Endovascular surgery does not mitigate the adverse effects of frailty on the risk of losing life or limb.

OBJECTIVES: Evidence behind frail patients preferentially undergoing minimally invasive endovascular interventions for peripheral arterial disease remains sparse; thus, we evaluated the association of frailty and revascularization-approach with long-term mortality and major adverse limb events (MALEs).

METHODS: The Vascular Quality Initiative-Medicare-linked Vascular Implant Surveillance and Interventional Outcomes Network databases were queried for patients who had their first infrainguinal open or endovascular (endo) procedure between 2011 and 2015 (n = 27,200). Frailty was measured using the Vascular Quality Initiative Risk Analysis Index (RAI) and dichotomized into frail (RAI ≥ 37) and nonfrail (RAI < 37). The primary end points were 4-year mortality and MALE (major amputation and/or reintervention). Associations of frailty and approach were estimated using Kaplan-Meier analysis and multivariable Cox hazards regression using an interaction term and stratified by whether the procedure was performed for claudication or chronic-limb threatening ischemia (CLTI).

RESULTS: Frail patients experienced significantly worse mortality and amputation-free survival, but both frail and nonfrail patients experienced worse survival after an endovascular first approach (both log-rank P < .001). In adjusted Cox regression, frail patients with CLTI were at significantly increased risk of amputation (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.18-1.56; P < .0001), MALE (HR, 1.09; 95% CI, 1-1.19; P = .049), and mortality (HR, 2.70; 95% CI, 2.51-2.89; P < .0001) and an endovascular approach for CLTI demonstrated a similar pattern of adverse outcomes. However, interaction terms were not significant; the effects of frailty and approach did not influence each other. In patients with claudication, frailty was associated with increased mortality (HR, 3.05; 95% CI, 2.40-3.86; P < .0001) but not MALE, and an endovascular approach was associated with increased MALE but not amputation; interaction terms were again not significant.

CONCLUSIONS: Endovascular approach did not mitigate the adverse effects of frailty on life and limb-related outcomes, thereby underscoring the need for frailty screening and accordingly tailoring treatment and managing expectations given their high mortality risk.