Superior limb salvage with endovascular therapy in octogenarians with critical limb ischemia

Objective: The goal of this study is to compare our results following open and endovascular infrainguinal revascularizations in patients >= 80 and <80 years old presenting with critical limb ischemia (CLI) and to determine if limb salvage (LS) attempt is justified in patients >= 80 with CLI, especially following endovascular interventions. Methods: A retrospective analysis of 344 consecutive patients (399 limbs) who presented with CLI and underwent infrainguinal open or endovascular (EV) revascularizations between June 2001 and December 2007 was performed. Patients >= 80 (89 patients, 101 limbs) and <80 years old (255 patients, 298 limbs) were compared for demographics, characteristics, patency, limb salvage, sustained clinical success (preservation of limb, freedom from target extremity revascularization (TER), and resolution of symptoms), secondary clinical success (preservation of limb and resolution of symptoms), overall improvement (preservation of limb, improvement of symptoms), and survival. Results: Patients a:80 were more likely to be nonambulatory and have coronary artery disease, whereas those <80 were more likely to have hypertension, hyperlipidemia, dialysis-dependence, active tobacco abuse, and taking beta-blockers. Primary amputation rates were similar between two groups (<80 vs >= 80, 6.7% vs 8.1%, P = .530). Perioperative mortality was significantly worse in >= 80 group in the open-treated group (16.2% vs 2.9%, P = .009), whereas it was similar in ENT-treated patients (3.1% vs 0.6%, P = .197). The patency rates were similar between groups, however, LS was significantly better in >= 80 EV-treated patients than <80 group, whereas it was similar between groups in open-treated patients. Sustained clinical success, secondary clinical success, and overall improvement rates were similar between age groups. Endovascular-treated patients in >= 80 had significantly better overall improvement than those who were treated by open revascularization (24-month overall improvement 83% +/- 5% vs 61% +/- 9%, P = .043). Multivariate analysis showed diabetes, infrapopliteal intervention, presence of gangrene, nonambulatory status, dialysis-dependence, and runoff status being associated with limb loss whereas age being >= or <80 was not. Age, coronary artery disease, chronic obstructive pulmonary disease, nonambulatory status, and dialysis-dependence were found to be independently associated with decreased survival. Conclusions: Our results suggest that revascularization in patients >= 80 with CLI is justified, especially when an endovascular intervention can be accomplished. Although limb salvage following endovascular interventions were better in the >= 80 group, sustained clinical success, and secondary clinical success rates were similar following open and endovascular interventions in both age groups. Open procedures carry a high perioperative mortality in the >= 80 age group and should be avoided if possible. (J Vasc Surg 2009;50:305-16.)