Critical Limb Ischemia in Nonagenarians: A Challenge of Our Times

Abstract

Background As a result of the increasing life expectancy of the western population, the number of older patients with chronic limb-threatening ischemia (CLTI) seeking medical care is growing. Our objective was to describe the characteristics of a consecutive series of nonagenarian patients with CLTI and evaluate the outcomes of their management. Materials and methods Retrospective analysis of a consecutive series of nonagenarian patients with CLTI attended at our institution between 2005 and 2019. Primary endpoints were 1-year limb salvage and survival rates. Results A total of 171 patients were included (mean age 92.7, 51.5% women), of which in 59 (34.5%) primary major amputation (n = 10) or palliative care (n = 49) was indicated at presentation because of severe dementia (n = 30, 50.8%), knee retraction (n = 17, 28.8%), terminal condition (n = 13, 22%) or a non-salvageable foot (n = 28, 47.4%). In the remaining 112 (65.5%), the need for a revascularization was further assessed finally performing A) conservative treatment/minor amputation (n = 57, 50.9%), B) revascularization (n = 50, 44.6%) or C) direct major amputation (n = 5, 4.4%), with 1-year limb salvage and survival rates of 93.1 and 57.4%, respectively. Predictive factors for lower survival included age [92 years (HR = 1,59, p = 0.041), hemoglobin \10.5 mg/dL (HR 2,34, p \ 0.001), congestive heart failure (HR = 1.65, p = 0.036), non-severe dementia (HR 3,11, p \ 0.001) and current mobility with wheelchair (HR 1,74, p = 0.014). Conclusion Nearly one-third of nonagenarian patients with CLTI have a direct indication for amputation or palliative care at presentation. In the remaining, a judicious approach with conservative treatment, minor amputation or revascularization procedures yields excellent limb salvage rates. Survival is, however, the cornerstone of these patients. It can be predicted with certain clinical factors which may help decision-making.

Managing Chronic Limb‐Threatening Ischaemia in Patients at the Extremes of Older Age Requires a Patient‐Focused Approach

“…In this issue of the World Journal of Surgery , Dr Casajuana Urgell and colleagues share the results of their retrospective cohort study of 171 patients aged 90 years or older, who were diagnosed with CLTI [ 1 ]. They included nonagenarians in whom limb salvage was not considered (59, 35%), and those with potentially salvageable limbs who underwent either revascularisation (50, 29%), conservative treatment or minor amputation without revascularisation (57, 33%), or major amputation (5, 3%).…”

“…How do these findings by Casajuana Urgell et al impact our current approaches to CLTI in patients of extreme older age? [ 1 ]. For many patients aged 90 years or older, their presentation with CLTI represents a terminal event for which neither amputation nor treatment appear to strongly influence.…”

“…For some older patients, amputation may be a preferable outcome to improve quality of life and health status [ 2 ]. This study by Casajuana Urgell et al acts as a timely reminder that our approach to the care of older patients with CLTI needs to be adapted to their unique care needs [ 1 ].…”

“…Frailty is increasingly recognized as predicting patients at risk of reduced survival and adverse CLTI outcomes. Non-ambulatory status and physical dependence act as frailty surrogates in Casajuana Urgell et al, predicting those patients unlikely to survive beyond one year [ 1 ]. Acknowledging the limitations of their single-centre, retrospective cohort study, Casajuana Urgell et al report that premorbid function had an important influence on subsequent treatment decisions and outcomes [ 1 ].…”

“…Non-ambulatory status and physical dependence act as frailty surrogates in Casajuana Urgell et al, predicting those patients unlikely to survive beyond one year [ 1 ]. Acknowledging the limitations of their single-centre, retrospective cohort study, Casajuana Urgell et al report that premorbid function had an important influence on subsequent treatment decisions and outcomes [ 1 ]. The decision not to proceed with limb salvage in older patients is often driven by factors other than CLTI severity, such as severe dementia, concurrent terminal illness, or poor ambulatory function.…”