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Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age
Tanner I Kim1, Edouard Aboian1, Uwe Fischer1
1Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
Background:
Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups.
Methods:
Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50 years old), 51-84 years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed.
Results:
There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84 years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84 years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P < 0.001), while perioperative and 1-year mortality increased with age (P < 0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR = 1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84 years old (OR = 0.61 [0.51-0.73]).
Conclusions:
Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.
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Jugular Venous Pressure (JVP) Measurement
Position the patient at a thirty- to forty-five-degree angle or in a semi-fowler's position. Look for the highest point of pulsation in the internal jugular vein and measure the vertical distance to the angle of Loius or sternal angle. A normal JVP is 3-4 cm above...