Pub Date : 2025-12-01DOI: 10.1053/j.semvascsurg.2025.08.002
Christopher E. Holden-Wingate , Lucinda R. Holden-Wingate , Abraham Hussain , Navya R.K. Kotturu , Danielle Montano , Abena Appah-Sampong , Aurelie Tran , Brett J. Salomon , C. Keith Ozaki , Dirk M. Hentschel , Mohamad A. Hussain
More than 800,000 people live with end-stage kidney disease (ESKD) in the United States, and the incidence continues to rise. Further, the treatment landscape is evolving due to increasing prevalence of risk factors, such as diabetes and the aging United States population. More than ever, the creation and management of hemodialysis accesses require a multidisciplinary, team-based approach to provide care effectively. However, there is limited available research on the effects of multidisciplinary team (MDT)-based care in arteriovenous (AV) access outcomes and there remains no widely accepted standard regarding the composition and function of the required processes within an MDT. This manuscript provides an overview of the current literature on MDTs in AV access care, utilizing 5 specific examples where an MDT would be especially pertinent for optimizing patient care and outcomes. Our findings suggest a benefit from initiating an MDT model in AV access care and highlight potential improvements in catheter-free days and patient and provider satisfaction.
{"title":"Team-based approach to arteriovenous access management","authors":"Christopher E. Holden-Wingate , Lucinda R. Holden-Wingate , Abraham Hussain , Navya R.K. Kotturu , Danielle Montano , Abena Appah-Sampong , Aurelie Tran , Brett J. Salomon , C. Keith Ozaki , Dirk M. Hentschel , Mohamad A. Hussain","doi":"10.1053/j.semvascsurg.2025.08.002","DOIUrl":"10.1053/j.semvascsurg.2025.08.002","url":null,"abstract":"<div><div>More than 800,000 people live with end-stage kidney disease (ESKD) in the United States, and the incidence continues to rise. Further, the treatment landscape is evolving due to increasing prevalence of risk factors, such as diabetes and the aging United States population. More than ever, the creation and management of hemodialysis accesses require a multidisciplinary, team-based approach to provide care effectively. However, there is limited available research on the effects of multidisciplinary team (MDT)-based care in arteriovenous (AV) access outcomes and there remains no widely accepted standard regarding the composition and function of the required processes within an MDT. This manuscript provides an overview of the current literature on MDTs in AV access care, utilizing 5 specific examples where an MDT would be especially pertinent for optimizing patient care and outcomes. Our findings suggest a benefit from initiating an MDT model in AV access care and highlight potential improvements in catheter-free days and patient and provider satisfaction.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 4","pages":"Pages 404-411"},"PeriodicalIF":2.4,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145712386","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.07.003
Gloria Sanin, Elizabeth Wood, Heather Ots, Hope Werenski, Gabriela Velazquez
Renal artery aneurysms (RAAs) are rare but clinically significant vascular abnormalities. The management of RAA in older adults poses unique challenges related to their baseline comorbidities and age-related vascular changes. Traditionally, open surgery has been the gold standard for large or complex RAA. However, recent data and guidelines support a more conservative threshold for intervention and broader adoption of endovascular therapies, which offer lower perioperative morbidity, shorter hospital stays, and overall faster recovery. General indications for repair include symptomatic aneurysms, medically refractory hypertension, and lesions ≥3 cm. Medical management and surveillance are appropriate for asymptomatic patients with stable aneurysms < 3 cm, especially for those with limited life expectancy. Open surgical techniques include both in situ and ex vivo reconstructions with demonstrated long-term durability but are associated with higher perioperative risk. Endovascular techniques, including coil embolization and stent grafting, are increasingly being used in anatomically suitable patients with high success. Postoperative outcomes suggest comparable long-term results between open and endovascular approaches. However, endovascular repair is associated with fewer complications and is increasingly preferred in elderly or high-risk populations. An individualized approach is essential to optimize outcomes, balancing the risks of intervention with the natural history of the disease. This is a review of the epidemiology, diagnosis, management, and outcomes of RAAs in older adults.
{"title":"Management and Outcomes of Renal Artery Aneurysms in Older Adults","authors":"Gloria Sanin, Elizabeth Wood, Heather Ots, Hope Werenski, Gabriela Velazquez","doi":"10.1053/j.semvascsurg.2025.07.003","DOIUrl":"10.1053/j.semvascsurg.2025.07.003","url":null,"abstract":"<div><div>Renal artery aneurysms (RAAs) are rare but clinically significant vascular abnormalities. The management of RAA in older adults poses unique challenges related to their baseline comorbidities and age-related vascular changes. Traditionally, open surgery has been the gold standard for large or complex RAA. However, recent data and guidelines support a more conservative threshold for intervention and broader adoption of endovascular therapies, which offer lower perioperative morbidity, shorter hospital stays, and overall faster recovery. General indications for repair include symptomatic aneurysms, medically refractory hypertension, and lesions ≥3 cm. Medical management and surveillance are appropriate for asymptomatic patients with stable aneurysms < 3 cm, especially for those with limited life expectancy. Open surgical techniques include both in situ and ex vivo reconstructions with demonstrated long-term durability but are associated with higher perioperative risk. Endovascular techniques, including coil embolization and stent grafting, are increasingly being used in anatomically suitable patients with high success. Postoperative outcomes suggest comparable long-term results between open and endovascular approaches. However, endovascular repair is associated with fewer complications and is increasingly preferred in elderly or high-risk populations. An individualized approach is essential to optimize outcomes, balancing the risks of intervention with the natural history of the disease. This is a review of the epidemiology, diagnosis, management, and outcomes of RAAs in older adults.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 258-270"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.07.005
Oliver O. Aalami , Matthew A. Corriere
Claudication from peripheral artery disease is a common mobility-limiting condition in older adults. Exercise therapy, whether delivered through supervised programs or structured home-based programs, plays a central role in claudication care for older adults, offering substantial functional gains with minimal risk, and should be the cornerstone of management alongside optimized medical therapy. This review examines contemporary management of claudication in the aging population, with emphasis on exercise therapy. Treatment modalities, including best medical therapy, supervised exercise therapy, home-based exercise programs, and invasive interventions (endovascular and open surgery) are critically evaluated. Pharmacotherapy (eg, cilostazol) can modestly improve walking distance, and aggressive risk factor control (eg, smoking cessation and statins) is imperative for all patients. Invasive revascularization is reserved for select individuals with lifestyle-limiting claudication unresponsive to conservative measures, given procedural risks and the potential for repeated interventions. Recent society guidelines (American College of Cardiology and the American Heart Association 2016 and European Society for Vascular Surgery 2024) and the Society for Vascular Surgery's 2025 focused update uniformly endorse exercise and medical therapy as initial management, restricting revascularization to severe claudication after conservative therapy trials and emphasizing individualized shared decision-making approaches. Claudication outcomes (ankle–brachial index changes, 6-minute walk improvements, and patient-reported outcomes) across treatments are reviewed alongside indications, contraindications, and benefits of each strategy.
{"title":"Management of claudication in older adults and the role of exercise therapy","authors":"Oliver O. Aalami , Matthew A. Corriere","doi":"10.1053/j.semvascsurg.2025.07.005","DOIUrl":"10.1053/j.semvascsurg.2025.07.005","url":null,"abstract":"<div><div>Claudication from peripheral artery disease is a common mobility-limiting condition in older adults. Exercise therapy, whether delivered through supervised programs or structured home-based programs, plays a central role in claudication care for older adults, offering substantial functional gains with minimal risk, and should be the cornerstone of management alongside optimized medical therapy. This review examines contemporary management of claudication in the aging population, with emphasis on exercise therapy. Treatment modalities, including best medical therapy, supervised exercise therapy, home-based exercise programs, and invasive interventions (endovascular and open surgery) are critically evaluated. Pharmacotherapy (eg, cilostazol) can modestly improve walking distance, and aggressive risk factor control (eg, smoking cessation and statins) is imperative for all patients. Invasive revascularization is reserved for select individuals with lifestyle-limiting claudication unresponsive to conservative measures, given procedural risks and the potential for repeated interventions. Recent society guidelines (American College of Cardiology and the American Heart Association 2016 and European Society for Vascular Surgery 2024) and the Society for Vascular Surgery's 2025 focused update uniformly endorse exercise and medical therapy as initial management, restricting revascularization to severe claudication after conservative therapy trials and emphasizing individualized shared decision-making approaches. Claudication outcomes (ankle–brachial index changes, 6-minute walk improvements, and patient-reported outcomes) across treatments are reviewed alongside indications, contraindications, and benefits of each strategy.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 271-280"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.06.001
Yashashwini Sudina , Hind Anan , Joelle Daher , Rabih A. Chaer
Chronic mesenteric ischemia (CMI) is a rare, yet increasingly prevalent, condition, especially among older adults. Diagnosing CMI in older adults presents significant challenges. Along with the burden of comorbidities and the physiological changes associated with aging, timely intervention is often delayed, leading to poorer outcomes. Current diagnostic protocols and treatment guidelines do not address the unique challenges faced by this population. In this comprehensive review, the authors examined the existing literature on diagnostic strategies and management options for CMI in older adults. The importance of a thorough preoperative workup and early optimization to minimize perioperative stress, while considering nutritional and functional capabilities, is emphasized. Risk stratification models incorporating frailty and other geriatric-specific indices can inform therapeutic decisions and improve outcomes. Despite the increasing disease burden in this group, there are limited data on long-term outcomes, the impact of nutrition, and quality of life metrics after intervention. This emphasizes the necessity for more prospective studies to address these gaps and implement age-specific approaches for the evaluation and treatment of older adult patients with CMI.
{"title":"Management and outcomes of chronic mesenteric ischemia in older adults: A comprehensive review","authors":"Yashashwini Sudina , Hind Anan , Joelle Daher , Rabih A. Chaer","doi":"10.1053/j.semvascsurg.2025.06.001","DOIUrl":"10.1053/j.semvascsurg.2025.06.001","url":null,"abstract":"<div><div>Chronic mesenteric ischemia (CMI) is a rare, yet increasingly prevalent, condition, especially among older adults. Diagnosing CMI in older adults presents significant challenges. Along with the burden of comorbidities and the physiological changes associated with aging, timely intervention is often delayed, leading to poorer outcomes. Current diagnostic protocols and treatment guidelines do not address the unique challenges faced by this population. In this comprehensive review, the authors examined the existing literature on diagnostic strategies and management options for CMI in older adults. The importance of a thorough preoperative workup and early optimization to minimize perioperative stress, while considering nutritional and functional capabilities, is emphasized. Risk stratification models incorporating frailty and other geriatric-specific indices can inform therapeutic decisions and improve outcomes. Despite the increasing disease burden in this group, there are limited data on long-term outcomes, the impact of nutrition, and quality of life metrics after intervention. This emphasizes the necessity for more prospective studies to address these gaps and implement age-specific approaches for the evaluation and treatment of older adult patients with CMI.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 250-257"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007591","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.06.006
Shannon N. Radomski, Courtenay M. Holscher
As the world’s elderly population continues to grow, the proportion of people living with chronic medical conditions is also increasing. Cardiovascular diseases including hypertension, diabetes, and atherosclerosis are among the most common, and as a result peripheral artery disease (PAD) is increasingly prevalent in this population. It is estimated that 15% to 20% of the elderly population has been diagnosed with PAD, and consequentially there is also a large proportion who have progressed to chronic limb threatening ischemia (CLTI). The management of this end stage of PAD is complex regardless of age, as there is high variability in current practice patterns and a lack of consensus on endovascular or surgical bypass as the initial treatment modality. The treatment paradigm becomes even more complicated in the elderly population, and special considerations must be given to treatment including the decision to offer revascularization (surgical or endovascular) vs primary amputation. This article explores the risks and benefits of the 2 approaches in the context of mortality, quality of life, and cost in the elderly population. Although there is good evidence that revascularization confers benefits in mortality, quality of life, and cost, there are also data that indicate that this approach should only be offered to fully independent individuals as outcomes in those with a nonambulatory status preoperatively are poor. Overall, the authors advocate for a patient-centered, multidisciplinary approach to treating CLTI in this population that focuses first and foremost on patient goals.
{"title":"Navigating treatment decisions for CLTI in older adults: Primary amputation vs revascularization","authors":"Shannon N. Radomski, Courtenay M. Holscher","doi":"10.1053/j.semvascsurg.2025.06.006","DOIUrl":"10.1053/j.semvascsurg.2025.06.006","url":null,"abstract":"<div><div>As the world’s elderly population continues to grow, the proportion of people living with chronic medical conditions is also increasing. Cardiovascular diseases including hypertension, diabetes, and atherosclerosis are among the most common, and as a result peripheral artery disease (PAD) is increasingly prevalent in this population. It is estimated that 15% to 20% of the elderly population has been diagnosed with PAD, and consequentially there is also a large proportion who have progressed to chronic limb threatening ischemia (CLTI). The management of this end stage of PAD is complex regardless of age, as there is high variability in current practice patterns and a lack of consensus on endovascular or surgical bypass as the initial treatment modality. The treatment paradigm becomes even more complicated in the elderly population, and special considerations must be given to treatment including the decision to offer revascularization (surgical or endovascular) vs primary amputation. This article explores the risks and benefits of the 2 approaches in the context of mortality, quality of life, and cost in the elderly population. Although there is good evidence that revascularization confers benefits in mortality, quality of life, and cost, there are also data that indicate that this approach should only be offered to fully independent individuals as outcomes in those with a nonambulatory status preoperatively are poor. Overall, the authors advocate for a patient-centered, multidisciplinary approach to treating CLTI in this population that focuses first and foremost on patient goals.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 291-300"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007517","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.06.008
Lucinda R. Holden-Wingate , Christopher E. Holden-Wingate , Abena Appah-Sampong , Melissa Cruz , C. Keith Ozaki , Dirk M. Hentschel , Mohamad A. Hussain
The rate of end-stage kidney disease (ESKD) is steadily rising in the United States, and older adults (ie, 65 years and older) represent the fastest-growing segment in need of hemodialysis. This demographic shift presents unique challenges due to age-related comorbidities, frailty, and increased procedural risks. Despite these challenges, there is limited guidance for risk stratification and management of renal replacement therapy in older patients with ESKD. The authors provide a review of current literature and tools to characterize high-risk older patients with ESKD, focusing on the following three key considerations when planning for permanent hemodialysis access placement: vascular anatomy, frailty, and ESKD Life-Plan considerations. Within this population of older patients, consideration of areas of focus for the history and physical examination, preoperative vascular imaging studies, hemodialysis access type, timing of access placement, type of anesthesia used, and multidisciplinary teams are discussed. Our findings suggest that applying a systematic approach to care that incorporates these key considerations may present a route for improving outcomes in this vulnerable population; however, further research is needed.
{"title":"Hemodialysis access planning and outcomes in older adults","authors":"Lucinda R. Holden-Wingate , Christopher E. Holden-Wingate , Abena Appah-Sampong , Melissa Cruz , C. Keith Ozaki , Dirk M. Hentschel , Mohamad A. Hussain","doi":"10.1053/j.semvascsurg.2025.06.008","DOIUrl":"10.1053/j.semvascsurg.2025.06.008","url":null,"abstract":"<div><div>The rate of end-stage kidney disease (ESKD) is steadily rising in the United States, and older adults (ie, 65 years and older) represent the fastest-growing segment in need of hemodialysis. This demographic shift presents unique challenges due to age-related comorbidities, frailty, and increased procedural risks. Despite these challenges, there is limited guidance for risk stratification and management of renal replacement therapy in older patients with ESKD. The authors provide a review of current literature and tools to characterize high-risk older patients with ESKD, focusing on the following three key considerations when planning for permanent hemodialysis access placement: vascular anatomy, frailty, and ESKD Life-Plan considerations. Within this population of older patients, consideration of areas of focus for the history and physical examination, preoperative vascular imaging studies, hemodialysis access type, timing of access placement, type of anesthesia used, and multidisciplinary teams are discussed. Our findings suggest that applying a systematic approach to care that incorporates these key considerations may present a route for improving outcomes in this vulnerable population; however, further research is needed.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 314-322"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007525","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.06.002
Carly G. Sobol, Corinne Praska, Margaret L. Schwarze
Vascular surgeons are often responsible for navigating treatment decisions when caring for older adults. Care for these patients is informed by the surgeon’s assessment of the patient’s decision-making capacity, use of advance care planning, and understanding of futility. Having difficult conversations with patients and their families is supported by strategies that promote empathic communication and shared decision making with older adults with serious illness due to, and associated with, vascular disease. These strategies include avoiding the cognitive trap, using heads-up and headline statements, best case and worst case to manage uncertainty, and better conversations to provide informed consent.
{"title":"Ethical considerations and the role of shared decision making in the vascular care of older adults","authors":"Carly G. Sobol, Corinne Praska, Margaret L. Schwarze","doi":"10.1053/j.semvascsurg.2025.06.002","DOIUrl":"10.1053/j.semvascsurg.2025.06.002","url":null,"abstract":"<div><div><span><span>Vascular surgeons are often responsible for navigating treatment decisions when caring for older adults. Care for these patients is informed by the surgeon’s assessment of the patient’s decision-making capacity, use of </span>advance care planning, and understanding of futility. Having difficult conversations with patients and their families is supported by strategies that promote empathic communication and </span>shared decision making<span> with older adults with serious illness due to, and associated with, vascular disease. These strategies include avoiding the cognitive trap, using heads-up and headline statements, best case and worst case to manage uncertainty, and better conversations to provide informed consent.</span></div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 332-338"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.07.004
Grace Yu , Yana Etkin , Jeffrey Silpe
Peripheral arterial disease (PAD) is a prevalent and debilitating condition in elderly patients, often leading to critical limb threatening ischemia (CLTI) and major amputations. While endovascular interventions are usually preferred for their lower perioperative risk, open surgical revascularization should also be considered due to its durability and superior patency in complex disease patterns. Age alone does not determine suitability for surgery; rather, candidacy hinges on frailty, functional status, comorbidities, and anatomical considerations. Contemporary global guidelines endorse a patient-centered approach that integrates these multidimensional factors. This scoping review will evaluate the outcomes of open infrainguinal revascularization in patients over 70, compared to endovascular approaches, and discuss how these findings align with contemporary guidelines and clinical decision-making paradigms. A scoping review was performed using one independent reviewer who screened PubMed to identify peer-reviewed observational studies and randomized controlled trials (2004-2024) involving patients aged >70 undergoing open infrainguinal revascularization. Keywords included “infrainguinal PAD,” “open revascularization,” and “elderly.” Key data extracted included perioperative morbidity, mortality, graft patency, limb salvage, and comparative effectiveness against endovascular strategies. A total of 1,574 articles were identified through reference search. We then screened these articles and assessed 265 full-text articles for eligibility. After exclusion, 19 full-text articles were selected for final inclusion. Nineteen eligible studies were included. Open revascularization in the elderly demonstrated 30-day mortality rates of 2% to 5% and 80% to 90% limb salvage rates in patients. Compared to endovascular techniques, open bypass yielded lower reintervention rates and superior long-term patency, especially when an autologous vein was used. Endovascular procedures were favored in high-risk or frail patients for their favorable perioperative profile. Frailty, functional independence, and conduit availability emerged as key determinants of surgical success. Open infrainguinal revascularization remains a viable and often preferable option for select elderly PAD patients. Decision-making should prioritize biological age, anatomical suitability, and patient preferences over chronological age. A multidisciplinary, guideline-driven approach can optimize outcomes, minimize risk, and preserve limb function and quality of life in this growing population.
{"title":"Open revascularization for infrainguinal peripheral arterial disease in elderly patients: A scoping review","authors":"Grace Yu , Yana Etkin , Jeffrey Silpe","doi":"10.1053/j.semvascsurg.2025.07.004","DOIUrl":"10.1053/j.semvascsurg.2025.07.004","url":null,"abstract":"<div><div>Peripheral arterial disease (PAD) is a prevalent and debilitating condition in elderly patients, often leading to critical limb threatening ischemia (CLTI) and major amputations. While endovascular interventions are usually preferred for their lower perioperative risk, open surgical revascularization should also be considered due to its durability and superior patency in complex disease patterns. Age alone does not determine suitability for surgery; rather, candidacy hinges on frailty, functional status, comorbidities, and anatomical considerations. Contemporary global guidelines endorse a patient-centered approach that integrates these multidimensional factors. This scoping review will evaluate the outcomes of open infrainguinal revascularization in patients over 70, compared to endovascular approaches, and discuss how these findings align with contemporary guidelines and clinical decision-making paradigms. A scoping review was performed using one independent reviewer who screened PubMed to identify peer-reviewed observational studies and randomized controlled trials (2004-2024) involving patients aged >70 undergoing open infrainguinal revascularization. Keywords included “infrainguinal PAD,” “open revascularization,” and “elderly.” Key data extracted included perioperative morbidity, mortality, graft patency, limb salvage, and comparative effectiveness against endovascular strategies. A total of 1,574 articles were identified through reference search. We then screened these articles and assessed 265 full-text articles for eligibility. After exclusion, 19 full-text articles were selected for final inclusion. Nineteen eligible studies were included. Open revascularization in the elderly demonstrated 30-day mortality rates of 2% to 5% and 80% to 90% limb salvage rates in patients. Compared to endovascular techniques, open bypass yielded lower reintervention rates and superior long-term patency, especially when an autologous vein was used. Endovascular procedures were favored in high-risk or frail patients for their favorable perioperative profile. Frailty, functional independence, and conduit availability emerged as key determinants of surgical success. Open infrainguinal revascularization remains a viable and often preferable option for select elderly PAD patients. Decision-making should prioritize biological age, anatomical suitability, and patient preferences over chronological age. A multidisciplinary, guideline-driven approach can optimize outcomes, minimize risk, and preserve limb function and quality of life in this growing population.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 301-313"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007523","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.07.001
Karen Velez, Julia Caldropoli, Sonia Talathi
As medicine evolves and life expectancy increases, octogenarians and nonagenarians represent growing populations that are at increased risk of ischemic stroke from asymptomatic carotid stenosis (ACS). Despite the significant disability and mortality that results from stroke in older adults, there are few data on the management of ACS in this population to inform clinical practice guidelines. The authors sought to assess the current body of literature on the management and outcomes of ACS in older adults. Prior landmark randomized controlled trials comparing carotid endarterectomy with best medical therapy alone have been questioned, as modern best medical therapy strategies have significantly evolved since their conception. These studies either do not include octogenarians and nonagenarians or involve a limited sample size, making it challenging to apply these findings to older adult population. Two particular areas of interest in our review are the potential benefits of carotid revascularization and risk stratification. Retrospective studies suggest that carotid endarterectomy may improve cognitive functioning in older adults. Frailty is shown to be associated with worse postoperative outcomes of carotid revascularization in the general population, although few data exist on the impact of frailty on outcomes in octogenarians and nonagenarians. Overall, there is a limited body of literature informing the clinical management of ACS in octogenarians and nonagenarians, and future randomized controlled trials are needed to compare outcomes of carotid revascularization with best medical therapy alone in this population.
{"title":"Management and outcomes of asymptomatic carotid stenosis in octogenarians and nonagenarians","authors":"Karen Velez, Julia Caldropoli, Sonia Talathi","doi":"10.1053/j.semvascsurg.2025.07.001","DOIUrl":"10.1053/j.semvascsurg.2025.07.001","url":null,"abstract":"<div><div>As medicine evolves and life expectancy increases, octogenarians and nonagenarians represent growing populations that are at increased risk of ischemic stroke from asymptomatic carotid stenosis (ACS). Despite the significant disability and mortality that results from stroke in older adults, there are few data on the management of ACS in this population to inform clinical practice guidelines. The authors sought to assess the current body of literature on the management and outcomes of ACS in older adults. Prior landmark randomized controlled trials comparing carotid endarterectomy with best medical therapy alone have been questioned, as modern best medical therapy strategies have significantly evolved since their conception. These studies either do not include octogenarians and nonagenarians or involve a limited sample size, making it challenging to apply these findings to older adult population. Two particular areas of interest in our review are the potential benefits of carotid revascularization and risk stratification. Retrospective studies suggest that carotid endarterectomy may improve cognitive functioning in older adults. Frailty is shown to be associated with worse postoperative outcomes of carotid revascularization in the general population, although few data exist on the impact of frailty on outcomes in octogenarians and nonagenarians. Overall, there is a limited body of literature informing the clinical management of ACS in octogenarians and nonagenarians, and future randomized controlled trials are needed to compare outcomes of carotid revascularization with best medical therapy alone in this population.</div></div>","PeriodicalId":51153,"journal":{"name":"Seminars in Vascular Surgery","volume":"38 3","pages":"Pages 219-224"},"PeriodicalIF":2.4,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-01DOI: 10.1053/j.semvascsurg.2025.07.007
Colby Meinke, Kristina A. Giles
As life expectancy increases, the prevalence of ruptured abdominal aortic aneurysms (rAAA) poses a significant challenge for our healthcare system. Aging induces biochemical changes, including degradation of the extracellular matrix and loss of vascular smooth muscle cells, which increase the propensity for the development of aneurysms and subsequent rupture due to compromised integrity of the aortic wall. The mortality rate for elderly patients presenting with rAAA is high, ranging from 80 to 90%. Both open and endovascular repair come with substantial risk for elderly patients. While EVAR has been shown to have lower perioperative mortality in this population, elderly patients face significant post-operative recovery challenges related to age and frailty. In determining who should be offered surgery for rAAA, patient selection is crucial. Frailty and existing comorbidities should be factored into whether or not patients are offered surgery. A tailored approach that is individualized to patient specific goals and accounts for pre-existing comorbidities and functional status is essential to improving outcomes for elderly patients presenting with rAAA.
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