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Editor's Choice - Mortality and Major Amputation after Revascularisation in Octogenarians Versus Non-Octogenarians
Lina F Wübbeke1, Caroline C L M Naves2, Jan-Willem H C Daemen1
1Department of Vascular Surgery, Maastricht University Medical Centre, the Netherlands.
Insights
Octogenarians with chronic limb threatening ischemia (CLTI) undergoing revascularisation have a 32% one-year mortality rate. While amputation rates were similar to younger patients, survival outcomes were worse, highlighting the need for careful consideration of treatment options.
Area of Science:
- Vascular Surgery
- Geriatric Medicine
- Clinical Outcomes Research
Background:
- Chronic limb threatening ischemia (CLTI) poses significant risks, particularly in elderly populations.
- Octogenarians represent a growing demographic facing complex vascular challenges.
- Revascularisation is a key treatment modality for CLTI, but outcomes in the oldest patients require detailed assessment.
Purpose of the Study:
- To systematically review and meta-analyze clinical outcomes following revascularisation in octogenarians with CLTI.
- To compare mortality, amputation rates, and amputation-free survival (AFS) between octogenarians and non-octogenarians.
- To evaluate the impact of different revascularisation strategies and conservative management in this elderly cohort.
Main Methods:
- Systematic review and meta-analysis of Medline, Embase, and Cochrane Library databases.
- Inclusion of 21 observational studies, with meta-analysis performed on 12 studies (17,118 patients).
- Analysis of one-year mortality, major amputation, and AFS, with GRADE assessment for evidence quality.
Main Results:
- One-year mortality in octogenarians was 32%, significantly higher than non-octogenarians (17%).
- Amputation rates were comparable between octogenarians (15%) and non-octogenarians (12%).
- Amputation-free survival was significantly lower in octogenarians; conservative treatment showed higher mortality than revascularisation.
Conclusions:
- Revascularisation in octogenarians with CLTI is associated with a substantial one-year mortality rate of 32%.
- Amputation rates are similar across age groups, but overall survival is compromised in the oldest patients.
- The findings are based on low-quality evidence from observational studies, necessitating further high-quality research.
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.
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