title: Revascularization for chronic critical lower limb ischemia in octogenarians is worthwhile.
abstract: OBJECTIVE
  Advanced age is considered a relative contraindication for surgical revascularization in patients with peripheral arterial occlusive disease. Our aim was to analyze the usefulness of endovascular and surgical revascularization in patients older than 80 years with chronic critical leg ischemia (CLI). Our hypothesis was that the clinical benefit of lower extremity revascularization is limited in octogenarians.
  
  
  METHODS
  This was a prospective cohort study with a 1-year follow-up. Subjects included a consecutive series (January 1999 to June 2004) of patients presenting with CLI. Revascularization cohorts were either open surgical or endovascular with conservatively treated patients as a reference group. Prospective follow-up occurred after 30 days and 2, 6, and 12 months. The primary end point was sustained clinical success, defined as a categorical upward shift in clinical symptoms according to Rutherford, without major amputation and without the need for repeated target extremity revascularization (TER). Secondary clinical success was defined accordingly, including repeated TER. Mortality, major amputation, and TER were separately calculated end points. All results were stratified for age categories of nonoctogenarians (<80 years) and octogenarians (> or =80 years). Cumulative outcome was determined by the Kaplan-Meier method, and differences were assessed by log-rank tests. Multivariable analysis was performed by using Cox proportional regression.
  
  
  RESULTS
  A total of 376 patients (158 women; mean age, 75.8 +/- 10.7 years) with 416 critically ischemic limbs were analyzed. Overall, 150 patients (39.9%) were older than 80 years, and 85 limbs were treated surgically (26 octogenarians; 30.6%), 207 limbs (96 octogenarians; 46.4%) were treated by endovascular means, and 124 limbs (45 octogenarians; 36.3%) were treated conservatively, including delayed revascularization procedures. Both sustained and secondary clinical success rates, as well as limb salvage rates, were higher in the revascularization cohorts as compared with conservatively treated patients, regardless of age category (P < .001, P < .001, and P = .006, respectively, by Cox proportional hazard model). Mortality was significantly higher in octogenarians (P = .006 by Cox proportional hazard model), particularly within 30 days after surgical revascularization (hazard ratio, 5.35; 95% confidence interval, 1.15-24.9). Patient age category did not affect the rate of major amputations or TER.
  
  
  CONCLUSIONS
  Individually tailored revascularization improves the outcome of CLI in octogenarians as well as in nonoctogenarians; even so, endovascular revascularization should be preferred in octogenarians because of the higher mortality associated with surgery.
authors.affiliation: Division of Clinical and Interventional Angiology, Swiss Cardiovascular Centre, University Hospital, Bern, Switzerland.
authors.forename: Philippe
authors.initials: P
authors.lastname: Brosi
authors.forename: Florian
authors.initials: F
authors.lastname: Dick
authors.forename: Dai Do
authors.initials: DD
authors.lastname: Do
authors.forename: Juerg
authors.initials: J
authors.lastname: Schmidli
authors.forename: Iris
authors.initials: I
authors.lastname: Baumgartner
authors.forename: Nicolas
authors.initials: N
authors.lastname: Diehm
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D017130:Angioplasty / Q000401:mortality; D016638:Critical Illness; D005260:Female; D005500:Follow-Up Studies; D006299:Health Services for the Aged; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D018579:Patient Selection; D016016:Proportional Hazards Models; D011446:Prospective Studies; D020127:Recovery of Function; D012086:Reoperation; D012107:Research Design; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000401:mortality