Frailty: What Happens When We Are Too Late in Critical Lower Limb Ischemia

This condition, now “trending” among patients undergoing transcatheter aortic valve replacement (TAVR), has expanded to almost all patients we treat, always with the same outcome: the prognosis is bad, so bad that it might warrant making the difficult decision of not going forward. The association between frailty and bad prognosis is easy to see and derives from common sense; studies only provide figures. The difficult task here lies in its definition, since many aspects are quite subjective.

The results of this work are not surprising; they simply translate into statistics a reality we already imagined.

This study enrolled 643 patients with critical lower limb ischemia, among whom 486 were treated with endovascular therapy and 157 were treated with surgery. Each patient was assessed using a 9-level clinical frailty scale, and patients were divided into 3 groups: low (level 1-3, 213 patients), intermediate (level 4-6, 196 patients), and high (level 7-9, 213 patients) frailty. The follow-up period for these patients was 2 years.

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The survival rates in the low, intermediate, and high frailty groups were 80.5%, 63.1%, and 49.3%, respectively (p < 0.001). The amputation-free survival rates were 77.9 %, 60.5 %, and 46.2 %, respectively (p < 0.001).

In a multivariate analysis, higher frailty was independently associated with all-cause death and a composite of all-cause death and amputation. This association was observed in patients aged ≤75 as well as >75 years, both in those who underwent endovascular therapy or surgery, and in those with renal failure or normal kidney function.

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Frailty is here to stay and we will continue seeing it in our daily practice. However, the calculation of multiple scores is anything but practical and far from reality.

Conclusion

Frailty was independently associated with 2-year survival and major amputation in patients with critical lower limb ischemia regardless of age, revascularization type, or renal failure status.

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

Reference: Yasuaki Takeji et al. Circ Cardiovasc Interv. 2018;11:e006778.

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