Infrainguinal bypass for limb salvage has comparable mortality and affords a better chance of home discharge than amputation among octogenarians

Abstract

Objective

Infrainguinal bypass for chronic limb-threatening ischemia in octogenarians is considered a high-risk procedure due to the presumed associated frailty of the patient population. However, the alternative, which is major amputation, may not be a better option. This study retrospectively compares the outcomes of bypass vs major amputation for functionally independent and partially dependent patients.

Methods

Patients greater than and equal to 80 years old who underwent nonemergent infrainguinal bypasses for chronic limb-threatening ischemia presenting with rest pain/tissue loss were selected from the targeted American College of Surgeons National Surgical Quality Improvement Program database between 2011 and 2022. Patients with major amputations (Current Procedural Terminology codes 27,880, 27,882, 27,590, 27,592) for atherosclerosis by International Classification of Diseases-9/-10 codes were selected from the general database. We stratified the patients based on functional status (independent or partially dependent) and compared outcomes of bypass vs amputation within each group. Multivariable logistic regression was performed for 30-day mortality, major organ dysfunction, length of stay, and discharge destinations.

Results

There were 2419 patients who underwent a bypass and 1326 patients who underwent an amputation in the independent functional group. Patients with bypass were generally healthier. Multivariable analysis revealed that having a bypass was associated with significantly higher major adverse cardiac events (adjusted odds ratio [aOR], 1.7; P < .01), bleeding requiring transfusion (aOR, 4.3; P < .01), and wound complications (aOR, 1.7; P < .01). There was no significant difference in mortality, renal complications, or sepsis. Additionally, bypass patients had longer operation time (P < .01) and return to the operating room (aOR, 2.7; P < .01). However, bypass patients were more likely to be discharged to home rather than to a facility (aOR, 4.2; P < .01). Similar outcomes were observed for partially dependent patients, except that bypass patients had a longer length of stay (12.40 ± 9.86 vs 10.78 ± 9.94 days; P < .01).

Conclusions

Bypass for limb salvage for octogenarians does incur higher morbidities than amputation but does not increase mortality. The immediate higher morbidities of bypass should be weighed against a better chance of home discharge, which could potentially imply less functional decline.