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THE JOURNAL OF CARDIOVASCULAR SURGERY

A Journal on Cardiac, Vascular and Thoracic Surgery


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ORIGINAL ARTICLE  VASCULAR SECTION


The Journal of Cardiovascular Surgery 2017 October;58(5):665-73

DOI: 10.23736/S0021-9509.16.09159-X

Copyright © 2016 EDIZIONI MINERVA MEDICA

language: English

Complex infrapopliteal revascularization in elderly patients with critical limb ischemia: impact of multidisciplinary integrated care on mid-term outcome

Lukla BIASI 1 , Sanjay D. PATEL 1, Talia LEA 1, Tommaso DONATI 1, Konstantinos KATSANOS 2, Judith S. PARTRIDGE 3, Jugdeep K. DHESI 3, Hany ZAYED 1

1 Department of Vascular and Endovascular Surgery, Guy’s St. Thomas’ NHS Foundation Trust, London, UK; 2 Department of Radiology, Guy’s St. Thomas’ NHS Foundation Trust, London, UK; 3 Department of Ageing and Health, Guy’s St. Thomas’ NHS Foundation Trust, London, UK


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BACKGROUND: The incidence of critical limb ischemia (CLI) is exponentially rising among our aging population. There is a paucity of scientific evidence on best management and clinical outcome of infra-popliteal (IP) revascularizations in elderly CLI patients.
METHODS: A prospectively collected database was analyzed to identify consecutive octogenarian and nonagenarian patients who underwent IP revascularizations (bypass or angioplasty) for CLI (Rutherford 4-6) in a single center between 2010-2014. The primary end points were overall amputation-free-survival (AFS) and overall survival (OS) at 1 and 2 years. Secondary endpoints were primary, assisted-primary, secondary patency and limb-salvage (LS) rates by Kaplan-Meier analysis. Univariate and multivariate analysis was performed to find factors predicting outcome.
RESULTS: A total of 129 limbs in 120 patients were treated with IP bypass (N.=42) and endovascular (N.=87) revascularizations with a mean age of 85(±5) years. The overall primary patency, assisted-primary patency and secondary patency were 58%, 65% and 70%, respectively at 12 months and 34%, 48% and 59% at 24 months. Primary, assisted-primary and secondary patency analyzed by treatment method (endovascular vs. bypass) was 54% vs. 52%, 61% vs. 70%, 69% vs. 75% at 1 year and 21% vs. 36%, 24% vs. 62%, 31% vs. 72% at 2 years. The overall AFS at 12 and 24 months was 62% and 46% respectively; AFS was 71%-68% in the bypass group and 53-21% in the Endovascular group (P<0.001). LS was 89% at 12 months and 84% at 24 months, with no significant difference between the bypass and endovascular groups (P=0.24). The overall perioperative mortality rate was 2%. OS by Kaplan-Meier was 68% and 54% at 1 and 2 years respectively. Diabetes (P=0.046) and low eGFR (P=0.041) were predictors of worse AFS and OS, respectively.
CONCLUSIONS: IP revascularizations (either endovascular or surgical) is feasible and effective in octogenarians and nonagenarians with CLI. By adopting a patient-tailored approach, both revascularizations strategies have satisfactory technical and clinical outcomes in this high-risk group. Subgroup analysis suggests that bypass surgery may have better mid-term secondary patency and AFS rates.


KEY WORDS: Endovascular procedures - Vascular surgical procedures - Tibial arteries - Limb salvage - Survival rate - Perioperative care

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Publication History

Issue published online: July 6, 2017
Article first published online: May 19, 2016
Manuscript accepted: May 18, 2016
Manuscript revised: May 2, 2016
Manuscript received: September 30, 2015

Cite this article as

Biasi L, Patel SD, Lea T, Donati T, Katsanos K, Partridge JS, et al. Complex infrapopliteal revascularization in elderly patients with critical limb ischemia: impact of multidisciplinary integrated care on mid-term outcome. J Cardiovasc Surg 2017;58:665-73. DOI: 10.23736/S0021-9509.16.09159-X

Corresponding author e-mail

luklabiasi@gmail.com