Superior limb salvage with endovascular therapy in octogenarians with critical limb ischemia

Article Outline

• Abstract
• Material and methods
  • Design
  • Methodology
  • Definitions
  • Statistical analysis
• Results
• Discussion
• Conclusion
• Author contributions
• Table (online only). 
• References
• Copyright

Objective

The goal of this study is to compare our results following open and endovascular infrainguinal revascularizations in patients ≥80 and <80 years old presenting with critical limb ischemia (CLI) and to determine if limb salvage (LS) attempt is justified in patients ≥80 with CLI, especially following endovascular interventions.

Methods

A retrospective analysis of 344 consecutive patients (399 limbs) who presented with CLI and underwent infrainguinal open or endovascular (EV) revascularizations between June 2001 and December 2007 was performed. Patients ≥80 (89 patients, 101 limbs) and <80 years old (255 patients, 298 limbs) were compared for demographics, characteristics, patency, limb salvage, sustained clinical success (preservation of limb, freedom from target extremity revascularization (TER), and resolution of symptoms), secondary clinical success (preservation of limb and resolution of symptoms), overall improvement (preservation of limb, improvement of symptoms), and survival.

Results

Patients ≥80 were more likely to be nonambulatory and have coronary artery disease, whereas those <80 were more likely to have hypertension, hyperlipidemia, dialysis-dependence, active tobacco abuse, and taking beta-blockers. Primary amputation rates were similar between two groups (<80 vs ≥80, 6.7% vs 8.1%, P = .530). Perioperative mortality was significantly worse in ≥80 group in the open-treated group (16.2% vs 2.9%, P = .009), whereas it was similar in EV-treated patients (3.1% vs 0.6%, P = .197). The patency rates were similar between groups, however, LS was significantly better in ≥80 EV-treated patients than <80 group, whereas it was similar between groups in open-treated patients. Sustained clinical success, secondary clinical success, and overall improvement rates were similar between age groups. Endovascular-treated patients in ≥80 had significantly better overall improvement than those who were treated by open revascularization (24-month overall improvement 83% ± 5% vs 61% ± 9%, P = .043). Multivariate analysis showed diabetes, infrapopliteal intervention, presence of gangrene, nonambulatory status, dialysis-dependence, and runoff status being associated with limb loss whereas age being ≥ or <80 was not. Age, coronary artery disease, chronic obstructive pulmonary disease, nonambulatory status, and dialysis-dependence were found to be independently associated with decreased survival.

Conclusions

Our results suggest that revascularization in patients ≥80 with CLI is justified, especially when an endovascular intervention can be accomplished. Although limb salvage following endovascular interventions were better in the ≥80 group, sustained clinical success, and secondary clinical success rates were similar following open and endovascular interventions in both age groups. Open procedures carry a high perioperative mortality in the ≥80 age group and should be avoided if possible.

The increase in the octogenarian and nonagenarian population has resulted in an increased number of patients in this age group who present with critical limb ischemia (CLI).¹ Several studies suggest that comparable limb salvage can be achieved with bypass procedures in patients over 80,², ³, ⁴, ⁵ which may increase survival if amputation can be avoided.⁶, ⁷ However, these studies often included patients who were ambulatory or functionally independent, and the results may not be applicable to patients over 80 years of age who present with CLI and have a limited functional capacity. Morbidity and mortality is high in this elderly patient population,⁸, ⁹ while the increased use of endovascular interventions has enabled vascular surgeons to attempt limb salvage in a larger proportion of these patients.⁸, ¹⁰, ¹¹ Similar limb salvage and sustained clinical benefit was observed in a recent series of patients who underwent endovascular and open revascularizations, with both groups having better outcomes than those who were initially treated conservatively.⁸

The maintenance of functional capacity and independent living status has been suggested as important goals for the outcome of lower extremity revascularization in elderly patients, however, previous series have reported that improved functional capacity is infrequent.², ¹¹ Taylor et al¹² suggested that in patients who are unsuitable for open surgery, the advantage of angioplasty in maintenance of ambulation and independent status were lost after 12 and 3 months, respectively, compared with primary amputation. In addition, patients who were treated with angioplasty had poorer survival than the primary amputation group.

We have increasingly adopted an endovascular-first approach, whenever feasible for all patients presenting with CLI in all ages since 2002. The goal of this study is to compare our results following infrainguinal open and endovascular revascularizations in patients ≥80 and <80 years old presenting with critical limb ischemia, and to determine if limb salvage (LS) attempt is justified in patients ≥80 with CLI, especially following endovascular interventions.

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Material and methods 

Design 

All consecutive patients who presented to the Veterans' Administration Western New York Healthcare System between June 1, 2001 and December 31, 2007 with critical limb ischemia (Rutherford category 4-6)¹³ who underwent infrainguinal revascularization either by endovascular or open bypass procedures were identified, and retrospectively analyzed from our prospectively maintained database. Patients were grouped into those ≥80 or <80 years old.

Methodology 

The patients' demographics, comorbidities, clinical presentation, number of runoff vessels, preoperative functional status (ambulatory, ambulatory at home, wheelchair-bound, independent, nonambulatory transfers only, bedridden), noninvasive arterial studies, other imaging studies, details of the procedures performed, the most distal level of intervention, postoperative course, length of stay (LOS), follow-up arterial studies, and status of their limbs on last follow-up were recorded. The original TransAtlantic Society Consensus (TASC) classification of the endovascular-treated lesions¹⁴ was used until January 2007, after which TASC II classification¹⁵ was used.

All patients were seen by a member of the anesthesia department prior to any intervention scheduled in the operating room. In addition to the routine preanesthetic evaluation (including a history and physical examination), this clinic coordinates with the primary care services to medically optimize surgical patients prior to their procedures. The American Heart Association/American College of Cardiology guidelines¹⁶, ¹⁷ were used to identify the high-risk patients based on the presence or absence of major clinical predictors, functional capacity, and surgery-specific risk. Patients who met the requirements for perioperative beta blockade were administered metoprolol, which was titrated to the desired effect prior to the surgical procedure, and metoprolol was continued intra- and postoperatively. The beta-blocker protocol was more strictly adhered to after 2003. Patients were not routinely started on statins, but were continued if already started by their primary physician preoperatively.

All endovascular procedures were performed by vascular surgeons in the operating room using the OEC 9800 system (General Electric Medical Systems, Salt Lake City, Utah). The decision to proceed with endovascular intervention or open bypass was made by the vascular surgeon, with increasing complex endovascular interventions over the study period. Primary amputation was offered primarily to bedridden patients, however, revascularization was performed if the patient or family adamantly refused a major amputation, and if the patient did not have severe flexion contractures or foot sepsis. Balloon angioplasty with provisional stenting for flow-limiting dissections, or residual stenosis, and recoil of >30% was used for most interventions. Debulking procedures as an adjunct were used in a small number of patients (Excimer laser atherectomy; Spectranetics Corp, Colorado Springs, Colo, 25 patients; SilverHawk atherectomy; Foxhollow Inc, Redwood City, Calif, 8 patients).

All patients were followed by clinical assessment and by our vascular laboratory during the first postoperative visit (1-4 weeks), and at 3, 6 months, and every 6 months thereafter. All patients with open wounds were followed in vascular surgery wound clinic until wounds were healed. Angiography was performed when noninvasive studies suggested restenosis (defined as an elevated ratio of greater than three times the velocity of the more proximal normal segment) or occlusion, or adequacy of foot perfusion was in question. Reinterventions were performed for maintaining patency, or when clinically indicated. We perform reinterventions for asymptomatic restenoses both on endovascular- or open-treated patients to maintain patency, however, do not reintervene for asymptomatic occlusions. Society for Vascular Surgery (SVS) reporting standards for lower extremity arterial procedures were followed.¹³

Definitions 

Target extremity revascularization (TER) was defined as any intervention (endovascular or open) performed on the extremity to maintain assisted-primary, secondary patency, or a new revascularization (open or endovascular). Sustained clinical success was defined as clinical improvement without the need for TER and without major amputation. Clinical improvement was defined as upward shift of one Rutherford category¹³ for those with rest pain, and of two categories for those with tissue loss, in combination with hemodynamic improvement of ankle-brachial index (ABI) of at least 0.1. Secondary clinical success was defined as clinical improved with or without TER, and major amputation. We also assessed overall clinical improvement, which we defined as no need for major amputation, improving wounds with excellent pain control, and ability to maintain treatment on an outpatient basis. A patent runoff vessel was defined as an infrapopliteal vessel without a hemodynamically significant (<50%) angiographic stenosis distal to the treated site, and the number of adequately patent runoff vessels (0-3) was calculated after all interventions were completed for that limb. In-line flow was defined as reinstitution of uninterrupted flow by at least one non-diseased infrapopliteal runoff vessel (anterior tibial, posterior tibial or peroneal artery) to the foot following revascularization. If the only runoff vessel was peroneal artery, this was noted. Primary amputation was defined as a major (supramalleolar) amputation which was performed without any revascularization attempt.

Statistical analysis 

Data analysis was performed using SPSS 16.0 software (SPSS Inc, Chicago, Ill). Kaplan-Meier analysis, and log rank test were used to compare groups for sustained clinical success, secondary clinical success, overall improvement, primary patency (PP), assisted-primary patency (APP), secondary patency (SP), limb salvage (LS), and overall survival on an intent-to-treat basis. Continuous variables are given as mean ± standard deviation. Demographic comparisons were made using two-tailed Fisher exact test for categorical variables, and by two-tailed t test for continuous variables. Cox-proportional hazard model was used to estimate the risk ratio and the 95% confidence interval. The stepwise Cox-proportional hazard model was used for the multivariate analysis with the entry alpha = 0.20 and stay alpha = 0.10. All P values were two sided. All P values were considered significant if <.05. Institutional Review Board approval was obtained for the study.

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Results 

A total of 344 patients (399 limbs, 99% males) were included. There were 89 patients (101 limbs) who were ≥80 years old and 255 patients (298 limbs) who were <80 years old. Demographic and preoperative characteristics of patients are shown in Table I. Patients in the ≥80-year-old group were more likely to be nonambulatory and have coronary artery disease (CAD), whereas patients <80 years old were more likely to have hyperlipidemia, be dialysis-dependent, be an active smoker, and taking beta-blockers. Indication for intervention was not significantly different between groups (≥80 vs <80; rest pain 13% vs 20%, P = .104; non-healing ulcer 38% vs 37%, P = .906; gangrene 49% vs 43%, P = .248). There were more patients with gangrene in the endovascular-treated group (49.6% vs 37.7%, P = .02), whereas non-healing ulcers was similar (36.0% vs 37.9%, P = 1.0). In the open group, patients ≥80 were more likely to have gangrene (51.4% vs 34.1%, P = .059), whereas presence of gangrene was similar in endovascular-treated patients (50.0% vs 48.4%, ≥80 vs <80, P = .883).

Table I. Demographics, comorbidities, and clinical presentation in patients

CAD, Coronary artery disease; DM, diabetes mellitus; CVD, cerebrovascular disease; HTN, hypertension; COPD, chronic obstructive pulmonary disease; CRI, chronic renal insufficiency; ESRD, end-stage renal disease on dialysis.

The procedures performed in each group are listed in Table II. Although more patients in <80 group had open procedures, this was not statistically significant (36.6% vs 46.3%, ≥80 vs <80; P = .104). The percentage of patients having infrapopliteal interventions were similar between age groups (55.4% vs 48.3%, ≥80 vs <80; P = .131). In the open group, infrapopliteal revascularizations were marginally more frequent in ≥80 group (79.6% vs 57.2%, P = .057) whereas there was no difference in endovascular group (≥80 vs <80; 43.8% vs 40.6%, P = .764). In the ≥80 group who had infragenicular bypasses, 62% were performed using prosthetic grafts, whereas this was 46% in the <80 group (P = .157). The reason for not using autologous grafts were either due to unavailability or small size (<3 mm) of the available veins. The distribution of the TASC classification of the endovascular-treated patients was similar between two age groups. In ≥80 group, 13% had TASC A, 5% had TASC B, 27% had TASC C, and 55% had TASC D lesions, whereas these were 6%, 12%, 30%, and 52% in <80 group, respectively (P = .589).

Table II. Operations performed in groups

	≥80	<80
Open:
Femoral-AK popliteal bypass	3	26
(with iliac PTA/stent)		(6)
Femoral-BK popliteal bypass	4	26
(with iliac PTA/stent)		(6)
Fem-distal bypass	28	79
(with iliac/SFA PTA/stent)	(4)	(8)
Femoral endarterectomy	2	7
(with iliac/SFA PTA/stent)		(4)
Total	37	138
Endovascular:
Femoropopliteal
PTA/S	36	94
(with iliac stent)	(3)	(18)
(unsuccessful)	(2)	(2)
Foxhollow		1
Total	36	95
Infrapopliteal
PTA/S	22	44
(with SFA stent)	(9)	(16)
(with iliac stent)		(4)
(unsuccessful)		(1)
Foxhollow		4
(with SFA stent)		(1)
Excimer	6	17
(with SFA stent)	(4)	(6)
Total	28	65
Overall total	64	160

AK, Above-knee; BK, below-knee; SFA, superficial femoral artery; PTA/S, percutaneous luminal angioplasty/stenting.

Technical success was 97.7% and inline flow to the foot was achieved in 93.1% in ≥80 group, and 96.6% in <80 group (P = 1.0). Peroneal artery was the only runoff vessel in 43.6% in ≥80 group and 22.1% in <80 group (P < .001). Inline flow was established in 97.1% in open-treated patients and 94.6% in endovascular-treated patients (P = .318), and the runoff vessel was peroneal artery in 28.0% in open-treated patients and 27.2% in endovascular-treated patients (P = .910). The in-line flow to the foot and runoff status in endovascular and open revascularized patients in different age groups are shown in Table III. The number of patent runoff vessels were significantly more (P < .001) in <80 group for both open- and endovascular-treated patients.

Table III. Runoff status at the end of revascularization procedures in groups

	≥80 group	<80 group	P value
All patients
In-line flow	93.1%	96.6%	.152
Peroneal-only runoff	43.6%	22.1%	<.001
Number of runoff vessels	1.2±0.6	1.5±0.8	<.001
Endovascular-treated patients
In-line flow	90.1%	96.3%	.106
Peroneal-only runoff	43.8%	20.6%	.001
Number of runoff vessels	1.2±0.6	1.7±0.8	<.001
Open-treated patients
In-line flow	97.3%	97.1%	1.0
Peroneal-only runoff	43.2%	23.9%	.024
Number of runoff vessels	1.1±0.4	1.4±0.7	.019

The ABI was reliable in only 68% of patients. The ipsilateral ABI increased from 0.43 ± 0.28 to 0.82 ± 0.21 in ≥80 group, and 0.41 ± 0.25 to 0.88 ± 0.16 in <80 group. The preoperative ABI was similar (P = .575) in both age groups, however, postoperative ABI was significantly higher in <80 group (P = .027). The postoperative ABI was significantly lower in ≥80 patients than <80 group who underwent endovascular interventions (0.80 ± 0.23 vs 0.92 ± 0.14, P = .001), whereas they were similar after open revascularizations (0.84 ± 0.19 vs 0.84 ± 0.18, P = .960) in both age groups.

The LOS was similar between groups (≥80 vs <80 age groups, 8.1 ± 10.6 vs 7.8 ± 10.3, P = .840). As expected, LOS was significantly less in patents who underwent endovascular interventions (10.9 ± 11.5 vs 5.5 ± 8.6, P < .001), with no difference between age groups in either treatment modality.

Postoperative complications are listed in Table IV. Any complication or death was significantly more in ≥80 group (19.8% vs 10.1%, P = .015), both in the endovascular-treated patients (≥80 vs <80, 10.9% vs 2.5%, P = .014), and open-treated patients (35.1% vs 18.8%, P = .045). Infectious complications (superficial and deep wound infections, pneumonia) were limited to open-treated patients and were similar between groups (≥80 vs <80, 5.4% vs 11.6%, P = .370). Postoperative major amputation rates were similar between groups (2.0% vs 3.0%, P = .737), with no difference between subgroups. Postoperative mortality was similar between age groups in endovascular-treated patients (≥80 vs <80, 3.1% vs 0.6%, P = .197), however, there was a significantly higher mortality among patients ≥80 who underwent open revascularizations (16.2% vs 2.9%, P = .007).

Table IV. Perioperative (30-day) complications after revascularizations

	≥80 group		<80 group
	EV (%)	Open (%)	EV (%)	Open (%)
Non-fatal MI	2(3.1)	1(2.7)	0	2(1.4)
Pneumonia	0	1(2.7)	0	1(0.7)
Bleeding	0	1(2.7)	1(0.6)	2(1.4)
Infection superficial	0	1(2.7)	0	11(8.0)
Infection deep	0	0	0	3(2.2)
Pseudoaneurysm	1(1.6)	0	1(0.6)	0
Limb ischemia (early graft/stent occlusion)	1(1.6)	3(8.1)	1(0.6)	2(1.4)
Bowel obstruction	0	0	0	1(0.7)
Stroke	1(1.6)	0	0	0
Death	2(3.1)	6(16.2)	1(0.6)	4(2.9)

EV, Endovascular; MI, myocardial infarction.

There were 13 30-day mortalities in this series; eight in ≥80 group and five in <80 group. Nine of these were in the open group (six in ≥80 group), and four underwent endovascular interventions (two in ≥80 group). There was only one bedridden patient (aged 81) in this group, who died on day 29 in a nursing home after an endovascular intervention for gangrene of his great toe. Additional four patients were nonambulatory (transfer only), three of whom were ≥80 (two had bypass, one had endovascular intervention).

Five of the eight patients who died in the ≥80 group were not on beta-blockers (due to severe chronic obstructive pulmonary disease [COPD]), and four of them were not on statins. Five of the eight mortalities were due to myocardial infarctions between 2 to 7 days after the index procedure. Two of the remaining patients died of pneumonia and one from an unknown cause on 18th postoperative day in the nursing home.

Significantly more patients came from home in <80 group than ≥80 group (78% vs 65%, P = .018). Only 34% of the ≥80 group was discharged to home, 29% were sent back to a nursing home, 30% were sent to rehabilitation centers, and 8% died in the hospital. In the <80 group, 59% were sent home, 18% were sent to nursing homes, 23% were sent to rehabilitation centers, and 1% died in the hospital. At last follow-up (mean 20.7 ± 18.5 months), 51% of ≥80 group who survived past 30 days were at home, 43% were in nursing homes, 4% were in hospice, and 2% died while still in hospital beyond 30 days. In the ≥80, 9% patients who initially came from home eventually ended up in nursing homes, 3% were sent to hospice, and only one patient (1%) who was in a nursing home eventually went back to independent living at home.

Ambulatory status of patients in both age groups before the intervention and during last follow-up is shown on Table V. There were more patients who were preoperatively nonambulatory in the ≥80 group, whereas there were more patients who were wheelchair-bound but independent in the <80 group. There were no significant differences in ambulatory status at last follow-up in the ≥80 group, whereas there were more patients who became wheelchair-bound in the <80 group (26% vs 15%, P = .079). Although the percentage of patients who were ambulatory were similar in ≥80 and <80 groups (56% vs 60%), nonambulatory patients were still more in the ≥80 group. In the ≥80 group, four patients who were ambulatory preoperatively became either wheelchair-bound, or bedridden. On the contrary, one patient who was transfer-only became ambulatory with assistive device, and 12 patients had significant improvement in their ambulatory status, and became ambulatory outside the house. The remaining patients stayed at their preoperative ambulatory status. Of note, 11 of the 15 patients who were bedridden and underwent revascularization had endovascular interventions, and only one died perioperatively, and eight did not undergo an amputation, however, 1-year survival was only 33% in this patient population.

Table V. Ambulatory status of patients in both age groups before the intervention, and during last follow-up

The mean follow-up was 25.0 ± 19.2 months. There was no difference in patency rates between age groups. The 12-month and 24-month primary patency rates for endovascular-treated patients were 78% ± 6% and 78% ± 6% for ≥80, and 73% ± 4% and 59% ± 5% for <80 group patients (P = .192), secondary patency rates were 91% ± 4% and 87% ± 6% for ≥80, and 88% ± 3% and 86% ± 3% for <80 (P = .902). The 12-month and 24-month primary patency rates for open-treated patients were 64% ± 9.6% and 39% ± 11% for ≥80, and 68% ± 4% and 63% ± 5% for <80 group patients (P = .167), secondary patency rates were 74% ± 9% and 56% ± 11% for ≥80, and 75% ± 4% and 71% ± 4% for <80 (P = .395). Although the primary patency rates were similar between open and endovascular-treated patients in <80 group (P = .714), this was significantly better in ≥80 group (P = .011). The secondary patency rates were significantly better for endovascular-treated patients than open-treated patients, which remained significant in both age groups (P = .005 for <80, P = .027 for ≥80 groups).

Primary amputation rates were similar during the study period (<80 vs ≥80, 6.7% vs 8.1%, P = .530). Limb salvage rates in open-treated patients were similar in ≥80 and <80 age groups (12-month and 24-month LS rates, 77% ± 9% and 61% ± 11% vs 81% ± 4% and 76% ± 4%, P = .405, Fig 1), whereas the LS rate in ≥80 group was significantly better than <80 group in endovascular-treated patients (12- and 24-month LS rates, 93% ± 3% and 93% ± 3% vs 82% ± 3% and 77% ± 4%, P = .015, Fig 2). When the dialysis patients were excluded, the LS rates in the endovascular-treated patients were still better in the ≥80 than <80 group (24-month LS 93% ± 3% vs 80% ± 4%, P = .041), whereas they were still similar in open-treated patients (12-month LS 77% ± 9% vs 83% ± 4%, P = .274). Incidentally, the LS rates in infrageniculate bypasses using autologous vein grafts were only marginally better than those performed using synthetic grafts (24-month LS 80% ± 5% vs 62% ± 7%, P = .084), with no difference between age groups. Multilevel interventions did not have a significant impact on LS rates in both age groups (data not shown).

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• Fig 1. 

  Limb salvage following open revascularizations in ≥80 and <80 age groups. The number of patients at risk at each time interval is shown below the figure. Hashed line indicates standard error >10%.

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• Fig 2. 

  Limb salvage following endovascular interventions in ≥80 and <80 age groups. The number of patients at risk at each time interval is shown below the figure.

Freedom from TER was similar between age groups (P = .829) and between endovascular- and open-treated patients in the <80 group (P = .538), however, freedom from TER was significantly better among endovascular-treated patients than open-treated patients in ≥80 group (24-month freedom from TER 85% ± 5% vs 54% ± 11.5%, P = .007). In the endovascular group, freedom from TER was marginally better in ≥80, than <80 patients (24-month 85% ± 5% vs 66% ± 5%, P = .108). The sustained clinical success rates, secondary clinical success rates, and overall improvement rates were also similar between age groups (Table VI). However, ≥80 endovascular group had significantly better overall improvement than those who were treated by open revascularization (24-month overall improvement 83% ± 5% vs 56% ± 9%, P = .023). There were no significant differences between treatment groups among <80 patients.

Table VI. Sustained clinical success (SusCS), secondary clinical success (SecCS), overall clinical improvement (OCI), and freedom from target extremity revascularization (f-TER) in patients ≥80 and <80 who underwent endovascular (EV) or open interventions

	SusCS		SecCS		OCI		f-TER
	12 mo	24 mo	12 mo	24 mo	12 mo	24 mo	12 mo	24 mo
≥80 EV (n = 64)	61%±6%	61%±6%	73%±6%	73%±6%	83%±5%	83%±5%	85%±5%	85%±5%
<80 EV (n = 160)	59%±4%	49%±5%	69%±4%	67%±4%	79%±3%	76%±4%	80%±4%	66%±5%
P value		.265		.274		.314		.108
≥80 Open (n = 37)	52%±9%	38%±9.7%	66%±8%	57%±9%	66%±8%	56%±9%	67±9.5%	54%±11.5%
<80 Open (n = 138)	63%±4%	58%±5%	76%±4%	71%±4%	78%±4%	74%±4%	78±4%	75%±4%
P value		.111		.219		.086		.079

In patients who had infrageniculate interventions (n = 231), the LS was marginally better in patients who had bypass using autologous vein grafts than other grafts (P = .084), but it was not different from endovascular-treated patients (P = .233). However, TER (P = .03), sustained clinical success (P = .002), secondary clinical success (P = .002), and overall improvement (P = .03) were significantly better in those who had bypasses with autologous veins than those who had bypasses using other grafts or endovascular interventions (Table VII, online only). However, in the ≥80 group, LS was marginally better in those who had endovascular interventions than those who had bypasses with either autologous vein grafts or synthetic grafts (P = .134). However, sustained clinical success rate was similar between endovascular and autologous vein graft group, both of which were better than prosthetic bypass group (P = .049), which was also similar for both secondary clinical success rates (P = .075) and overall clinical improvement rates (P = .005). The patients in the younger age group had the best results with autologous vein grafts (Table VII, online only). When we compared the age groups, the only difference was in the endovascular-treated patients, in whom the ≥80 group had better LS rates (P = .02), freedom from TER (P = .087), sustained clinical success (P = .037), secondary clinical success (P = .022), and overall clinical success rates (P = .012) than those in the <80 group, whereas these rates were similar in patients treated with autologous vein or synthetic grafts (P > 0.12 for all) (Table VII, online only).

There were four amputations in patients ≥80 who had endovascular revascularizations (n = 64), two within 30 days, one after 1 month, and one at 3 months following the intervention. Three patients had patent endovascular-treated segments, but amputation was necessary due to infections leading to extensive tissue loss. The fourth patient presented with occlusion of the popliteal artery, resulting in irreversible ischemia and amputation. One patient had failed revascularization, refused further interventions, and died at 3 months with rest pain. There were nine amputations (24%) in the ≥80 group who had open revascularizations (n = 37). Five were in patients who had femoral-distal bypasses using polytetrafluoroethylene (PTFE) grafts (one was patent), three had great saphenous vein (GSV) bypasses (one was patent), and one who underwent femoral endarterectomy for rest pain, developed foot infection and had an amputation 24 months after the initial procedure.

The overall survival was significantly worse in ≥80 group, with no difference between endovascular- and open-treated patients. The 12-month, 36-month, and 60-month survival rates were 57% ± 5%, 37% ± 6%, and 29% ± 7% for ≥80 group, and 77% ± 2%, 56% ± 3%, and 39% ± 4% for <80 group (P <.001). The survival in ≥80 patients who survived the open revascularization was similar to those <80 years old (12-month and 36-month survival, 65% ± 9% and 40% ± 9.6% in ≥80, vs 78% ± 4% and 59% ± 5% in <80, P = .120). The survival remained significantly worse in endovascular-treated ≥80 patients who survived the intervention (12-month and 36-month survival, 61% ± 6% and 40% ± 8% in ≥80, vs 79% ± 3% and 54% ± 5% in <80, P = .019).

Univariate analysis showed diabetes, dialysis-dependence, gangrene, level of intervention being infrapopliteal, nonambulatory status, number of runoff vessels, and COPD being associated with poorer LS rates (Table VIII). However, on multivariate analysis, only diabetes, infrapopliteal interventions, nonambulatory status, dialysis-dependence, presence of gangrene, and number of runoff were found to be associated with limb loss (Table IX), but not age ≥80, COPD, and peroneal-artery-only runoff.

Table VIII. Univariate analysis (Cox regression) for limb salvage

CAD, Coronary artery disease; DM, diabetes mellitus; CVD, cerebrovascular disease; HTN, hypertension; COPD, chronic obstructive pulmonary disease.

Table IX. Multivariate analysis (stepwise Cox regression) for limb salvage

DM, Diabetes mellitus.

Mortality during follow-up was associated with advanced age, nonambulatory status, CAD, diabetes mellitus (DM) , COPD, dialysis-dependence, and presence of gangrene on univariate analysis (Table X), however, multivariate analysis showed age >80, CAD, COPD, nonambulatory status, and dialysis-dependence being independently associated with poorer survival (Table XI), whereas DM, CVD, presence of gangrene, level of most distal intervention, and type of intervention were not.

Table X. Univariate analysis (Cox regression) for survival

CAD, Coronary artery disease; DM, diabetes mellitus; CVD, cerebrovascular disease; HTN, hypertension; COPD, chronic obstructive pulmonary disease.

Table XI. Multivariate analysis (stepwise Cox regression) for survival

CAD, Coronary artery disease; DM, diabetes mellitus; COPD, chronic obstructive pulmonary disease.

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Discussion 

The oldest old (≥80) is the fastest growing component of the world's population, and the United States was estimated to have had approximately 13% (9.2 million people) of the world's over 80 population in 2001.¹⁸ This naturally resulted in more elderly patients being treated for CLI by vascular surgeons and is now a relatively common problem in a modern vascular surgery practice.

Major amputation in the elderly is associated with increased overall morbidity and mortality² and worse outcome compared with younger patients.¹⁹ Also, the costs associated with major amputation was estimated to be higher than the cost for a successful revascularization.²⁰, ²¹ Open reconstructions have acceptable outcomes in good risk patients over 80,², ³, ⁴, ⁵ compared with younger patients, however, postoperative morbidity and mortality remains significant, ranging from 2% to 20%. Reports of lower mortality rates often favored patients who were ambulatory, independent, and lower surgical risk than those reporting higher mortality rates. Plecha et al⁹ reported 9% mortality in patients ≥80 undergoing infrainguinal reconstruction for claudication or CLI, and the 30-day mortality for patients having femoro-femoral bypass was 19%. Brosi et al⁸ reported 20% 30-day mortality in a consecutive patient series, which was significantly higher than the 1.9% in those <80 years old. In another study by Pomposelli et al,² the 30-day mortality was 2.3%, however, 96% of the patients had independent living status, and 92% were ambulatory preoperatively. Our 30-day mortality in patients ≥80 who underwent open bypass procedures was 16.2%, which was significantly higher than the 2.9% in those <80, and than the 3.1% in those who underwent endovascular interventions in the same age group. However, it was similar to the mortality reported by Brosi et al,⁸ who included both low- and high-risk patients in their study. Increased perioperative usage of beta-blockers²², ²³ and statins²⁴, ²⁵ may potentially play an even more important role in the octogenarian population as the mortality associated with these procedures seems excessive in our experience.

We have adopted an endovascular-first approach to our patients presenting with CLI, and noted a decrease in the primary amputation rate and overall limb salvage, without a significant impact on survival.²⁶ This is similar to other groups, and is pertinent to older patients, since endovascular interventions have been associated with less cardiovascular morbidity, lower infection rates, and a shorter length of stay.²⁷, ²⁸ We found that in the ≥80 group, patients who underwent endovascular revascularization for the treatment of CLI had a significantly lower mortality rate at 3.1%, similar to the previously reported 2% to 12%.², ³, ⁴, ⁸, ¹⁰

The limb salvage rates in open treatment groups were similar between the two age groups, however, the LS rate was significantly better in the ≥80 group who had endovascular revascularizations than those <80 years, which remained valid even when dialysis patients in the <80 group were excluded. To our knowledge, this is the first study reporting superior LS rates in octogenarians than nonoctogenarians with endovascular interventions. Although there was likely a significant selection bias for the type of revascularization in this study, it is hard to explain this difference based only on this bias. When we compared the two age groups who underwent endovascular interventions, we found that patients in ≥80 group had marginally fewer diabetics (59% vs 73%, P = .079), fewer active smokers (8% vs 39%, P < 0.001), and fewer dialysis-dependent patients (0% vs 13%, P < 0.001). No difference in gangrene and infrapopliteal interventions was noted among this age group. However, bedridden status was more frequent in the older group (9% vs 3%, P = .081). These factors may have contributed to the results in addition to the selection bias for endovascular-treated cases. It is of note that the TASC classification of the treated lesions was TASC C or D in 82% of both age groups, with no difference between groups.

The use of prosthetic grafts, especially in the infrageniculate group was noted to be high in the study population, however, this was a consecutive patient series, and reflects our patient population with lack of adequate veins for infrageniculate bypass. We found that patients who had infrageniculate bypass using vein grafts overall performed better than those who had bypasses using other grafts and endovascular interventions. However, in the ≥80 group, patients who had endovascular interventions either performed better (LS and freedom from TER), or similar (sustained clinical success, secondary clinical success and overall improvement) to those who had bypasses using autologous grafts. In this age group, patients who had bypasses using other conduits performed worse in terms of clinical success rates than endovascular-treated patients or those who had bypasses using autologous veins. These results were mainly due to the fact that the outcomes in ≥80 group who had infrageniculate endovascular interventions were significantly better than the younger patients, although the results with bypasses using any type of conduits were similar. These results suggest that endovascular interventions should be preferred in the octogenarians who need infrageniculate revascularizations whenever feasible, even in patients who have TASC C or D lesions and suitable veins, due to the less morbidity and mortality involved.

Although we do not advocate limb salvage attempt in bedridden patients, we have performed revascularization procedures in nonambulatory patients, some of whom were bedridden. Adamant refusal of an amputation by a mentally competent patient or the next of kin is not rare in our practice, and unless the patient had severe flexion contractures or advanced infection or tissue loss, we have performed (mostly endovascular) revascularizations in selected cases. Although the survival was very poor in these patients, over half of them did not undergo an amputation, before they died.

Limb salvage by itself does not necessarily indicate a clinical benefit, since maintenance of independence and ambulatory status, need for reinterventions, and resolution of symptoms, were also suggested as important factors for assessing and comparing outcomes.², ⁵, ¹¹ We found that the sustained clinical success in those ≥80 and <80 were similar, and was not different in those who had open or endovascular interventions. When need for TER was not considered, the secondary clinical success rates were also similar between age groups, with no difference in the ≥80 groups between endovascular and open groups. These results were somewhat better than the recent study by Brosi et al,⁸ and similar to the primary clinical success of 64% to 79% in other reports,³, ¹⁰, ¹¹ although the criteria were not as strict in those studies.

Parameters that define success in previous studies included mortality and limb salvage, as well as full resolution of symptoms and freedom from repeat revascularizations.⁸ However, factors such as freedom from pain, or improved pain control, and preserving a sense of body wholeness were frequently ignored. We therefore evaluated in both patient groups, the overall clinical improvement of symptoms, healing of wounds, freedom from pain, and ability to be managed as outpatients. There was no difference between the two age groups in overall symptom improvement by last follow-up. However, patients in the ≥80 group who had endovascular interventions had significantly better results than those who underwent open interventions. We surmise that overall improvement is a more important assessment of outcome in this age group than freedom from reintervention and should be routinely assessed in the elderly patients undergoing interventions.

Survival of the older group was significantly worse both in the endovascular- and open-treated patients. The 12, 36 and 60-month survival in our ≥80 group was 59%, 40%, and 25%, which was similar to the study by Brosi et al⁸ (12-month survival 68% in endovascular, 63% in open-treated group), and Salas et al¹⁰ (24-month survival 59%, vs 55% in our endovascular-treated patients), both of which consist of patients treated mostly by endovascular means. Studies on open reconstructions have much better overall survival rates, with 5-year survival between 42% and 44%.², ¹¹ Our multivariate analysis showed age ≥80, CAD, COPD, dialysis-dependence, and nonambulatory status being independently associated with poorer survival. This concurs with Taylor et al²⁹ (nonambulatory status, end-stage renal disease on dialysis [ESRD], age >70, COPD, CAD) in their multivariate analysis of 1000 limb revascularizations in 841 patients who underwent endovascular or open procedures for CLI. In addition, both studies found that age was not an independent risk factor for limb loss, but DM, ESRD, smoking and ambulatory status were.

Although preoperative functional status is closely related to outcomes, an increasing number of patients who have limited independence and ambulatory function are being referred for evaluation. The ideal approach to these patients creates not only a medical, but also an ethical dilemma. Taylor et al¹² reviewed their experience with angioplasty in a group of high-risk patients with poor functional status, who were unsuitable for open surgery (n = 131) to those who underwent primary amputation (n = 183). The LS rate was 63% in 12 months, and the percutaneous luminal angioplasty (PTA) group had significantly lower rates of ambulatory failure, and loss of independence, but had significantly lower overall survival than the amputation group. In addition, the ambulation advantage lasted only 12 months, and maintenance of independent living lasted only 3 months. It is important to point out that the 30-day mortality in their amputation group was only 4.4%, which is significantly less than the previous reports. The 30-day mortality rate in our ≥80 population is 33% following primary amputation, and 15% in all patients who present with CLI and undergo primary amputation. All mortalities in our octogenarians who underwent primary amputations occurred in either hospice or nursing homes due to their extremely poor medical condition, unrelated to the procedures. The 24-month survival in nonambulatory patients ≥80, who underwent primary amputation was 42% in our patients, whereas it was 39% in endovascular-treated nonambulatory patients (data not shown). Thus, our experience does not support Taylor et al's findings that angioplasty is associated with increased mortality, although there is no significant survival benefit outside of the perioperative period.

Postoperative complications were significantly higher in ≥80 group, both in the open- and endovascular-treated patients. Dick et al³⁰ recently reported similar results with major complications occurring in 11.1% of patients ≥80, whereas this was 1.8% in younger patients (P < .001). They speculated that this was due to differences in vessel wall stiffness, calcification, as well as having proportionately more women (65% vs 40%, P < .001) in the older group who had more comorbidities and likely smaller vessels. Although our population was almost exclusively a male group, our results were very similar, suggesting that the vessel wall characteristics (vessel wall calcification, stiffness) may play a more important role than gender for the increased complication rates seen in older patients. Brosi et al⁸ suggested that octogenarians with CLI had better results with revascularization, compared to those who were conservatively managed. We believe that CLI should be treated with an endovascular-first approach for octogenarians.

There are some limitations of our study. It was a single center, retrospective study from a prospectively maintained database, and treatment allocation was made at the discretion of the vascular surgeon. The endovascular first approach was increasingly used starting in 2002, with increasing complexity as experience was gained. Another limitation was that the study population was predominantly males (99%), while most other studies predominantly (60% to 75%)², ³, ⁴, ⁵, ⁸, ¹⁰ had more females in their ≥80 groups. Our results may therefore be skewed in the sense that we may be treating higher risk mostly male patients with poorer preoperative functional capacity. Although the percentage of patients who had nonautologous grafts was high, this did not seem to affect the overall conclusions of our study. Lastly, we did not perform any analysis using questionnaires (such as SF-36) to assess the quality of life as perceived by the patients. However, a significant proportion of our patients are not able to complete such extensive surveys.

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Conclusion 

In conclusion, our results suggest that revascularization in patients ≥80 with CLI is justified, especially when an EV intervention can be accomplished. Although limb salvage following endovascular interventions was better in the ≥80 group, sustained clinical success, and secondary clinical success rates were similar following open and endovascular interventions in both age groups. Open procedures carry a high perioperative mortality in the ≥80 age group and should be avoided as much as possible, even in patients with TASC C and D lesions. Although age was associated with poorer overall survival, it was not associated with limb loss. Aggressive revascularization for attempted LS is justified in patients ≥80 years old.

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Author contributions 

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Table (online only) 

Table VII (online only). Limb salvage (LS), freedom from target extremity revascularization (f-TER), sustained clinical success (susCS), secondary clinical success (secCS), and overall clinical improvement (OCI) rates in patients who underwent infrageniculate revascularizations following endovascular interventions, bypass procedures with autologous vein grafts (AVG) or other grafts (OTH) in both age groups

	LS		SusCS		SecCS		OCI		f-TER
	12 mo	24 mo	12 mo	24 mo	12 mo	24 mo	12 mo	24 mo	12 mo	24 mo
EV (n = 94)	77%±5%	72%±5%	49%±5%	44%±6%	59%±5%	58%±5%	73%±5%	69%±5%	75%±6%	65%±7%
AVG (n = 68)	82%±5%	80%±5%	72%±6%	70%±6%	82%±5%	82%±5%	81%±5%	81%±5%	89%±4%	83%±5%
OTH (n = 69)	71%±6%	62%±7%	46%±6%	39%±6%	59%±6%	51%±6%	63%±6%	55%±7%	67%±7%	64%±7%
P value		.248		.002		.002		.03		.03
≥80 EV (n = 29)	93%±5%	93%±5%	65%±9%	65%±9%	76%±8%	76%±8%	90%±6%	90%±6%	87%±7%	87%±7%
≥80 AVG (n = 12)	78%±14%	65%±17%	69%±15%	57%±17%	80%±13%	80%±13%	80%±13%	80%±13%	76%±15%	64%±17%
≥80 OTH (n = 20)	72%±12%	62%±14%	36%±12%	27%±12%	55%±11%	47%±12%	55%±11%	47%±12%	54%±15%	54%±15%
P value		.134		.049		.075		.005		.04
<80 EV (n = 65)	70%±6%	64%±7%	42%±6%	35%±7%	52%±6%	50%±6%	66%±6%	60%±7%	69%±7%	55%±9%
<80 AVG (n = 6)	83%±5%	83%±5%	72%±6%	72%±6%	82%±5%	82%±5%	81%±5%	81%±5%	87%±5%	87%±5%
<80 OTH (n = 49)	71%±7%	62%±8%	51%±7%	43%±7%	61%±7%	53%±7%	68%±7%	59%±8%	72%±7%	67%±8%
P value		.109		.001		.001		.055		.02

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References 

1. Diehm C, Schuster A, Allenberg JR, Darius H, Haberl R, Lange S, et al. High prevalence of peripheral arterial disease and comorbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis. 2004;172:95–105
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (155 KB)
   • CrossRef
2. Pomposelli FB, Arora S, Gibbons GW, Frykberg R, Smakowski P, Campbell DR, et al. Lower extremity arterial reconstruction in the very elderly: successful outcome preserves not only the limb but also residential status and ambulatory function. J Vasc Surg. 1998;28:215–225
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (88 KB)
   • CrossRef
3. Chang JB, Stein TA. Infrainguinal revascularization in octogenarians and septuagenarians. J Vasc Surg. 2001;34:133–138
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (22 KB)
   • CrossRef
4. Scher LA, Veith FJ, Ascer E, White RA, Samson RH, Sprayregen S, et al. Limb salvage in octogenarians and nonagenarians. Surgery. 1986;99:160–165
   • View In Article
   • MEDLINE
5. Nehler MR, Moneta GL, Edwards JM, Yeager RA, Lloyd MT, Porter JM. Surgery for chronic lower extremity ischemia in patients 80 or more years of age: operative results and assessment of postoperative independence. J Vasc Surg. 1993;18:618–626
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (862 KB)
   • CrossRef
6. Kalra M, Gloviczki P, Bower TC, Panneton JM, Harmsen WS, Jenkins GD, et al. Limb salvage after successful pedal bypass grafting is associated with improved long-term survival. J Vasc Surg. 2001;33:6–16
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (229 KB)
   • CrossRef
7. Klevsgard R, Risberg BO, Thomsen MB, Hallerg IR. A 1-year follow-up quality of life study after hemodynamically successful or unsuccessful surgical revascularization of lower limb ischemia. J Vasc Surg. 2001;33:114–122
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (191 KB)
   • CrossRef
8. Brosi P, Dick F, Do Do D, Schmidli J, Baumgartner I, Diehm N. Revascularization for chronic critical lower limb ischemia in octogenarians is worthwhile. J Vasc Surg. 2007;46:1198–1207
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (819 KB)
   • CrossRef
9. Plecha FR, Bertin VJ, Plecha EJ, Avellone JC, Farrell CJ, Hertzer NR, et al. The early results of vascular surgery in patients 75 years of age and older: an analysis of 3259 cases. J Vasc Surg. 1985;2:769–774
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (517 KB)
   • CrossRef
10. Salas CA, Adam DJ, Papavassiliou VG, London NJ. Percutaneous transluminal angioplasty for critical limb ischemia in octogenarians and nonagenarians. Eur J Vasc Endovasc Surg. 2004;28:142–145
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (82 KB)
    • CrossRef
11. Taylor SM, Kalbaugh CA, Blackhurst DW, Langan EM, Cull DL, Snyder BA, et al. Postoperative outcomes according to preoperative medical and functional status after infrainguinal revascularization for critical limb ischemia in patients 80 years and older. Am Surg. 2005;71:640–645
    • View In Article
    • MEDLINE
12. Taylor SM, Kalbaugh CA, Blackhurst DW, Kellicut DC, Langan EM, Youkey JR. A comparison of percutaneous transluminal angioplasty versus amputation for critical limb ischemia in patients unsuitable for open surgery. J Vasc Surg. 2007;45:304–311
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (297 KB)
    • CrossRef
13. Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–538
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (1996 KB)
    • CrossRef
14. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD) (TASC Working Group. TransAtlantic Inter-Society Consensus (TASC)). J Vasc Surg. 2000;31:S1–S296
    • View In Article
    • MEDLINE
    • CrossRef
15. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–S67
    • View In Article
    • Full Text
    • Full-Text PDF (1677 KB)
    • CrossRef
16. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, et al. Guidelines for perioperative cardiovascular evaluation for non-cardiac surgery (Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)). J Am Coll Cardiol. 1996;27:910–948
    • View In Article
    • Full-Text PDF (4946 KB)
    • CrossRef
17. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines ACC/AHA guidelines update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2002;105:1257–1267
    • View In Article
18. Kinsella K, Velkoff VA. US Census Bureau, Series P95/01-1, An Aging World, 2001. Washington DC: US Government Printing Office; 2001;
    • View In Article
19. Harris KA, van Shie L, Carroll SE, Deathe A, Maryniak O, Meads GE, et al. Rehabilitation potential of elderly patients with major amputations. J Cardiovasc Surg. 1991;32:463–467
    • View In Article
20. Mackey WC, McCullough JL, Conlon TP, Shepard AD, Deterling RA, Callow AD, et al. The costs of surgery for limb-threatening ischemia. Surgery. 1985;98:26–35
    • View In Article
21. Panayiotopoulos YP, Tyrrell MR, Owen SE, Reidy JF, Taylor PR. Outcome and cost analysis after femorocrural and femoropedal grafting for critical limb ischemia. Br J Surg. 1997;84:207–212
    • View In Article
    • MEDLINE
    • CrossRef
22. Lindenauer PK, Pekow P, Wang K, Mamidi DK, Guiterrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Eng J Med. 2005;353:349–361
    • View In Article
23. Feringa HH, Bax JJ, Boersma E, Kertai MD, Meij SH, et al. High dose β-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation. 2006;114(Suppl II):344–349
    • View In Article
24. Poldermans D, Bax JJ, Kertai MD, Krenning B, Weterhout CM, Schinkel AFL, et al. Statins are associated with reduced incidence of Perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation. 2003;107:1848–1851
    • View In Article
    • CrossRef
25. Schanzer A, Havelone N, Owens CD, Beckman JA, Belkin M, Conte MS. Statins are independently associated with reduced mortality in patients undergoing infrainguinal bypass graft surgery for critical limb ischemia. J Vasc Surg. 2008;47:774–781
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (200 KB)
    • CrossRef
26. Dosluoglu HH, O'Brien-Irr MS, Lukan J, Harris LM, Dryjski ML, Cherr GS. Does preferential use of endovascular interventions by vascular surgeons improve limb salvage, control of symptoms and survival in patients presenting with critical limb ischemia?. Am J Surg. 2006;192:572–576
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (197 KB)
    • CrossRef
27. Nasr MK, McCarthy RJ, Hardman J, Chalmers A, Horrocks M. The increasing role of percutaneous transluminal angioplasty in the primary management of critical limb ischemia. Eur J Vasc Endovasc Surg. 2002;23:398–403
    • View In Article
    • Abstract
    • Full-Text PDF (169 KB)
    • CrossRef
28. Faglia E, Dalla Paola L, Clerici G, Clerissi J, Graziani L, Fusaro M, et al. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg. 2005;29:620–627
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (250 KB)
    • CrossRef
29. Taylor SM, Kalbaugh CA, Blackhurst DW, Cass AL, Trent EA, Langan EM, et al. determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions. J Vasc Surg. 2006;44:747–756
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (211 KB)
    • CrossRef
30. Dick P, Barth B, Mlekusch W, Sabeti S, Amighi J, Schlager O, et al. Complications after peripheral vascular interventions in octogenarians. J Endovasc Ther. 2008;15:383–389
    • View In Article
    • CrossRef