In octogenarians with chronic limb-threatening ischaemia (CLTI), researchers found a one-year mortality rate of 32% after revascularisation, which was significantly higher than in non-octogenarians. Amputation rates were comparable between both age groups.
The authors—Lina F Wübbeke (Maastricht University Medical Centre, Maastricht, The Netherlands), Barend ME Mees (Maastricht University Medical Centre, European Vascular Centre, Aachen-Maastricht, Germany, and European Vascular Centre, Maastricht, the Netherlands) and colleagues—comment that this mortality rate is “substantial”.
Writing in the European Journal of Vascular and Endovascular Surgery (EJVES), they remark: “This [outcome] is of major importance to clinical practice to inform patients and colleagues adequately during the decision-making process of any intervention in this fragile patient group.”
The authors do acknowledge, however, that only low-quality evidence could be obtained supporting the results of this meta-analysis, because only observational studies were available for inclusion. Therefore, they stress that the results should be “interpreted with caution”.
Discussing their methods, Wübbeke, Mees, and colleagues detail that two independent researchers searched systematically Medline, Embase, and Cochrane Library databases. Meta-analyses were performed to analyse one-year mortality, one-year major amputation, and one-year amputation-free survival (AFS) after revascularisation.
They specify that pooled outcome estimates were reported as percentages and odds ratio (OR) with 95% confidence intervals (CI). In addition, sensitivity and subgroup analyses were performed and the quality of evidence was determined according to the GRADE system.
Wübbeke, Mees et al write that the review includes 21 observational studies with patients who were treated for CLTI, and that a meta-analysis of 12 studies with a total of 17,118 patients was performed.
Writing in EJVES, the authors report that a mortality rate of 32% was found in octogenarians (95% CI 27–37%), which was almost double the mortality rate in the non-octogenarians (17%, 95% CI 11–22%/OR 2.52, 95% CI 1.93–3.29; GRADE: “low”).
They also state that no significant difference in amputation rate was found (octogenarians 15%, 95% CI 11–18%; non-octogenarians 12%, 95% CI 7–14%; GRADE: “very low”), and that amputation-free survival (AFS) was significantly lower in the octogenarian group (OR 1.55, 95% CI 1.03–2.43; GRADE: “very low”).
In a subgroup analysis differentiating between endovascular and surgical revascularisation, amputation rates were comparable, Wübbeke and colleagues detail. For octogenarians, those treated conservatively had a mortality rate significantly higher than those treated by revascularisation (OR 1.76, 95% CI 1.19–2.6; GRADE: “very low”). No significant difference in mortality rate was found between primary amputation and revascularisation in octogenarians (OR 0.7, 95% CI 0.24–2.03; GRADE: “very low”).
In the discussion of their findings, Wübbeke, Mees et al recognise that their study is limited by the weakness of the available evidence.
“No randomised controlled trials were available for inclusion,” they write, adding that 19 of the 21 studies were retrospective cohort studies, “increasing the risk of information bias”. They add that the current Global Vascular Guidelines on the Management of CLTI also stressed that high-quality data on ‘evidence-based revascularisation’ is limited.
Considering future research, Wübbeke, Mees et al recognise that additional studies are needed “to provide more solid results and to determine the optimal management of octogenarians with CLTI”. Moreover, they write that outcomes after revascularisation have to be compared with outcomes after conservative treatment or primary amputation and standardised study designs and endpoints should be used as promoted by the current Global Vascular Guidelines on the Management of CLTI.
Finally, they state that these results should also be used to develop adequate risk scores, enabling appropriate patient selection, and that quality of life studies should be performed to decide whether revascularisation interventions are always indicated in this group of frail patients.