Division of Vascular Surgery, Department of Surgery, Madison School of Medicine and Public Health, University of Wisconsin, Madison, WI.
Division of Vascular Surgery, Department of Surgery, Madison School of Medicine and Public Health, University of Wisconsin, Madison, WI.
Ann Vasc Surg. 2023 Sep;95:178-183. doi: 10.1016/j.avsg.2023.04.003. Epub 2023 Apr 15.
Elderly patients with critical limb ischemia are an especially frail and vulnerable group of patients. There is little literature investigating outcomes and resource utilization in nonagenarians undergoing major lower extremity amputation (MLEA). This study aims to elucidate the outcomes of this unique set of patients for whom amputation may often be considered a "palliative" intervention.
Analyzing over 16,000 records from the Vascular Quality Initiative (VQI) database, we collected demographic, operative, and postoperative data on all patients who underwent an MLEA. We performed univariate analysis comparing nonagenarians to younger patients examining both short-term and long-term outcomes. Multimodel inference was used to analyze the effect of age on clinically meaningful outcomes: mortality and long-term living disposition.
With 392 nonagenarians and 16,349 patients under the age of 90, we found nonagenarians were less comorbid and less likely to have a prior bypass or amputation. Despite experiencing lower rates of reoperation and individual postoperative complications, nonagenarians suffered higher long-term mortality (46% vs. 22%, P < 0.0005) and were more likely to be living in a facility at follow-up (34% vs. 15%, P < 0.0005). Incorporating important demographic and clinical factors, multimodel inference demonstrated that, the nonagenarian age group was a critical predictor of nonhome living status (Akaike Importance weight 0.99).
Although nonagenarians were less comorbid than their younger counterparts and suffered fewer perioperative complications, MLEA leads to a poorer outcome with significant mortality and a higher likelihood of residing in a facility at long-term follow-up. These findings underscore the importance of frank goals of care discussions in nonagenarians considering major amputation.
患有严重肢体缺血的老年患者是一组特别脆弱和易受伤害的患者群体。很少有文献研究接受大肢体截肢（MLEA）的 90 岁以上患者的结局和资源利用情况。本研究旨在阐明这组独特患者的结局，对于这些患者来说，截肢通常可能被视为一种“姑息性”干预。
我们分析了血管质量倡议（VQI）数据库中的超过 16000 个记录，收集了所有接受 MLEA 的患者的人口统计学、手术和术后数据。我们进行了单变量分析，比较了 90 岁以上的老年人与年轻患者，检查了短期和长期结局。多模型推理用于分析年龄对有临床意义的结局的影响：死亡率和长期生存状况。
在 392 名 90 岁以上的老年人和 16349 名 90 岁以下的患者中，我们发现 90 岁以上的老年人合并症较少，且不太可能有先前的旁路或截肢。尽管再手术率和个别术后并发症较低，但 90 岁以上的老年人长期死亡率较高（46%比 22%，P<0.0005），在随访时更有可能居住在机构中（34%比 15%，P<0.0005）。多模型推理纳入了重要的人口统计学和临床因素，结果表明，90 岁以上的年龄组是非居家生活状态的关键预测因素（Akaike 重要性权重 0.99）。
尽管 90 岁以上的老年人比年轻患者合并症少，围手术期并发症少，但 MLEA 导致死亡率显著增加，且长期随访时更有可能居住在机构中，结局较差。这些发现强调了在考虑大截肢时，与 90 岁以上的老年人进行坦率的治疗目标讨论的重要性。
