Acute limb ischemia in nonagenarians: Characteristics and factors related to outcomes in a single-center consecutive series.

BACKGROUND: The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. RESULTS: A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. CONCLUSION: Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.

Comparison Between Several CT-Derived Psoas Muscle Sarcopenia Markers for Predicting Survival After Abdominal Aortic Aneurysm Repair.

BACKGROUND: Multiple CT-derived measurements of sarcopenia have been described yet their relationship with survival after abdominal aortic aneurysm (AAA) repair has not been properly assessed. We aimed to define and compare the relationship between several psoas CT-derived measurements and the 5-year survival after AAA repair and to evaluate their potential contribution to survival prediction. METHODS: Preoperative CT area (TPA) and density (MTPD) of the psoas muscle at L3 were measured in 218 consecutive AAA patients electively intervened. Additional measurements were obtained by normalizing TPA by anthropometric data or L3-vertebra surface or by TPAxMTPD multiplication (lean psoas muscle area-LPMA). The association of sarcopenia markers with survival was evaluated with Cox models adjusted by age, sex, type of intervention and the Charlson Comorbidity Index, and their contribution to survival prediction assessed with the C-statistic and the Continuous Net Reclassification Index (c-NRI). RESULTS: Sixty patients (27.5%) died during the first 5 years after surgery. There was a statistically significant and linear (spline analysis) relationship of sarcopenia markers with 5-year survival in all multivariate models, except that including LPMA. Despite this association, the inclusion of sarcopenia markers did not improve the C-statistic and moderately increased the c-NRI. None normalized sarcopenia markers performed better than TPA. CONCLUSION: The majority of CT-derived psoas muscle measurements of sarcopenia showed a significant and independent relationship with survival after elective AAA repair. Despite this association, they did not appear to improve sufficiently our survival prediction ability to become an efficient tool for decision-making.

Critical Limb Ischemia in Nonagenarians: A Challenge of Our Times.

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.

Outcome of elective endovascular repair of abdominal aortic aneurysms in octogenarians.

AIM: The need to adjust the indications of elective abdominal aortic aneurysm (AAA) repair among patients with a limited life-span deserves a specific evaluation for octogenarians. The aim of this study was to compare the postoperative results and the long-term survival after endovascular repair of abdominal aortic and/or iliac aneurysms (EVAR) in octogenarians compared with patients under 80 years of age. METHODS: Retrospective analysis of 241 consecutive patients who underwent an elective EVAR between 2000 and 2017. EVAR was not considered among patients with clear life-limiting conditions. Patients receiving other than commercially standard infra-renal endoprostheses were excluded. RESULTS: Seventy patients (29.0%) were octogenarians. They had a lower rate of active smoking (10.0% vs. 30.4%, P < 0.001) and a higher prevalence of previous cerebrovascular disease (21.4% vs. 11.7%, P = 0.055) than younger patients. Thirty-day/in-hospital complication and mortality rates were not significantly higher among octogenarians when compared with younger patients (24.3% vs. 16.9% and 2.9% vs. 2.4%, respectively). Octogenarians had a lower long-term survival at 1, 3 and 5 years (92.6% vs. 93.3%, 67.7% vs. 78.0% and 39.3% vs. 60.6%, P = 0.039) in the bivariate analysis. However, an age ≥ 80 years per se was not an independent predictor of survival after adjustment for confounding factors. CONCLUSION: An age above 80 years was not associated with an increased risk of postoperative complications or long-term mortality. Our results suggest that EVAR can be considered in elderly patients without a clear life-limiting condition and with a suitable aneurysm anatomy. Geriatr Gerontol Int 2021; 21: 392-397.