Navigating treatment decisions for CLTI in older adults: Primary amputation vs revascularization

As the world's elderly population continues to grow, the proportion of people living with chronic medical conditions is also increasing. Cardiovascular diseases including hypertension, diabetes, and atherosclerosis are among the most common, and as a result peripheral artery disease (PAD) is increasingly prevalent in this population. It is estimated that 15% to 20% of the elderly population has been diagnosed with PAD, and consequentially there is also a large proportion who have progressed to chronic limb threatening ischemia (CLTI). The management of this end stage of PAD is complex regardless of age, as there is high variability in current practice patterns and a lack of consensus on endovascular or surgical bypass as the initial treatment modality. The treatment paradigm becomes even more complicated in the elderly population, and special considerations must be given to treatment including the decision to offer revascularization (surgical or endovascular) vs primary amputation. This article explores the risks and benefits of the 2 approaches in the context of mortality, quality of life, and cost in the elderly population. Although there is good evidence that revascularization confers benefits in mortality, quality of life, and cost, there are also data that indicate that this approach should only be offered to fully independent individuals as outcomes in those with a nonambulatory status preoperatively are poor. Overall, the authors advocate for a patient-centered, multidisciplinary approach to treating CLTI in this population that focuses first and foremost on patient goals.