Outcomes of Open and Endovascular Interventions in Octogenarians with Infrainguinal Chronic Limb-Threatening Ischemia

Despite prior studies showing that lower extremity revascularization in the elderly population could be performed safely, there continues to be significant debate regarding the outcomes in octogenarians with chronic limb-threatening ischemia (CLTI). The choice between bypass and endovascular therapy (ET) in this population is controversial. This study aimed to examine outcomes of bypass and ET in octogenarians presenting with CLTI using the Vascular Quality Initiative (VQI) database.

The VQI database was queried for all patients with infrainguinal CLTI that received bypass or ET between 2016 and 2023. Two cohorts, octogenarians (80-89 years old) and non-octogenarians (51 to 79 years old) were compared. Three types of revascularizations were compared within the age categories: bypass with a single-segment great saphenous vein (SSGSV), bypass with an alternative conduit (AC), and ET. Primary outcomes included postoperative myocardial infarction (MI) and 30-day mortality. Secondary outcomes included one-year rates of death, major amputation and major amputation/death. Multivariate logistic regression model was used for MI and 30-day mortality. Kaplan Meier survival and time-varying Cox regression analyses were used for one-year outcomes.

Data from a total of 134,808 limbs and 91,938 patients were analyzed (Octogenarian=25,547, 18.9%). Octogenarians had approximately two-fold higher 30-day mortality across all revascularization strategies compared to non-octogenarians. In octogenarians, the rates of SSGSV, AC, and ET were 6.3%, 7.4%, and 86.3%, respectively. After adjusting for potential confounders, ET was associated with lower odds of postoperative MI compared to SSGSV and AC bypasses, with no significant difference in 30-day mortality by revascularization type. At one year, AC bypass (aHR = 1.30 [95% CI: 1.20-1.41]; P < 0.001) and ET (aHR = 1.18 [95% CI: 1.10-1.28]; P < 0.001) were associated with higher hazards of major amputation/death compared to SSGSV bypass in octogenarians. ET had lower hazards of major amputation compared to SSGSV bypass (aHR = 0.78 [95% CI: 0.70-0.86]; P < 0.001) and AC bypass (aHR = 0.64 [95% CI: 0.57-0.70]; P < 0.001), as well as lower hazards of major amputation/death compared to AC bypass (aHR = 0.91 [95% CI: 0.85-0.97]; P = 0.004).

Octogenarians experience substantially higher perioperative mortality across all revascularization strategies. In octogenarians with CLTI, ET was the predominant approach and was associated with lower postoperative MI risk compared to bypass independent of the conduit. ET had higher hazards of combined major amputation/death compared to SSGSV bypass, driven solely by higher mortality. The higher mortality in ET may reflect these patients' higher overall risk profile. Moreover, ET was associated with lower hazards of combined major amputation/death compared to AC bypass.