Assessing Endovascular Aneurysm Repair Suitability According to Graft-Specific Instructions for Use in Patients With a Ruptured Abdominal Aortic Aneurysm.

PURPOSE: The purpose of the study is to ascertain endovascular aneurysm repair (EVAR) suitability in relation to stent-graft-specific instructions for use (IFU) in patients with a ruptured abdominal aortic aneurysm (RAAA). MATERIALS AND METHODS: Using the preoperative computed tomography angiography (CTA), the aortic morphology of patients undergoing surgical repair of a RAAA in 2 Dutch hospitals between January 2014 and December 2019 was retrospectively assessed. Three-dimensional and central luminal line reconstructions were used. Anatomical suitability was defined according to the IFU of the stent graft system used. RESULTS: Of 128 included patients, 112 (88%) were men and the mean age was 74.1 (SD=7.6) years. Anatomy within IFU for EVAR was present in 31 patients (24%). Overall, 94 patients (73%) were treated with open surgical repair (OSR) and 34 patients (27%) were treated with EVAR. Anatomy within IFU was present in 15 OSR patients (16%) and 16 EVAR patients (47%). In patients with anatomy outside of IFU, 90% (87/97) had unsuitable neck anatomy and 64% (62/97) had insufficient neck length. An unsuitable distal iliac landing zone was observed in 35 patients. Perioperative mortality was 27% (34/128), with no difference between OSR and EVAR (25/94 vs 9/34; p=0.989). CONCLUSION: Most RAAA patients in this series did not have aortic anatomy within IFU for EVAR, mainly due to insufficient neck length. However, whether anatomy outside of IFU equates to unsuitability for EVAR in an emergency setting remains a matter of debate and warrants further research. CLINICAL IMPACT: The treatment of a ruptured abdominal aortic aneurysm can consist of endovascular repair or open repair. Retrospective anatomical assessment shows that most patients do not have anatomy inside the instructions for use for endovascular aneurysm repair, mainly due to insufficient neck length. Whether anatomy outside the instructions for use equates unsuitability for endovascular aneurysm repair remains a matter of debate.

The Effect of Arterial Disease Level on Outcomes of Supervised Exercise Therapy for Intermittent Claudication: A Prospective Cohort Study.

OBJECTIVE: To assess whether level of arterial obstruction determines the effectiveness of SET in patients with IC. BACKGROUND DATA: Guidelines advocate SET before invasive treatment for IC, but early revascularization remains widespread, especially in patients with aortoiliac disease. METHODS: Patients were recruited from 10 Dutch centers between October 2017 and October 2018. Participants received SET first, followed by endovascular or open revascularization in case of insufficient effect. They were grouped according to level of stenosis (aortoiliac, femoropopliteal, multilevel, or rest group with no significant stenosis). Changes from baseline walking performance (maximal and functional walking distance on a treadmill test, 6-minute walk test) and vascular quality of life questionnaire-6 at 3 and 6 months were compared, after multivariate adjustment for possible confounders. Freedom from revascularization was estimated with Kaplan-Meier analysis. RESULTS: Some 267 patients were eligible for analysis (aortoiliac n = 70, 26%; femoropopliteal n = 115, 43%; multilevel n = 69, 26%; rest n = 13, 5%). No between group differences in walking performance or vascular quality of life questionnaire-6 were found. Mean improvement in maximal walking distance after 6 months was 439 m [99% confidence interval (CI) 297-581], 466 m (99% CI 359-574), 353 m (99% CI 210-496), and 403 m (99% CI 58-749), respectively (P = 0.40). Freedom from intervention was 73.9% for aortoiliac disease and 88.6% for femoropopliteal disease (hazard ratio 2.46, 99% CI 0.96 - 6.30, P = 0.013). CONCLUSIONS: Short-term effectiveness of SET for IC is not determined by the location of stenosis. Although aortoiliac disease patients improved walking performance and health-related quality of life similarly compared to other arterial disease level groups, they underwent revascularization more often.

Long-term Follow-up of a Randomized Clinical Trial Comparing Endovascular Revascularization Plus Supervised Exercise With Supervised Exercise Only for Intermittent Claudication.

OBJECTIVE: The goal of this study was to assess the long-term effectiveness of combination therapy for intermittent claudication, compared with supervised exercise only. BACKGROUND: Supervised exercise therapy is recommended as first-line treatment for intermittent claudication by recent guidelines. Combining endovascular revascularization plus supervised exercise shows promising results; however, there is a lack of long-term follow-up. METHODS: The ERASE study is a multicenter randomized clinical trial, including patients between May 2010 and February 2013 with intermittent claudication. Interventions were combination of endovascular revascularization plus supervised exercise (n = 106) or supervised exercise only (n = 106). Primary endpoint was the difference in maximum walking distance at long-term follow-up. Secondary endpoints included differences in pain-free walking distance, ankle-brachial index, quality of life, progression to critical limb ischemia, and revascularization procedures during follow-up. This randomized trial report is based on a post hoc analysis of extended follow-up beyond that of the initial trial. Patients were followed up until 31 July 2017. Data were analyzed according to the intention-to-treat principle. RESULTS: Median long-term follow-up was 5.4 years (IQR 4.9-5.7). Treadmill test was completed for 128/212 (60%) patients. Whereas the difference in maximum walking distance significantly favored combination therapy at 1-year follow-up, the difference at 5-year follow-up was no longer significant (53 m; 99% CI-225 to 331; P = 0.62). No difference in pain-free walking distance, ankle-brachial index, and quality of life was found during long-term follow-up. We found that supervised exercise was associated with an increased hazard of a revascularization procedure during follow-up (HR 2.50; 99% CI 1.27-4.90; P < 0.001). The total number of revascularization procedures (including randomized treatment) was lower in the exercise only group compared to that in the combination therapy group (65 vs 149). CONCLUSIONS: Long-term follow up after combination therapy versus supervised exercise only, demonstrated no significant difference in walking distance or quality of life between the treatment groups. Combination therapy resulted in a lower number of revascularization procedures during follow-up but a higher total number of revascularizations including the randomized treatment. TRIAL REGISTRATION: Netherlands Trial Registry Identifier: NTR2249.

A Systematic Review of Strategies for Preventing Delirium in Patients Undergoing Vascular Surgery.

BACKGROUND: Elderly patients undergoing vascular surgery are at a risk of developing postoperative delirium, which is associated with high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS: This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery,' 'prevention,' and 'delirium' and was last run on October 21, 2021 in the electronic databases PubMed, MEDLINE, Embase, Web of Science, the Cochrane library, and Emcare. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS: Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group vs. 11% in the intervention group, P = 0.018) and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group vs. 8.2% in the intervention group, P = 0.043, Odds Ratio = 0.56). A nonsignificant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group vs. 14.6% in the intervention group, P = 0.17). The study concerning the impact of the type of anesthesia on delirium in 11 older vascular surgical patients, of which 3 developed delirium, did not differentiate between the different types of anesthesia the patients received. CONCLUSIONS: Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients.

Age-Dependent Outcome of First-Line Endovascular and Surgical Revascularization Strategies in Chronic Limb-Threatening Ischemia.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) has a high mortality and amputation risk even after revascularization. Owing to an aging population the incidence of peripheral arterial disease is rising. However, the current age distribution in patients with CLTI and the impact of age on outcomes remains unclear. For this reason we performed an age-dependent analysis of mortality, morbidity, and amputation-free survival after open surgical revascularization (OSR) and endovascular revascularization therapy (ERT) with identification of risk factors for mortality. Standardized mortality ratios (SMR) were calculated, comparing observed deaths in the study population to expected deaths based on age and gender specific mortality rates of the overall Dutch population. METHODS: Patients revascularized for the first episode of CLTI between 2013 and 2018 were included in this multicenter retrospective cohort study. The cohort was divided into 2 treatment groups (OSR and ERT) who were each stratified in 3 age groups: early age group < 65 years (G1), middle age group 65-74 years (G2), and elderly age group ≥ 75 years (G3). RESULTS: During the study period 274 limbs (43.9%) were treated with OSR and 350 limbs (56.1%) with ERT. The young population (G1) is only a small part of the whole CLTI population, namely for OSR 22% and ERT 18%. The risk profile of the early age group was characterized by male gender and smoking, whereas the elderly age group was characterized by poor arterial runoff, tissue loss, hypertension, hypercholesterolemia, chronic kidney disease, history of heart disease, chronic obstructive pulmonary disease, and cerebrovascular disease. One year amputation rates were similar between the age groups. However, significantly higher one-year mortality rates were observed in patients ≥ 75 years in comparison to the low mortality rates in patients < 75 years (OSR: G3 19.8% vs. G2 7.1% and G1 6.7%, P = 0.006; ERT: G3 30.7% vs. G2 12.7% and G1 7.8%, P = 0.001). The SMR in this elderly group equaled 3.72 after OSR and 4.04 after ERT. Independent risk factors for mortality after OSR were age, hazard ratio (HR) 1.03 (95% confidence interval [CI] 1.01-1.06; P = 0.006), preoperative hemoglobin level (HR 0.79; 95% CI 0.67-0.92; P = 0.003), tissue loss (HR 1.85; 95% CI 1.22-2.79; P = 0.004), cardiac history (HR 1.56; 95% CI 1.06-2.30; P = 0.024), and development of postoperative delirium (HR 2.75; 95% CI 1.61-4.71; P < 0.001). After ERT we identified age, HR 1.06 (95% CI 1.04-1.08; P < 0.001); preoperative hemoglobin level, HR 0.75 (95% CI 0.65-0.87; P < 0.001); tissue loss, HR 1.71 (95% CI 1.15-2.53; P = 0.008); history of chronic obstructive pulmonary disease, HR 1.99 (95% CI 1.43-1.79; P < 0.001); history of cerebrovascular accident (CVA), HR 1.55 (95% CI 1.09-2.21; P = 0.015); the development of postoperative pneumonia, HR 2.27 (95% CI 1.24-4.16; P = 0.008); postoperative acute kidney injury (AKI), HR 2.42 (95% CI 1.29-4.54; P = 0.006); and postoperative CVA, HR 8.17 (95% CI 1.96-34.15; P = 0.004) as risk factors. CONCLUSIONS: The current CLTI population consists mostly of elderly patients and only a small part is younger than 65 years. This shift in the population is important because increasing age is associated with considerable higher one-year mortality rates regardless of the method of revascularization in patients with CLTI. The mortality rates in the elderly group are 3 to 4 times larger than expected in the general population. In relation to the high mortality of the elderly patient, we assume that interventions to prevent postoperative delirium and correct preoperative anemia may be warranted as they appear to be independent risk factors for mortality.

Intravenous Iron in a Prehabilitation Program for Older Surgical Patients: Prospective Cohort Study.

BACKGROUND: Older patients often have iron deficiency anemia before surgery, which can be effectively treated with intravenous iron supplementation (IVIS). Anemia and blood transfusions are associated with an increased risk of delirium. The aim of this research was to assess the effectiveness and safety of using IVIS in a prehabilitation program. MATERIAL AND METHODS: Patients ≥70 y who underwent abdominal surgery between November 2015 and June 2018 were included in this single-center prospective cohort study. All patients were prehabilitated; however, only anemic patients received a single dose of 1000 mg intravenous iron (ferric carboxymaltose) to increase preoperative hemoglobin levels (IVIS group). Nonanemic patients received standard care (SC). The hemoglobin levels (primary outcome) were assessed at the outpatient clinic visit, at admission, and at discharge. Secondary outcomes were postoperative delirium, postoperative anemia, blood transfusion, complications other than delirium, and length of hospital stay. All outcomes were compared between the IVIS group and SC group. RESULTS: Of all patients (n = 248), 97 anemic patients received IVIS (39%). Of the anemic patients, 50 patients (52%) had iron deficiency. Initial differences in hemoglobin concentrations between the IVIS group and SC group at T1 and T2 (7.2 versus 8.8; P < 0.001 and 7.4 versus 8.6; P = 0.023, respectively) were no longer present at discharge (6.6 versus 7.2; P = 0.35). No statistically significant differences were observed for all secondary outcomes between the IVIS group and the SC group. No infusion-related adverse events occurred. CONCLUSIONS: Adding IVIS to prehabilitation programs is safe and diminishes differences in these concentrations between preoperatively anemic and nonanemic patients. IVIS may be worthwhile as an additional component of prehabilitation programs. Results merit further investigation.

The effects of elective aortic repair, colorectal cancer surgery and subsequent postoperative delirium on long-term quality of life, cognitive functioning and depressive symptoms in older patients.

Objectives: This study aimed to demonstrate the impact of elective major abdominal surgery and subsequent postoperative delirium on quality of life (QOL; primary outcome), cognitive functioning and depressive symptoms (secondary outcomes) in older surgical patients.Method: A single-centre, longitudinal prospective cohort study was conducted between November 2015 and June 2018, including patients ≥70 years old who underwent surgery for colorectal cancer or an abdominal aortic aneurysm. They were followed-up at discharge and at 6 and 12 months postoperatively until June 2019. QOL was assessed with the World Health Organization Quality of Life-BREF questionnaire (WHOQOL-BREF). Cognitive functioning was measured with the Mini-Mental State Examination and depressive symptoms with the CES-D 16.Results: In all patients (n = 265), physical and psychological health were significantly lower at discharge compared to baseline (p < 0.001 for both domains). Physical health restored after 6 months, but psychological health remained decreased for the complete study period. Psychological, social and environmental QOL were significantly worse in patients with delirium compared to patients without (p = 0.001, p = 0.006 and p = 0.001 respectively). The cognitive functioning score was significantly lower at baseline in patients with delirium compared to those without (p = 0.006). Patients with delirium had a significantly higher CES-D 16 score compared to those without after 12 months (p = 0.027).Conclusion: Physical and psychological QOL were decreased in the early postoperative period. While physical health was restored after 6 and 12 months, psychological health remained decreased. After 12 months, postoperative delirium resulted in worse psychological, social and environmental QOL and more depressive symptoms. Decreased cognitive functioning may be a risk factor for delirium.

A mortality prediction model for elderly patients with critical limb ischemia.

OBJECTIVE: To aid physicians in the process of shared decision-making, many predictive models for critical limb ischemia (CLI) have been constructed. However, none of these models is in widespread use. Predicting survival outcomes for a specific individual may be used to guide treatment selection. The aim of this study was to construct a 6-month survival-predicting model representative of elderly patients with CLI undergoing surgical or endovascular treatment. METHODS: An observational cohort study including all patients with CLI aged ≥65 years who underwent surgical or endovascular treatment of CLI between January 2013 and June 2018 was conducted. The model to predict survival at 6 months was based on a multivariable Cox proportional hazards regression model and a penalized likelihood method. The performance of the model was judged by means of the area under the receiver operating characteristic curve. RESULTS: In total, 449 patients were included in the study population. The median age was 76 years (range, 65-97 years), and 52.8% of the population was male. Surgical treatment was performed in 303 patients (67.5%), and 146 underwent endovascular treatment (32.5%). The estimated 30-day survival was 92.7% (standard error [SE], 1.2%); 6-month survival, 80% (SE, 1.9%); and 12-month survival, 71% (SE, 2.1%). Variables with the strongest association with 6-month mortality were age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class. The area under the receiver operating characteristic curve of the 6-month mortality model was 0.81 (95% confidence interval, 0.76-0.85; P < .001). CONCLUSIONS: A prediction model constructed for 6-month mortality of elderly patients undergoing surgical or endovascular treatment of CLI showed that age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class have the highest association with an increase in mortality. These factors may be used to identify patients at risk for mortality in shared decision-making.

Incidence and Risk Factors for Delirium in Elderly Patients with Critical Limb Ischaemia.

OBJECTIVE: Delirium is associated with adverse outcomes, such as increased mortality and prolonged hospital stay. Information on the risk factors for delirium in elderly patients with critical limb ischaemia (CLI) is scarce. The aim of this study was to analyse the incidence of delirium and to identify risk factors for delirium in elderly patients undergoing surgical or endovascular treatment. METHODS: A retrospective cohort study was conducted including patients aged ≥ 65 years undergoing surgical or endovascular treatment for CLI between January 2013 and June 2018. Delirium was scored using the DOSS (Delirium Observation Screening Scale) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. Risk factors for delirium were analysed using logistic regression. The discriminative ability of the model was calculated using the area under the receiver operating characteristics (AUROC) curve. RESULTS: In total, 392 patients were included, of which 70 (17.9%) developed delirium. Factors associated with an increased risk of delirium were: age, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.0-1.1), history of femoral endarterectomy, OR 4.7 (95% CI 1.5-15), physical impairment, OR 2.2 (95% CI 1.1-4.5), history of delirium, OR 2.7 (95% CI 1.4-5.3), general anaesthesia, OR 2.6 (95% CI 1.2-5.7) and pre-operative anaemia, OR 5.9 (95% CI 2.3-15). The AUROC was .82 (95% CI 0.76-0.87, p < .001). Delirium was associated with more respiratory, renal and surgical complications, as well as a prolonged hospital stay and a more frequent discharge to a nursing home. CONCLUSION: Delirium occurs frequently in patients with critical limb ischaemia undergoing any type of invasive treatment. This study identified multiple risk factors for delirium that may be helpful to delineate patients susceptible to its development.

Is a Good Quality of Life and Health Status Possible in Older Patients Dying from Critical Limb-Threatening Ischemia: A Prospective Clinical Study.

BACKGROUND: Revascularization is the cornerstone in the treatment of patients with critical limb-threatening ischemia (CLTI). However, the 2-year mortality rate is up to 50% in these patients. Therefore, the clinical benefit of revascularization needs to be considered carefully. The question emerges if there are changes in quality of life (QoL) and health status (HS) in the end-of-life phase of CLTI in older patients. METHODS: Patients with CLTI and of an age of 70 years or older were included in a prospective observational cohort study. Treatment consisted of endovascular revascularization, surgical revascularization, or conservative therapy. The follow-up period was 2 years. Within this follow-up period, patients completed the following questionnaires at six specified time intervals: the WHOQOL-BREF and the SF-12. Patients who died within 2 years after inclusion were analyzed. Final scores were defined as the last measurement at end of follow-up or death. RESULTS: Eighty two patients (42.1%) died during the 24-month follow-up. QoL and HS before death did not decrease with treatment (option: endovascular intervention, surgical revascularization, or conservative therapy). CONCLUSIONS: Older patients with CLTI and a life expectancy less than 2 years had no differences in QoL and HS before death compared to their previous measurement. Except for the mental HS domain, no differences in the percentage of patients showing significant individual change in QoL and HS were found between the treatments. For clinicians, it is important to use patient-reported outcome measure when discussing treatment for older frail patients with CLTI in a shared decision-making process.

Impact of the COVID-19 Lockdown Strategy on Vascular Surgery Practice: More Major Amputations than Usual.

BACKGROUND: The aim of this study is to investigate the impact of the coronavirus disease 2019 (COVID-19) lockdown period on the number and type of vascular procedures performed in the operating theater. METHODS: A total of 38 patients who underwent 46 vascular procedures during the lockdown period of March 16th until April 30th, 2020, were included. The control groups consisted of 29 patients in 2019 and 54 patients in 2018 who underwent 36 and 66 vascular procedures, respectively, in the same time period. Data were analyzed using SPSS Statistics. RESULTS: Our study shows that the lockdown during the COVID-19 pandemic resulted in a significant increase in the number of major amputations (42% in 2020 vs. 18% and 15% in 2019 and 2020, respectively; P-value 0.019). Furthermore, we observed a statistically significant difference in the degree of tissue loss as categorized by the Rutherford classification (P-value 0.007). During the lockdown period, patients presented with more extensive ischemic damage when than previous years. We observed no difference in vascular surgical care for patients with an aortic aneurysm. CONCLUSIONS: Measurements taken during the lockdown period have a significant effect on non-COVID-19 vascular patient care, which leads to an increased severe morbidity. In the future, policy makers should be aware of the impact of their measurements on vulnerable patient groups such as those with peripheral arterial occlusive disease. For these patients, medical care should be easily accessible and adequate.

A Comparison of Quality of Life in Elderly Patients with Intermittent Claudication and Chronic Limb-Threatening Ischemia.

BACKGROUND: Intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) are both associated with a decreased health status and possibly quality of life (QOL). A better understanding of the differences in QOL between patients with IC and CLTI could be of additional value in shared decision-making. The aim of this study was to compare the QOL at baseline between patients with IC and patients with CLTI. METHODS: The study population was based on 2 study cohorts, 1 cohort consisted of patients with IC (ELECT registry) and the other cohort of patients with CLTI (KOP-study). Patients with an age of ≥70 years were included. QOL at baseline was measured by the WHOQOL-BREF questionnaire. Nonresponders were excluded from data analyses. Student's t-tests and analysis of covariance (ANCOVA) analyses were used to compare QOL between the 2 groups. Outcomes of the ANCOVA analyses were expressed as estimated marginal means. RESULTS: In total, 308 patients were included, 115 patients with IC and 193 patients with CLTI. Patients with CLTI were older (median age 80 years vs. 75 years, P < 0.001) and had more comorbidities. Patients with IC had a statistically significant higher QOL regarding physical health (mean 13.7 [standard deviation (SD) 2.3] vs. 10.8 [SD 2.8], P < 0.001), psychological health (mean 15.3 [SD 2.1] vs. 14.1 [SD 2.4], P < 0.001), environment (mean 16.3 [SD 2.4] vs. 15.5 [SD 2.0], P < 0.002), and the overall domain (mean 3.5 [SD 0.7] vs. 3.1 [SD 0.9], P < 0.001). After correcting for the confounding effect of age and sex, patients with IC still had a statistically significant higher QOL in the physical, psychological, environment, and overall domain. CONCLUSIONS: Patients with IC had a significantly higher QOL in the physical, psychological, environment, and overall domains of the WHOQOL-BREF questionnaire compared with patients with CLTI. This underlines the importance of strategies that reduce disease progression as disease progression is associated with a decrease in QOL.

Adverse Cardiac Events and Mortality in Patients with Critical Limb Ischemia.

BACKGROUND: Both surgical and endovascular treatment in elderly patients with critical limb ischemia are associated with high mortality rates. Patients with critical limb ischemia are at increased risk of adverse cardiovascular events and subsequent cardiovascular death. Little is known about the incidence and consequences of these adverse events. The aim of this study was to investigate the effect of adverse cardiac events on mortality in patients with critical limb ischemia undergoing surgical or endovascular treatment. METHODS: A retrospective cohort study including all patients with critical limb ischemia aged ≥65 undergoing surgical or endovascular treatment for critical limb ischemia between January 2013 and June 2018 was conducted. Data on adverse cardiac events were collected from medical records. The effect of an adverse cardiac event on mortality during 6 months follow-up was analyzed with a multivariable cox proportional hazards model to adjust for confounders. Effects are displayed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: A total number of 449 patients were included. Median age was 76 years, 52.8% of patients were male. In total, 51 patients (11%) developed an adverse cardiac event, 31 patients (10%) in the surgical group and 20 patients (14%) in the endovascular group. After adjustment for confounders, adverse cardiac events were associated with an increased risk of mortality (HR 3.5 95% CI 2.1-5.9). CONCLUSIONS: This study showed that adverse cardiac events commonly occur in elderly patients with critical limb ischemia. Adverse cardiac events continue to occur even months after treatment and are associated with an increased mortality risk. These findings justify routine cardiac evaluation in both surgical and endovascular treatment. Additionally, frequent postdischarge cardiac follow-up in the outpatient clinic may be helpful in limiting the occurrence of adverse cardiac events.

Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients.

PURPOSE: The long-term outcomes of surgery followed by delirium after multimodal prehabilitation program are largely unknown. We conducted this study to assess the effects of prehabilitation on 1-year mortality and of postoperative delirium on 1-year mortality and functional outcomes. METHODS: The subjects of this study were patients aged ≥ 70 years who underwent elective surgery for abdominal aortic aneurysm (AAA) or colorectal cancer (CRC) between January 2013, and June 2018. A prehabilitation program was implemented in November 2015, which aimed to optimize physical health, nutritional status, factors of frailty and preoperative anemia prior to surgery. The outcomes were assessed as mortality after 6 and 12 months, compared between the two treatment groups; and mortality and functional outcomes, compared between patients with and those without delirium. RESULTS: There were 627 patients (controls N = 360, prehabilitation N = 267) included in this study. Prehabilitation did not reduce mortality after 1 year (HR 1.31 [95% CI 0.75-2.30]; p = 0.34). Delirium was significantly associated with 1-year mortality (HR 4.36 [95% CI 2.45-7.75]; p < 0.001) and with worse functional outcomes after 6 and 12 months (KATZ ADL p = 0.013 and p = 0.004; TUG test p = 0.041 and p = 0.011, respectively). CONCLUSIONS: The prehabilitation program did not reduce 1-year mortality. Delirium and the burden of comorbidity are both independently associated with an increased risk of 1-year mortality and delirium is associated with worse functional outcomes. TRIAL REGISTRATION: Dutch Trial Registration, NTR5932. https://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932 .

Cost-effectiveness of the treatments for critical limb ischemia in the elderly population.

OBJECTIVE: The treatment of critical limb ischemia (CLI), with the intention to prevent limb loss, is often an intensive and expensive therapy. The aim of this study was to examine the cost-effectiveness of endovascular and conservative treatment of elderly CLI patients unsuitable for surgery. METHODS: In this prospective observational cohort study, data were gathered in two Dutch peripheral hospitals. CLI patients aged 70 years or older were included in the outpatient clinic. Exclusion criteria were malignant disease, lack of language skills, and cognitive impairment; 195 patients were included and 192 patients were excluded. After a multidisciplinary vascular conference, patients were divided into three treatment groups (endovascular revascularization, surgical revascularization, or conservative therapy). Subanalyses based on age were made (70-79 years and ≥80 years). The follow-up period was 2 years. Cost-effectiveness of endovascular and conservative treatment was quantified using incremental cost-effectiveness ratios (ICERs) in euros per quality-adjusted life-years (QALYs). RESULTS: At baseline, patients allocated to surgical revascularization had better health states, but the health states of endovascular revascularization and conservative therapy patients were comparable. With an ICER of €38,247.41/QALY (∼$50,869/QALY), endovascular revascularization was cost-effective compared with conservative therapy. This is favorable compared with the Dutch applicable threshold of €80,000/QALY (∼$106,400/QALY). The subanalyses also established that endovascular revascularization is a cost-effective alternative for conservative treatment both in patients aged 70 to 79 years (ICER €29,898.36/QALY; ∼$39,765/QALY) and in octogenarians (ICER €56,810.14/QALY; ∼$75,557/QALY). CONCLUSIONS: Our study has shown that endovascular revascularization is cost-effective compared with conservative treatment of CLI patients older than 70 years and also in octogenarians. Given the small absolute differences in costs and effects, physicians should also consider individual circumstances that can alter the outcome of the intervention. Cost-effectiveness remains one of the aspects to take into consideration in making a clinical decision.

Quality of Life and not Health Status Improves After Major Amputation in the Elderly Critical Limb Ischaemia Patient.

OBJECTIVES: A patient-oriented appraisal of treatment has become extremely important, particularly in elderly patients with critical limb ischaemia (CLI). Quality of life (QoL) is an important patient-reported outcome in vascular surgery. Frequently, the physical domain of QoL questionnaires represents an 'objective' evaluation of performing activities, which is expected to be impaired after major limb amputation. However, an objective appraisal of physical function is an assessment of health status (HS) and not of QoL. Little is known about the subjective appraisal of physical health (QoL). The goal of this study was to evaluate, prospectively, QoL in relation to HS in elderly CLI patients undergoing major limb amputation. METHODS: Patients suffering from CLI aged 70 years or older were included in a prospective observational cohort study with a follow-up period of 1 year. Patients were divided according to having had an amputation or not. The World Health Organization Quality Of Life-BREF (WHOQOL-BREF) was used to asses QoL. The 12-Item Short Form Health Survey (SF-12) was used to measure HS. These self-reported questionnaires were completed five times during follow-up. RESULTS: Two-hundred patients were included of whom 46 underwent a major limb amputation within one year. Amputees had a statistically significant improvement of their physical QoL after six months (14.0 vs. 9.0 (95% CI -7.84;-1.45),p = 0.005) and after a one-year follow-up (14.0 vs. 9.0 (95% CI -9.58;-1.46),p = 0.008). They did not however show any statistically significant difference in HS. For non-amputees, both physical QoL and HS improved. An instant statistically significant improvement of the physical QoL appeared 1 week after inclusion (12.0 vs. 10.9 (95% CI -1.57;-0.63),p<0.001). Similarly, statistically significant improvement in the physical HS first occurred at 1 week follow-up (29.0 vs. 28.9 (95% CI -5.78; -2.23),p = 0.003). CONCLUSIONS: There is a clear difference between patients' functioning (HS) and the patients' appraisal of functioning (QoL). In elderly CLI patients, this study clearly suggests a discrepancy between the physical QoL (WHOQOL-BREF) and HS (SF-12) measurements in vascular amputees. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. Individual treatment goals should be kept in mind when assessing the HS or QoL outcome of patients undergoing hospital care. With respect to shared decision making, distinctive and subjective QoL questionnaires, like the WHOQOL-BREF, provide a very important outcome measurement and should be used in future research.

Is There an Important Role for Anxiety and Depression in the Elderly Patients with Critical Limb Ischemia, Especially After Major Amputation?

BACKGROUND: In patients with critical limb ischemia, an association is assumed between depression and worse outcome for morbidity, such as major limb amputation. After major amputation, anxiety and depression are common. We aimed to determine the association of depressive and anxiety symptoms in the elderly with critical limb ischemia, especially after major limb amputation. METHODS: Patients with critical limb ischemia aged ≥70 years were included in this prospective observational cohort study between January 2012 and February 2016 in 2 Dutch hospitals. After a multidisciplinary vascular conference, patients were divided into 4 treatment groups: endovascular revascularization, surgical revascularization, conservative therapy, and primary major amputation. In a 1-year follow-up period, depression and anxiety were measured 4 times using the Dutch versions of the Center for Epidemiological Studies Depression Scale and the State-Trait Anxiety Inventory. RESULTS: One Hundred eighty-seven patients were included. Within 1 year, 44 patients underwent a major limb amputation. Lower amputation-free survival did not differ significantly for patients with versus without greater anxiety (X2 [1] = 0.689, P = 0.407) and also not for patients with versus without more depressive symptoms (X2 [1] = 0.614, P = 0.433). For both groups, there were no significant changes in anxiety scores over time. After a median follow-up time of 336.5 days and 365 days, depressive symptoms significantly decreased in amputees, respectively, 8.5 vs. 4.5 (95% CI 1.76-7.48, P = 0.002) and 8.5 vs. 4.3 (95% CI 0.61-9.82, P = 0.027) when compared to the baseline measurement. Similarly, nonamputees had significantly lower overall score for depressive symptoms after a median follow-up time of 365 days (10.1 vs. 4.1, 95% CI 4.49 to 6.90, P < 0.001). CONCLUSIONS: In the opinion of the medical health care provider, amputation is a severe and unwanted end phase of critical limb ischemia. However, depressive symptoms seem to decrease over time and anxiety symptoms do not seem to be affected in patients after major limb amputation. In addition, patients with greater trait anxiety or more depressive symptoms at baseline did not have significantly higher amputation rates. These findings are similar to the course of depressive and anxiety symptoms for the elderly patients without major limb amputation.

A multicomponent prehabilitation pathway to reduce the incidence of delirium in elderly patients in need of major abdominal surgery: study protocol for a before-and-after study.

BACKGROUND: Due to the increase in elderly patients who undergo major abdominal surgery there is a subsequent increase in postoperative complications, prolonged hospital stays, health-care costs and mortality rates. Delirium is a frequent and severe complication in the 'frail' elderly patient. Different preoperative approaches have been suggested to decrease incidence of delirium by improving patients' baseline health. Studies implementing these approaches are often heterogeneous, have a small sample and do not provide high-quality or successful strategies. The aim of this study is to prevent postoperative delirium and other complications by implementing a unique multicomponent and multidisciplinary prehabilitation program. METHODS: This is a single-center controlled before-and-after study. Patients aged ≥70 years in need of surgery for colorectal cancer or an abdominal aortic aneurysm are considered eligible. Baseline characteristics (such as factors of frailty, physical condition and nutritional state) are collected prospectively. During 5 weeks prior to surgery, patients will follow a prehabilitation program to optimize overall health, which includes home-based exercises, dietary advice and intravenous iron infusion in case of anaemia. In case of frailty, a geriatrician will perform a comprehensive geriatric assessment and provide additional preoperative interventions when deemed necessary. The primary outcome is incidence of delirium. Secondary outcomes are length of hospital stay, complication rate, institutionalization, 30-day, 6- and 12-month mortality, mental health and quality of life. Results will be compared to a retrospective control group, meeting the same inclusion and exclusion criteria, operated on between January 2013 and October 2015. Inclusion of the prehabilitation cohort started in November 2015; data collection is ongoing. DISCUSSION: This is the first study to investigate the effect of prehabilitation on postoperative delirium. The aim is to provide evidence, based on a large sample size, for a standardized multicomponent strategy to improve patients' preoperative physical and nutritional status in order to prevent postoperative delirium and other complications. A multimodal intervention was implemented, combining physical, nutritional, mental and hematinic optimization. This research involves a large cohort, including patients most at risk for postoperative adverse outcomes. TRIAL REGISTRATION: The protocol is retrospectively registered at the Netherlands National Trial Register (NTR) number: NTR5932 . Date of registration: 05-04-2016.

The importance of increased awareness for delirium in elderly patients with rib fractures after blunt chest wall trauma: a retrospective cohort study on risk factors and outcomes.

BACKGROUND: Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma. METHODS: A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months. RESULTS: Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance. CONCLUSION: Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.

Life Expectancy and Outcome of Different Treatment Strategies for Critical Limb Ischemia in the Elderly Patients.

BACKGROUND: The treatment of critical limb ischemia (CLI) in the elderly patients is challenging because of the comorbidity and fragility of these patients. We analyzed survival in relation to different treatment options and estimated life expectancy of our study group by age and gender. METHODS: All patients aged ≥70 years, presenting with chronic CLI, between 2006 and 2013 were included. The treatment was conservative, endovascular, surgical, or by primary major amputation. The interest was in the effect of conservative versus nonconservative treatment on survival. Furthermore, we compared mortality and life expectancy between the study population to the overall Dutch population by age and gender. RESULTS: In total, 686 legs in 651 patients were treated. Initial treatment of patients was conservative (n = 181), endovascular (n = 259), surgical (n = 169), or amputation (n = 42). The overall 1-year mortality was 29%. Patients were stratified by age: 70-79 (n = 350) years and ≥80 (n = 301) years. Higher mortality rate ratios (RR) were found in octogenarians compared with patients aged 70-79 years, in the endovascular (P < 0.001) and surgical (P < 0.001) group. The mortality RRs of conservative relatively to nonconservative treatment was 0.84 (95% confidence interval: 0.65-1.09; P = 0.19), not significantly differing between both age groups (P = 0.74). The mortality RR of 3.72 of our study population to the Dutch general population was high, with an excess mortality of 272%. Life expectancy at the age of 70 years was substantially decreased by 9 and 8 years for, respectively, the male and female population. CONCLUSIONS: Mortality rates in elderly patients with CLI are high, corresponding with a decreased life expectancy, regardless of the type of intervention. Revascularization is associated with high periprocedural mortality, especially in octogenarians. Conservative treatment is noninferior to nonconservative treatment in terms of mortality and should be considered as the treatment in octogenarians with substantial comorbidity.