collateral number and diameter and increased tortuosity, resulting in an increase in collateral resistance and infarct volume (eg, 6- and 3-fold, respectively, in 24-month-old mice) after artery occlusion. This was not associated with rarefaction of similarly sized arterioles. Collateral remodeling was also reduced.

CONCLUSIONS

Our findings demonstrate that aging causes rarefaction and insufficiency of the collateral circulation in multiple tissues, resulting in more severe ischemic tissue injury.

Limb ischemia after iliac ligation in aged mice stimulates angiogenesis without arteriogenesis

OBJECTIVE

Older patients are thought to tolerate acute ischemia more poorly than younger patients. Since aging may depress both angiogenesis and arteriogenesis, we determined the effects of age on both angiogenesis and arteriogenesis in a model of severe acute limb ischemia.

METHODS

Young adult (3-months-old) and aged (18-months-old) C57BL/6 mice underwent right common iliac artery and vein ligation and transection. Data were collected on days 0, 7, and 14. Perfusion was measured with a laser Doppler scan and compared to the contralateral limb. Functional deficits were evaluated with the Tarlov scale. Capillary density and endothelial progenitor cell (EPC) number were determined by direct counting lectin-positive/alpha-actin-negative cells and VEGFR2/CXCR4 dually-positive cells, respectively; angiography was performed to directly assess arteriogenesis.

RESULTS

Young adult and aged mice had a similar degree of decreased perfusion after iliac ligation (young, n = 15: 20.4 +/- 1.9%, vs aged, n = 20: 19.6 +/- 1.3%; P = .72, analysis of variance [ANOVA]); however, young mice recovered faster and to a greater degree than aged mice (day 7, 35 +/- 6% vs 17 +/- 4%, P = .046; day 14, 60 +/- 5% vs 27 +/- 7%, P = .0014). Aged mice had worse functional recovery by day 14 compared to young mice (2.3 +/- 0.3 vs 4.3 +/- 0.4; P = .0021). Aged mice had increased capillary density (day 7, 12.9 +/- 4.4 vs 2.8 +/- 0.3 capillaries/hpf; P = .02) and increased number of EPC incorporated into the ischemic muscle (day 7, 8.1 +/- 0.9 vs 2.5 +/- 1.9 cells; P = .007) compared to young mice, but diminished numbers of collateral vessels to the ischemic limb (1 vs 9; P = .01), as seen on angiography.

CONCLUSION

After severe hind limb ischemia, aged animals become ischemic to a similar degree as young animals, but aged animals have significantly impaired arteriogenesis and functional recovery compared to younger animals. These results suggest that strategies to stimulate arteriogenesis may complement those that increase angiogenesis, and may result in improved relief of ischemia.

Digest

Professor Keizo Sugimachi, Editor-in-Chief of Surgery Today (The Japanese Journal of Surgery), has selected from the January to March 1998 issues of his journal for this quarter's digest. A digest of BJS for the same period written by Mr Colin Johnson, European Editor, appears in the Japanese journal.

Pain and quality of life in patients with critical limb ischaemia: results of a randomized controlled multicentre study on the effect of spinal cord stimulation. ESES study group

We carried out an assessment of pain and quality of life of patients with critical limb ischaemia during the follow-up of a multicentre randomized trial in more detail than previously reported. In a multicentre clinical trial 120 patients were randomized between medical treatment and medical treatment plus spinal cord stimulation. Patients were selected on the basis of clinical symptoms and macrocirculatory data as described in the European consensus document on critical limb ischaemia. Data were collected at intake and then 1, 3, 6, 12 and 18 months later. Primary outcome measures were limb salvage, pain relief and quality of life. Patient and limb survival was estimated with the Kaplan-Meier method. Pain was evaluated using the visual analogue scale (VAS), the McGill pain questionnaire, the pain score of the Nottingham Health Profile (NHP) and the use of analgesics. Quality of life was evaluated using the NHP, the EuroQol and mobility subscore of the Sickness Impact Profile. The 2-year limb survival was 52% for SCS treatment and 46% for standard treatment (p =0.47). Pain relief was considerable in both treatment strategies (p<0.005) with no significant differences between the strategies. The improvement occurred within the first few months and remained stable during further follow-up. Patients with SCS used fewer non-narcotic and narcotic drugs (p<0.001 at t=1 and t=3, p<0.002 at t=6). The overall scores of quality of life improved significantly (p<0.05), with no difference in score between treatments. The subscores of mobility and energy of the NHP in non-amputated patients was significantly better in the SCS group (p<0.005). Amputation had a negative effect on mobility, resulting in a difficult rehabilitation but relieved pain substantially (p<0. 05). In contrast to the existing literature, the randomized trial revealed no major difference in overall pain and quality of life assessment between treatment groups. The effect on energy and mobility was significantly better in patients treated with SCS, who also used substantially fewer analgesics.