Frailty is Not Associated with WorseOutcomes following Lower ExtremityAngiograms for Limb Ischemia inNonagenarians
Jaclyn DeRieux, Dina Obed, Arianne Johnson, Michael J. Paisley, Michelle Wang, and
Kevin M. Casey, Santa Barbara, California, and Portland, Oregon
Background: Endovascular interventions are performed routinely with minimal risk in younger
populations. The safety and efficacy of endovascular interventions in nonagenarians is under
examined. We sought to examine the following (1) mortality and limb salvage rates in the nonagenarian population and (2) whether frailty was associated with outcomes following lower extremity (LE) interventions for both acute limb ischemia (ALI) and chronic limb threatening
ischemia (CLTI).
Methods: A retrospective review of patients 90 years who underwent a LE angiogram for ALI
or CLTI over a 12-year period at a single institution was performed. Primary outcomes were 30-day and 12-month limb salvage and mortality rates. Patient demographics, 30-day complications, and 12-month target vessel reintervention (TVR) were reviewed. Frailty scores were
calculated using the 11-factor modified frailty index (MFI-11).
Results: From 2009 to 2021, 76 patients (36% male) with a mean age of 93 (range: 90e102)
underwent endovascular procedures for ALI (n ¼ 13) and CLTI (n ¼ 63). 30-day amputation and
mortality rates were 6% and 8%, respectively. Patient demographics, preoperative functional
status, and TVR rates were not different between patients who had early amputation
( 30 days) and those who achieved limb salvage. Seventy-two patients (94%) had follow-up
data at 30 days. There was an 8% mortality rate at 30 days. Of those alive at 30 days, 94%
of patients had successful limb salvage. Fifty-eight patients had complete follow-up data at
12 months. Of the patients alive at 12-month follow-up (75%), the limb salvage rate was 98%.
Patients with amputation at 30 days had a significantly higher mortality rate at 12 months
compared to those who did not (83% vs. 19%; P < 0.01). Based on MFI-11 scoring, 35% of
the population was considered frail ( 0.27). Frail patients did not have significantly different
30-day outcomes (limb salvage: 94% vs. 88%; mortality 8% vs. 9%, P¼ 0.41 and 0.94, respectively) or 12-month outcomes (limb salvage: 82% vs. 94%; mortality: 32% vs. 22%, P¼ 0.28 and 0.39, respectively).
Conclusions: Endovascular procedures can be done safely in nonagenarians with low mortality and amputation rates. Patients with early amputation are at significantly higher risk of death at
12 months. Frailty, as measured by a validated index, was not associated with early or late outcomes. When compared to immediate amputation, nonagenarian patients and their families
should be counseled as to the benefit from a minimally invasive endovascular procedure.
INTRODUCTION
Endovascular procedures are frequently performed in patients for peripheral arterial disease (PAD) with good results and at minimal risk to most patients. However, there is a paucity of data examining the safety and efficacy of lower extremity (LE) angiograms for limb ischemia in the elderly.1e5 Frailty indices have been employed with increasing frequency in an attempt to assist physicians with risk stratification and to predict outcomes for patients prior to surgical procedures. Although more prevalent in the general surgery literature, several frailty indices have been studied in patients undergoing vascular procedures. The 11-factor modified frailty index (MFI-11) has been validated as a tool to evaluate frailty and stratify a vascular patient’s risk; however, nonagenarian patients are largely excluded from these studies and some of the studies are broad in their application to patients beyond limb ischemia.
This is increasingly relevant for the treatment of PAD as the population of the United States ages,
particularly in geographic areas in which the elderly population has a more robust functional
status than the national average. The relationship between frailty score and postoperative outcomes following LE vascular interventions has been investigated. Outcomes following LE bypass procedures suggest that frailty is predictive of postoperative outcomes. However, few studies have examined whether frailty is associated with worse outcomes following endovascular procedures. Given that the elderly would appear to be a high-risk population, it follows that any intervention in this cohort would be considered high-risk as well. The additional challenge of treating patients with limb ischemia makes such a prediction even more poignant. Examining which of these patients may safely undergo an intervention is of particular interest to vascular
surgeons and patients wishing to make informed decisions regarding their care.
The goal of this study was to examine nonagenarian patient outcomes following LE endovascular
procedures performed for limb ischemia at a single institution. The relationship between frailty and patient outcomes was also studied.
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