Treatment for critical lower limb ischemia in elderly patients

Critical limb ischemia (CLI) has a poor outcome when left untreated. The benefits of revascularization in the very elderly might be limited because of co-morbidities and short life expectancy. Therefore, optimal management of CLI in the elderly is not straightforward. We analyzed treatment results for elderly patients with CLI (Rutherford 4 or 5/6) in our clinic.

Hospital charts of all patients>70 years of age diagnosed with Rutherford stage 4-6 peripheral arterial disease between January 2006 and December 2009 were reviewed. We divided patients into two age groups (70-79 and ≥80 years) to compare treatment results. Primary interventions were defined as conservative, endovascular, reconstructive surgery, and amputation. Outcome measures were mortality, reintervention, and major amputation rates.

There were 191 patients [99 (52%) were women], median age 78.4 years, range 70-98 years. Altogether, 119 (62%) patients were aged 70-79 years, and 72 (38%) were ≥80 years. The primary intervention was equally divided over the two age groups (p=0.21). Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC II) classifications of aortoiliac lesions were not significantly different regarding intervention (p=0.62) or age (p=0.39). TASC II classification of femoropopliteal lesions was significantly different relative to intervention (p<0.01) but not different between age groups (p=0.68). Mortality rate after reconstructive surgery was significant higher in the oldest age group (p<0.01). After conservative treatment, endovascular treatment, or amputation, the mortality rates were not significantly different between the two age groups (respectively, p=0.06, p=0.33, p=0.76). Reintervention rate was 51% in the 70- to 79-year group compared to 32% in the ≥80-year group. After initial treatment, major amputations were performed in 10% in the 70- to 79-year group compared to 13% in the ≥80-year group.

In patients aged≥80 years, surgical revascularization resulted in a significant higher mortality rate in our clinic, whereas primary conservative, endovascular treatment and amputation resulted in similar mortality in both age groups. When considering surgical revascularization in the very elderly, surgeons should focus on careful patient selection.