Outcomes of Octogenarians and Nonagenarians Managed Under an Endovascular-First Approach to Chronic Limb-Threatening Ischemia: Treated versus Nonintervened Cohorts.

BACKGROUND

As life expectancy increases, the prevalence of chronic limb-threatening ischemia (CLTI) continues to rise, especially among octogenarians and nonagenarians. Endovascular interventions (EVIs) are associated with lower perioperative morbidity compared to open revascularization in elderly populations. The aim of this study was to evaluate outcomes among octogenarians and nonagenarians with CLTI managed under an endovascular-first approach, comparing those who underwent EVI to those who underwent diagnostic angiography without intervention (DX) due to anatomic or clinical unsuitability.

METHODS

This retrospective cohort study included patients aged ≥80 years with CLTI who underwent digital subtraction angiography between January 2019 and June 2023. Patients were excluded if younger than 80 years, had prior open bypass, or lacked follow-up. The decision to intervene was made intraoperatively by a vascular surgeon based on angiographic anatomy, comorbidities, frailty, and ambulation status. Limb salvage was the primary endpoint, and mortality and perioperative complications were secondary endpoints.

RESULTS

A total of 206 patients met the inclusion criteria (130 EVI and 76 DX). Demographics and comorbidities were comparable between groups. Limb salvage trended higher in the EVI group (79.3% vs. 67.6%; P = 0.06), while mortality was higher in the DX group (43.4% vs. 30%; P = 0.05). Frailty and renal impairment predicted mortality, while nonambulatory status and higher Global Limb Anatomic Staging System stage were associated with amputation.

CONCLUSION

An endovascular-first strategy is feasible and safe in elderly CLTI patients. When anatomically suitable, EVI should be offered, as it is associated with acceptable survival, limb salvage, and low complication rates. Frailty and functional status remain central to individualized treatment selection.