title: Complex infrapopliteal revascularization in elderly patients with critical limb ischemia: impact of multidisciplinary integrated care on mid-term outcome.
abstract: 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.
authors.affiliation: Department of Vascular and Endovascular Surgery, Guy's St. Thomas' NHS Foundation Trust, London, UK - luklabiasi@gmail.com.
authors.forename: Lukla
authors.initials: L
authors.lastname: Biasi
authors.affiliation: Department of Vascular and Endovascular Surgery, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Sanjay D
authors.initials: SD
authors.lastname: Patel
authors.affiliation: Department of Vascular and Endovascular Surgery, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Talia
authors.initials: T
authors.lastname: Lea
authors.affiliation: Department of Vascular and Endovascular Surgery, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Donati
authors.affiliation: Department of Radiology, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Katsanos
authors.affiliation: Department of Ageing and Health, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Judith S
authors.initials: JS
authors.lastname: Partridge
authors.affiliation: Department of Ageing and Health, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Jugdeep K
authors.initials: JK
authors.lastname: Dhesi
authors.affiliation: Department of Vascular and Endovascular Surgery, Guy's St. Thomas' NHS Foundation Trust, London, UK.
authors.forename: Hany
authors.initials: H
authors.lastname: Zayed
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D017130:Angioplasty / Q000009:adverse effects / Q000401:mortality; D016208:Databases, Factual; D018572:Disease-Free Survival; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008131:London; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000009:adverse effects / Q000401:mortality; D014654:Vascular Patency