Frailty and Critical Limb ischemia: Facing a New Challenge

Courtesy of Dr. Carlos Fava.

Critical limb ischemia is the final stage of peripheral vascular disease and is associated to pain at rest, trophic lesions, and gangrene. It is also associated to amputation and reduced mobility.

When it happens in frail patients, it presents a challenge. This population is on the rise and there is little information on its evolution.

The study looked at 643 patients with critical limb ischemia. 486 received PCI and 157 received surgery.

To assess frailty, researchers used the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), and divided patients in 3 groups according to risk: low = 234 patients (36.2%), intermediate = 196 (30.3%) and high = 213 (33%).

Read also: What Is the Prognosis for Reinterventions in Critical Lower Limb Ischemia?

Mean age was 74.5 years, 60% were men, 68% diabetic, 50% were on dialysis. They were all Rutherford class 4, 5, or 6. Half of them presented trophic lesions, more often those at high risk. Age and BMI ≤21 was higher in the high-risk group.

AT 2 year follow up, survival rate was 80.5% for the low risk group, 63.1% for the intermediate risk group, and 49.3% (p<0.001) for the high-risk group. Survival free of amputation was 77.9%, 60.5%, and 46.2% (P<0.001) for the low, intermediate and high-risk groups, respectively.

On multivariable analysis, frailty risk was independently associated with all-cause mortality (intermediate group: adjusted hazard ratio, 1.64; 95% confidence interval, 1.12-2.42; P=0.01; high CFS group: adjusted hazard ratio, 2.22; 95% confidence interval, 1.52-3.23; P<0.001) and the composite of all-cause mortality and major amputation (intermediate risk group: adjusted hazard ratio, 1.72; 95% confidence interval, 1.19-2.48; P=0.004; high risk group: adjusted hazard ratio, 2.34; 95% confidence interval, 1.64-3.35; P<0.001).

Read also: Lesion Targeting Seems to Be the Secret in Critical Ischemia.

In addition, frailty was independently associated to all-cause mortality and major amputation of patients >75 and <75 years, regardless of PCI or surgery and regardless renal function.

Conclusion

At 2 year follow up, frailty was independently associated to survival and survival free of amputation in patients with critical limb ischemia treated with revascularization, regardless age, type of revascularization and kidney function.

Commentary

These findings show us that frailty itself, as risk factor, presents bad evolution at 2 years in terms of mortality and major amputation, showing a direct correlation with patient risk.

As we know, at present, this population is growing, and it presents a challenge, given that most times aggressive intervention is not recommended, since it would increase periprocedural complications.

Courtesy of Dr. Carlos Fava.

Original title: Impact of Frailty on Clinical Outcomes in Patients With Critical Limb Ischemia

Reference: Yasuaki Takeji, et al. Circulation: Cardiovascular Interventions. 2018;11:e006778

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