Contemporary Outcomes of Peripheral Bypass Compared to Amputation in Octogenarians.

INTRODUCTION: and Objectives: Chronic limb threatening ischemia (CLTI) in octogenarians presents unique treatment challenges in patients with multiple comorbidities and variable functional status. Endovascular interventions offer a better risk profile; however, this is not always a feasible option for anatomic or disease specific reasons. This study compares outcomes of peripheral bypass versus amputation in octogenarians.

METHODS: The ACS-NSQIP database was queried from 2013 to 2016 for patients >80 years-old undergoing femoral-popliteal (FPB), femoral-tibial (FTB), or popliteal-tibial (PTB) bypass with vein or prosthetic graft versus above-knee (AKA) or below-knee amputation (BKA). Patients presenting with SIRS, sepsis, septic shock, or a leukocytosis > 11,000 were excluded. Patient demographics, risk factors, and 30-day unadjusted outcomes were analyzed. Multivariate regression analysis was then performed to compare risk adjusted 30-day morbidity and mortality.

RESULTS: The bypass group contained 2226 patients compared to 1253 patients in the amputation group. AKA represented 59.9% of the amputation group. The largest portion of bypasses were FPBs at 58.6%. Total pre-op functional dependence was 1.3% for bypass versus 18.2% for amputation (p-value, <0.01). Risk factors for amputation over bypass included age, minority race, ASA class IV-V, diabetes, CHF, dialysis, preoperative open wound, facility of origin, and functional dependence. Unadjusted 30-day mortality was 3.6% for bypasses and 7.7% for amputations (p-value, <0.01), with an in-hospital mortality of 2.0% v. 3.2% and a mortality after discharge of 1.6% v. 4.5%, respectively (p-value <0.01). Unadjusted morbidity was not significantly different between the two groups (18.7% bypass v. 17.8% amputation, p-value, 0.52). After multivariate risk adjustment, there was no statistically significant difference in mortality or morbidity between the groups.

CONCLUSIONS: Contemporary risk-adjusted 30-day morbidity and mortality for bypass versus amputation in octogenarians shows no significant difference. This data demonstrates that aggressive surgical limb salvage can be safe in well-selected patients in this age group.