Favorable outcomes of very elderly patients with critical limb ischemia who undergo distal bypass surgery

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.

Tension-Free Management of Surgical Wound in Paramalleolar Bypass

Objective: In paramalleolar bypass for critical limb-threatening ischemia (CLTI), excessive skin tension may occur for the closure of surgical wounds around the ankle. Furthermore, these surgical incisions are often proximal to infectious ischemic ulcers. Wound dehiscence caused by skin tension and surgical site infection carries a risk of graft exposure, anastomotic disruption, or graft insufficiency. Patients and Methods: Tension-free wound management was adopted in eight patients who underwent paramalleolar bypass for CLTI. Tension-free closure was adopted for surgical incisions for distal anastomotic site of the paramalleolar bypass, whereas the incisions for saphenous vein harvest were left open. A relief incision was made as needed. The opened incisions were covered with artificial dermis. Results: All surgical incisions and ischemic wounds healed successfully within 1.8 months after bypass. Two postoperative graft stenoses occurred, which were rescued by additional endovascular intervention. Secondary graft patency, wound healing, and limb salvage rates were 100% during an average follow-up period of 30 months. Conclusion: Tension-free wound closure using artificial dermis was effective in selected cases of paramalleolar bypass for CLTI.

Editor's Choice - Mortality and Major Amputation after Revascularisation in Octogenarians Versus Non-Octogenarians with Chronic Limb Threatening Ischaemia: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the clinical outcomes after revascularisation in octogenarians with chronic limb threatening ischaemia (CLTI).

METHODS

This was a systematic review and meta-analysis, in which the Medline, Embase, and Cochrane Library databases were searched systematically by two independent researchers. Meta-analyses were performed to analyse one year mortality, one year major amputation, and one year amputation free survival (AFS) after revascularisation. Pooled outcome estimates were reported as percentages and odds ratio (OR) with 95% confidence intervals (CI). In addition, sensitivity and subgroup analyses were performed and the quality of evidence was determined according to the GRADE system.

RESULTS

The review includes 21 observational studies with patients who were treated for CLTI. Meta-analysis of 12 studies with a total of 17 118 patients was performed. A mortality rate of 32% was found in octogenarians (95% CI 27-37%), which was significantly higher than in the non-octogenarians (17%, 95% CI 11-22%/OR 2.52, 95% CI 1.93-3.29; GRADE: "low"). No significant difference in amputation rate was found (octogenarians 15%, 95% CI 11-18%; non-octogenarians 12%, 95% CI 7-14%; GRADE: "very low"). AFS was significantly lower in the octogenarian group (OR 1.55, 95% CI 1.03-2.43; GRADE: "very low"). In a subgroup analysis differentiating between endovascular and surgical revascularisation, amputation rates were comparable. For octogenarians, those treated conservatively had a mortality rate significantly higher than those treated by revascularisation (OR 1.76, 95% CI 1.19-2.60; GRADE: "very low"). No significant difference in mortality rate was found between primary amputation and revascularisation in octogenarians (OR 0.70, 95% CI 0.24-2.03; GRADE: "very low").

CONCLUSION

In octogenarians with CLTI, a substantial one year mortality rate of 32% was found after revascularisation. The amputation rates were comparable between both age groups. However, only low quality evidence could be obtained supporting the results of this meta-analysis because only observational studies were available for inclusion.

Preoperative hypoalbuminemia is associated with poor clinical outcomes after open and endovascular abdominal aortic aneurysm repair

OBJECTIVE

The effect of preoperative malnutrition on outcomes in patients undergoing major vascular surgery is unclear. We investigated the effects of preoperative hypoalbuminemia, a marker for malnutrition, on outcomes after open abdominal aortic aneurysm repair (OAR) and endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

Patients undergoing OAR or EVAR were identified in the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program database and stratified into three groups: normal albumin (serum albumin >3.5 g/dL), moderate hypoalbuminemia (2.8-3.5 g/dL), and severe hypoalbuminemia (<2.8 g/dL). Multivariable analyses were performed to assess the association of preoperative hypoalbuminemia with 30-day morbidity and mortality.

RESULTS

We identified 15,002 patients with a recorded preoperative serum albumin who underwent OAR (n = 4956) or EVAR (n = 10,046). Patients in both cohorts with hypoalbuminemia had a higher burden of comorbidity. In OAR patients, multivariable analyses demonstrated that moderate hypoalbuminemia was associated with an increased risk of 30-day mortality (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.02-1.70) and postoperative length of stay (LOS; means ratio [MR], 1.10; 95% CI, 1.04-1.16), whereas severe hypoalbuminemia was associated with increased 30-day mortality (OR, 1.92; 95% CI, 1.37-2.70), reoperation ≤30 days (OR, 1.80; 95% CI, 1.32-2.48), pulmonary complications (OR, 1.40; 95% CI, 1.06-1.86), and postoperative LOS (MR, 1.33; 95% CI, 1.21-1.45). In EVAR patients, moderate hypoalbuminemia was associated with an increased risk of 30-day mortality (OR, 1.90; 95% CI, 1.38-2.62), pulmonary complications (OR, 1.61; 95% CI, 1.26-2.04), reoperation ≤30 days (OR, 1.39; 95% CI, 1.12-1.74), and postoperative LOS (MR, 1.23; 95% CI, 1.18-1.29), whereas severe hypoalbuminemia was associated with increased 30-day mortality (OR, 2.98; 95% CI, 1.96-4.53), pulmonary complications (OR, 1.88; 95% CI, 1.32-2.67), reoperation ≤30 days (OR, 1.54; 95% CI, 1.08-2.19), and postoperative LOS (MR, 1.52; 95% CI, 1.40-1.65).

CONCLUSIONS

Preoperative hypoalbuminemia is associated with increased postoperative morbidity and mortality in a severity-dependent manner among patients undergoing OAR or EVAR. Evaluation and optimization of nutritional status should be performed preoperatively in this high-risk population.