Erben Young, Mena-Hurtado Carlos I, Miller Samuel M, Jean Raymond A, Sumpio Brandon J, Velasquez Camilo A, Mojibian Hamid, Aruny John, Dardik Alan, Sumpio Bauer E
Section of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Catheter Cardiovasc Interv. 2018 Jun;91(7):1331-1338. doi: 10.1002/ccd.27523. Epub 2018 Feb 6.
Treatment for lifestyle limiting claudication (LLC) that is due to infra-inguinal peripheral artery disease relies on either bypass, angioplasty, and/or stenting. Given the enthusiasm and shift toward more endovascular therapy for treatment of LLC, we sought to analyze whether octogenarians benefit from infra-inguinal interventions in the same manner as their younger counterparts.
We identified all patients admitted for elective treatment of LLC from the Nationwide Inpatient Sample from 2003 to 2012, who received open surgical or endovascular intervention for infra-inguinal peripheral arterial disease. These patients were divided into two groups including those between the ages 60-80 years (younger cohort) and those older than 80 years (octogenarians). Primary end-points included morbidity and mortality and the secondary end-points were length of hospital stay (LOS) and disposition after dismissal.
Among 59,323 discharges identified in the dataset, 34,658 (58%) were males. There were 50,323 (85%) patients in the younger cohort and 9,000 (15%) octogenarians. The mean age was 69.9 ± 5.7 years and 84.2 ± 3.0 years for the younger cohort and octogenarians, respectively. The mean Charlson comorbidity index (CCI) was higher in our younger cohort (2.1 ± 1.1, P < 0.001). Octogenarians mainly treated with open surgery prior to 2004 are now treated endovascularly and this trend has remained stable. The younger cohort's treatment modality has fluctuated through the study period and most recently is treated mainly with open surgery. The rate of acute kidney injury, exacerbation of congestive heart failure and mortality was higher in octogenarians (P < 0.001). The rate of infectious wound complications was higher in the younger cohort (P < 0.05). Octogenarians have longer LOS and are dismissed in higher percentage to a skilled nursing facility (P < 0.001). On binary logistic regression analysis, age over 80 years, female sex, higher CCI and having an open as opposed to an endovascular procedure are independent predictors of in-hospital mortality.
Although endovascular techniques seem to dominate the care for octogenarians with LLC, the overall morbidity and mortality rates are significantly higher in this patient population. Other options such as medical management and/or supervised exercise therapy should be explored in this patient group.
因腹股沟下外周动脉疾病导致的生活方式受限性跛行（LLC）的治疗依赖于搭桥、血管成形术和/或支架置入术。鉴于对LLC治疗采用更多血管内治疗的热情和转变，我们试图分析八旬老人是否能像年轻患者一样从腹股沟下干预中获益。
我们从2003年至2012年的全国住院患者样本中确定了所有因LLC择期治疗入院的患者，这些患者接受了腹股沟下外周动脉疾病的开放手术或血管内干预。这些患者被分为两组，包括60 - 80岁的患者（较年轻队列）和80岁以上的患者（八旬老人）。主要终点包括发病率和死亡率，次要终点是住院时间（LOS）和出院后的处置情况。
在数据集中确定的59323例出院病例中，34658例（58%）为男性。较年轻队列中有50323例（85%）患者，八旬老人有9000例（15%）。较年轻队列和八旬老人的平均年龄分别为69.9±5.7岁和84.2±3.0岁。较年轻队列的平均查尔森合并症指数（CCI）更高（2.1±1.1，P<0.001）。2004年前主要接受开放手术治疗的八旬老人现在采用血管内治疗，且这一趋势保持稳定。在研究期间，较年轻队列的治疗方式有所波动，最近主要采用开放手术治疗。八旬老人的急性肾损伤、充血性心力衰竭加重和死亡率更高（P<0.001）。较年轻队列的感染性伤口并发症发生率更高（P<0.05）。八旬老人的住院时间更长，出院后被送往专业护理机构的比例更高（P<0.001）。在二元逻辑回归分析中，80岁以上、女性、CCI较高以及接受开放手术而非血管内手术是院内死亡的独立预测因素。
尽管血管内技术似乎主导了对患有LLC的八旬老人的治疗，但该患者群体的总体发病率和死亡率显著更高。对于该患者群体，应探索其他选择，如药物治疗和/或监督运动疗法。
