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Reconstruction for lower limb occlusive disease in the elderly
Cardiovascular Surgery, Vol. 7, No. 1, pp. 58–61, 1999 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967–2109/98 $19.00 ⫹ 0.00
PII: S0967-2109(98)00049-0
Reconstruction for lower limb occlusive disease in the elderly J. J. Smith*, G. J. Toogood and R. B. Galland Department of Surgery, Royal Berkshire Hospital, Reading, UK Objectives: To determine the acceptability of performing distal limb bypass for occlusive vascular disease in the over 75’s. Method: Patients undergoing surgery between January 1988 and December 1996 were included. Data were obtained from a card system, operating ledgers, admission diaries and hospital notes. Results: A total of 166 patients were identified. There were 69 women and 97 men, 79 were aged 75–79 years, 81 were 80–89 years and six older than 90 years. A total of 171 procedures were performed: infrainguinal bypass in 131 (77%), aorto-femoral bifurcation grafts in 10 (6%) and extra-anatomic bypass in 30 (17%). This represents 28.1% of all reconstructions for occlusive disease during this time. Nine patients (5.4%) died within 30 days and one (0.6%) required a major amputation. During the follow-up period (median 12 months), 14 major and 10 minor amputations were required. Ten patients underwent a second successful reconstructive procedure. Conclusion: Reconstruction in this group of older patients can be carried out with acceptable 30-day mortality and limb salvage rates. 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved. Keywords: reconstruction, elderly patient, amputation
The elderly population in Britain is increasing [1–3], along with the prevalence of occlusive vascular disease [4]. Most elderly patients are independent and have a good quality of life [5, 6]. Only 5% of major amputees walk independently [7]. Amputation will reduce independence and quality of life in this already frail group. Successful vascular reconstruction should salvage limbs, and therefore maintain patient’s independence. However, the risks of reconstructive surgery have to be weighed against the potential benefits. This study describes the results of reconstruction in patients over 75 years of age, and the impact of these patients on overall vascular workload.
Correspondence to: Mr R. B. Galland, MD FRCS, Consultant General and Vascular Surgeon, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK *Present position is Lecturer in Surgery, Charing Cross Hospital, London, UK
58
Method As part of an ongoing audit, records of all patients undergoing lower limb vascular reconstruction over the age of 75 years were examined. Data were obtained from a card system kept by the consultant vascular surgeon (R.B.G.) in which details of initial diagnosis, presenting symptoms and signs, relevant risk factors, operation performed and outcomes were all recorded. Reconstructive procedures involving the lower limb included all infrainguinal bypasses, aorto-femoral bifurcation grafts and any extra-anatomical bypasses, such as femoro-femoro crossover and axillo-bifemoral grafts. Further information was obtained from admission diaries, theatre list registers and hospital notes. Both National Health Service (NHS) and private patients were included. All patients between January 1988 and December 1996 were included. A database was compiled using MicrosoftExcel V7.0.
CARDIOVASCULAR SURGERY
JANUARY 1999 VOL 7 NO 1
Reconstruction for lower limb occlusive disease in the elderly: J. J. Smith et al.
Thirty-day outcome
Results A total of 166 patients underwent lower limb vascular reconstruction, with 171 procedures being performed. There was a steady increase in the number of operations performed per year (Figure 1). There were 79 patients (47.6%) aged 75–79, 81 patients (48.8%) aged 80–89, and six patients (3.6%) aged over 90 years. There were 97 men and 69 women (approximately 1.4:1), with a median age of 80 years (range 75–96 years). The presenting symptoms were incapacitating claudication in 26%, rest pain in 20%, and ulceration or gangrene in 54%. In terms of risk factors, 23% were diabetic, 38% had cardiac problems (previous myocardial infarct or angina), 27% were hypertensive and 12% had a previous stroke. Of 171 operations performed, 10 (6%) were aortofemoral bifurcation grafts, 131 (77%) were infrainguinal bypass grafts and 30 (17%) were extra-anatomical bypass grafts. Five infrainguinal bypass procedures were combined with a more proximal procedure (aorto-femoral bifurcation grafts or femoro-femoro crossover). Autogenous vein was used in 59% of the infrainguinal bypasses. The operations performed in the over 75’s represented 28.1% of all the vascular reconstructions performed during this time.
Figure 1
Nine patients (5.4%) died within 30 days of surgery. All but two had pre-existing cardiorespiratory disease. Failure of the initial procedure within 30 days was seen in 10 patients (graft occlusion, major amputation, and death). This gives an initial success rate of 93.4%, a major amputation rate of 0.6% and a 30-day mortality of 5.4%. If those patients with incapacitating claudication are excluded from the analysis, then the limb salvage rate is 92% (Table 1). Overall outcome The median follow-up time was 12 months (range 1.5–84 months). During this period, 20 patients had documented graft occlusion. Of these, 10 underwent a further successful reconstruction, three underwent thrombolysis, only one of which was successful. Two patients had an infected graft removed, two required a sympathectomy and three were treated conservatively following occlusion. Fourteen patients required a major amputation, one of whom died within 30 days of the bypass procedure, giving an overall major amputation rate of 7.8%. Twelve amputations were in patients initially presenting with ulceration or gangrene, one with rest pain and one with incapacitating claudication. This gives an overall success rate of 83% over the
Number of reconstructions performed annually
CARDIOVASCULAR SURGERY
JANUARY 1999 VOL 7 NO 1
59
Reconstruction for lower limb occlusive disease in the elderly: J. J. Smith et al. Table 1 Thirty-day mortality and limb salvage rates following reconstruction in the elderly Reference
Mortality (%)
Limb salvage rate (%)
Age of cohort (years)
Humphreys [13] O’Brien et al. [15] Nehler et al. [6] Hosie et al. [5] Smith 1998 (present series)
6.5 10 6 12 5.4
80 85 91 90 92% (30 day) 78% (overall)
All > > > >
whole follow-up period. If patients with incapacitating claudication are excluded from the analysis, then the overall limb salvage rate is 78% (Table 1). Four of the 14 major amputations were below knee to above knee conversions. There were also 10 minor amputations (toes and forefoot).
Discussion As the number of elderly patients increases, the incidence of atherosclerotic disease in the population and thus occlusive vascular disease is expected to rise [1, 4]. As the proportion of the elderly population increases, greater numbers of reconstructive procedures are being performed. Furthermore, older patients are more likely to be referred with rest pain or ulceration than with claudication [8]. They are correspondingly more likely to require reconstruction than either angioplasty or conservative treatment. Thus while patients over 80 years of age represent less than 20% of those referred, they make up nearly 30% of those operated upon. The prevalence of atherosclerotic disease is difficult to measure. A necropsy study from the Oxford region [9] has shown that 15% of men and 5% of women have severe atherosclerotic disease affecting their common iliac arteries. Fowkes [4] has grouped together several major cardiovascular surveys from around the world. From those studies reporting on intermittent claudication in men and women, the overall ratio is approximately 2.4 to 1 (range 1.1:1– 4.5:1) in an age group of 20–82-year-olds. In the Oxford region this has been reported as 1.8:1 in a group of patients aged 45–69 years. The male to female ratio in the present series is approximately 1.4:1. It has already been mentioned that the prevalence of vascular disease is increasing [4]. However, over the age of 70 years the ratio of the prevalence of vascular disease in men and women begins to narrow [4]. A study of referral practice of General Practitioners in West Berkshire has shown substantial variation in referral practice, especially concerning elderly patients [10]. In this study it was found that over half of the general practitioners would not refer 60
ages (68.7 mean) 80 (83 mean) 80 (84 mean) 70 (76 median) 75 (81 median)
a 70-year-old with claudication at half a mile, or an 80-year-old with claudication at 100 m. According to Central Statistical Office data, a woman 60 years of age can be expected to live to the age of 82.6 years, and a woman of age 80 years to an age of 88.8 years in 1996. The corresponding ages for a man are 78.6 and 86.8 years, respectively [11]. However, it should be remembered that patients with occlusive vascular disease have a reduced survival compared with the normal population [12]. The prognosis for patients over 75 years undergoing vascular reconstruction in this series is reasonable with an all-cause mortality of 14.5% over the followup period irrespective of time from operation, and a 30-day mortality of 5.4%. Others have shown similar mortality rates (Table 1). The majority of deaths in this group were as a result of the associated cardiorespiratory disease. In a cost conscious health climate the type of treatment offered may be influenced by its cost. Figures from Humphreys [13] have shown that the total operative cost of reconstruction for occlusive disease is around £9500 per patient (including any subsequent revisions and secondary amputations). The equivalent cost for primary amputations is approximately £11,500. Total costs are even higher when long-term variables are taken into account, such as re-housing, social service support, etc., over the life of the patient. Figures are approximately £17,500 for reconstruction and £38,000 for amputations. What initially seems to be the cheaper and quicker option of amputation, in reality is not. Long-term prognosis of patients with peripheral vascular disease is known to be poor [14]. Quality of life is worse for an amputee, at 6 months’ 58% are institutionalized compared with 12% of those undergoing vascular reconstruction [5]. Therefore reconstruction should be considered in all patients regardless of age just on these two points alone.
Conclusion The data suggest that age should not be seen as a contraindication to reconstructive surgery. An aggressive approach to revascularization results in a CARDIOVASCULAR SURGERY
JANUARY 1999 VOL 7 NO 1
Reconstruction for lower limb occlusive disease in the elderly: J. J. Smith et al.
high limb salvage rate, acceptable mortality, reduced total costs and a high likelihood of maintaining an independent life.
References
9.
1. Craig, J., The growth of the elderly population. Office of Population Censuses and Surveys Population Trends, Vol. 32, HMSO, London, HMSO, London, 1983, pp. 28–33. 2. Williams, J. and Collin, J., Surgical care of patients over 80: a predictable crisis at hand. British Journal of Surgery, 1988, 75, 371–373. 3. Andrews, K., Demographic changes and resources for the elderly. British Medical Journal, 1985, 290, 1023–1024. 4. Fowkes, F. G., Epidemiology of atherosclerotic arterial disease in the lower limbs. European Journal of Vascular Surgery, 1988, 2, 283–289. 5. Hosie, K. B., Kockelberg, R., Newbury-Ecob, R. A. et al., A retrospective review of the outcome of patients over 70 years of age considered for vascular reconstruction in a district general hospital. European Journal of Vascular Surgery, 1990, 4, 313–315. 6. Nehler, M. R., Monetta, G. L., Edwards, J. et al., Surgery for chronic lower extremity ischemia in patients eighty or more years of age: operative results and assessment of post-operative independence. Journal of Vascular Surgery, 1993, 18, 618–626. 7. Houghton, A. D., Taylor, P. R., Thurlow, S. et al., Success rates
CARDIOVASCULAR SURGERY
8.
JANUARY 1999 VOL 7 NO 1
10. 11. 12.
13. 14. 15.
of rehabilitation of vascular amputees: implications for preoperative assessment and amputation level. British Journal of Surgery, 1992, 79(8), 753–755. Michaels, J. A. and Galland, R. B., Case mix and outcome of patients referred to the vascular serviceat a district general hospital. Annals of the Royal College of Surgeons, England, 1993, 75, 358–361. Mitchell, J. R. and Schwartz, C. J., Arterial Disease. Blackwell, Oxford, 1965. Michaels, J. A. and Galland, R. B., General practitioner referral of patients with symptoms of peripheral vascular disease. Journal of the Royal College of Surgeons, Edinburgh, 1994, 39, 103–105. Section 7.3. Social Trends. Central Statistical Office, UK, 1996. Michaels, J. A. and Galland, R. B. Overview of data relevant to decision making in vascular surgery. In Clinical Problems in Vascular Surgery, Ch. 27, ed. R. B. Galland and C. A. Clyne. Edward Arnold, 1994, pp. 247–258. Humphreys, W. V., An audit of the results of reconstructive vascular surgery or amputation for critical lower limb ischaemia. ChM thesis, Manchester University, 1994. Hoofwijk, A., The fate of the patient with critical limb ischaemia. Critical Ischaemia, 1991, 1(8), 15–21. O’Brien, T. S., Lamont, P. M., Crow, A. et al., Lower limb surgery in the octogenarian: is limb salvage surgery worthwhile. Annals of the Royal College of Surgeons, England, 1993, 75, 445– 447.
Paper accepted 2 February 1998
61
PII: S0967-2109(98)00049-0
Reconstruction for lower limb occlusive disease in the elderly J. J. Smith*, G. J. Toogood and R. B. Galland Department of Surgery, Royal Berkshire Hospital, Reading, UK Objectives: To determine the acceptability of performing distal limb bypass for occlusive vascular disease in the over 75’s. Method: Patients undergoing surgery between January 1988 and December 1996 were included. Data were obtained from a card system, operating ledgers, admission diaries and hospital notes. Results: A total of 166 patients were identified. There were 69 women and 97 men, 79 were aged 75–79 years, 81 were 80–89 years and six older than 90 years. A total of 171 procedures were performed: infrainguinal bypass in 131 (77%), aorto-femoral bifurcation grafts in 10 (6%) and extra-anatomic bypass in 30 (17%). This represents 28.1% of all reconstructions for occlusive disease during this time. Nine patients (5.4%) died within 30 days and one (0.6%) required a major amputation. During the follow-up period (median 12 months), 14 major and 10 minor amputations were required. Ten patients underwent a second successful reconstructive procedure. Conclusion: Reconstruction in this group of older patients can be carried out with acceptable 30-day mortality and limb salvage rates. 1998 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved. Keywords: reconstruction, elderly patient, amputation
The elderly population in Britain is increasing [1–3], along with the prevalence of occlusive vascular disease [4]. Most elderly patients are independent and have a good quality of life [5, 6]. Only 5% of major amputees walk independently [7]. Amputation will reduce independence and quality of life in this already frail group. Successful vascular reconstruction should salvage limbs, and therefore maintain patient’s independence. However, the risks of reconstructive surgery have to be weighed against the potential benefits. This study describes the results of reconstruction in patients over 75 years of age, and the impact of these patients on overall vascular workload.
Correspondence to: Mr R. B. Galland, MD FRCS, Consultant General and Vascular Surgeon, Royal Berkshire Hospital, London Road, Reading RG1 5AN, UK *Present position is Lecturer in Surgery, Charing Cross Hospital, London, UK
58
Method As part of an ongoing audit, records of all patients undergoing lower limb vascular reconstruction over the age of 75 years were examined. Data were obtained from a card system kept by the consultant vascular surgeon (R.B.G.) in which details of initial diagnosis, presenting symptoms and signs, relevant risk factors, operation performed and outcomes were all recorded. Reconstructive procedures involving the lower limb included all infrainguinal bypasses, aorto-femoral bifurcation grafts and any extra-anatomical bypasses, such as femoro-femoro crossover and axillo-bifemoral grafts. Further information was obtained from admission diaries, theatre list registers and hospital notes. Both National Health Service (NHS) and private patients were included. All patients between January 1988 and December 1996 were included. A database was compiled using MicrosoftExcel V7.0.
CARDIOVASCULAR SURGERY
JANUARY 1999 VOL 7 NO 1
Reconstruction for lower limb occlusive disease in the elderly: J. J. Smith et al.
Thirty-day outcome
Results A total of 166 patients underwent lower limb vascular reconstruction, with 171 procedures being performed. There was a steady increase in the number of operations performed per year (Figure 1). There were 79 patients (47.6%) aged 75–79, 81 patients (48.8%) aged 80–89, and six patients (3.6%) aged over 90 years. There were 97 men and 69 women (approximately 1.4:1), with a median age of 80 years (range 75–96 years). The presenting symptoms were incapacitating claudication in 26%, rest pain in 20%, and ulceration or gangrene in 54%. In terms of risk factors, 23% were diabetic, 38% had cardiac problems (previous myocardial infarct or angina), 27% were hypertensive and 12% had a previous stroke. Of 171 operations performed, 10 (6%) were aortofemoral bifurcation grafts, 131 (77%) were infrainguinal bypass grafts and 30 (17%) were extra-anatomical bypass grafts. Five infrainguinal bypass procedures were combined with a more proximal procedure (aorto-femoral bifurcation grafts or femoro-femoro crossover). Autogenous vein was used in 59% of the infrainguinal bypasses. The operations performed in the over 75’s represented 28.1% of all the vascular reconstructions performed during this time.
Figure 1
Nine patients (5.4%) died within 30 days of surgery. All but two had pre-existing cardiorespiratory disease. Failure of the initial procedure within 30 days was seen in 10 patients (graft occlusion, major amputation, and death). This gives an initial success rate of 93.4%, a major amputation rate of 0.6% and a 30-day mortality of 5.4%. If those patients with incapacitating claudication are excluded from the analysis, then the limb salvage rate is 92% (Table 1). Overall outcome The median follow-up time was 12 months (range 1.5–84 months). During this period, 20 patients had documented graft occlusion. Of these, 10 underwent a further successful reconstruction, three underwent thrombolysis, only one of which was successful. Two patients had an infected graft removed, two required a sympathectomy and three were treated conservatively following occlusion. Fourteen patients required a major amputation, one of whom died within 30 days of the bypass procedure, giving an overall major amputation rate of 7.8%. Twelve amputations were in patients initially presenting with ulceration or gangrene, one with rest pain and one with incapacitating claudication. This gives an overall success rate of 83% over the
Number of reconstructions performed annually
CARDIOVASCULAR SURGERY
JANUARY 1999 VOL 7 NO 1
59
Reconstruction for lower limb occlusive disease in the elderly: J. J. Smith et al. Table 1 Thirty-day mortality and limb salvage rates following reconstruction in the elderly Reference
Mortality (%)
Limb salvage rate (%)
Age of cohort (years)
Humphreys [13] O’Brien et al. [15] Nehler et al. [6] Hosie et al. [5] Smith 1998 (present series)
6.5 10 6 12 5.4
80 85 91 90 92% (30 day) 78% (overall)
All > > > >
whole follow-up period. If patients with incapacitating claudication are excluded from the analysis, then the overall limb salvage rate is 78% (Table 1). Four of the 14 major amputations were below knee to above knee conversions. There were also 10 minor amputations (toes and forefoot).
Discussion As the number of elderly patients increases, the incidence of atherosclerotic disease in the population and thus occlusive vascular disease is expected to rise [1, 4]. As the proportion of the elderly population increases, greater numbers of reconstructive procedures are being performed. Furthermore, older patients are more likely to be referred with rest pain or ulceration than with claudication [8]. They are correspondingly more likely to require reconstruction than either angioplasty or conservative treatment. Thus while patients over 80 years of age represent less than 20% of those referred, they make up nearly 30% of those operated upon. The prevalence of atherosclerotic disease is difficult to measure. A necropsy study from the Oxford region [9] has shown that 15% of men and 5% of women have severe atherosclerotic disease affecting their common iliac arteries. Fowkes [4] has grouped together several major cardiovascular surveys from around the world. From those studies reporting on intermittent claudication in men and women, the overall ratio is approximately 2.4 to 1 (range 1.1:1– 4.5:1) in an age group of 20–82-year-olds. In the Oxford region this has been reported as 1.8:1 in a group of patients aged 45–69 years. The male to female ratio in the present series is approximately 1.4:1. It has already been mentioned that the prevalence of vascular disease is increasing [4]. However, over the age of 70 years the ratio of the prevalence of vascular disease in men and women begins to narrow [4]. A study of referral practice of General Practitioners in West Berkshire has shown substantial variation in referral practice, especially concerning elderly patients [10]. In this study it was found that over half of the general practitioners would not refer 60
ages (68.7 mean) 80 (83 mean) 80 (84 mean) 70 (76 median) 75 (81 median)
a 70-year-old with claudication at half a mile, or an 80-year-old with claudication at 100 m. According to Central Statistical Office data, a woman 60 years of age can be expected to live to the age of 82.6 years, and a woman of age 80 years to an age of 88.8 years in 1996. The corresponding ages for a man are 78.6 and 86.8 years, respectively [11]. However, it should be remembered that patients with occlusive vascular disease have a reduced survival compared with the normal population [12]. The prognosis for patients over 75 years undergoing vascular reconstruction in this series is reasonable with an all-cause mortality of 14.5% over the followup period irrespective of time from operation, and a 30-day mortality of 5.4%. Others have shown similar mortality rates (Table 1). The majority of deaths in this group were as a result of the associated cardiorespiratory disease. In a cost conscious health climate the type of treatment offered may be influenced by its cost. Figures from Humphreys [13] have shown that the total operative cost of reconstruction for occlusive disease is around £9500 per patient (including any subsequent revisions and secondary amputations). The equivalent cost for primary amputations is approximately £11,500. Total costs are even higher when long-term variables are taken into account, such as re-housing, social service support, etc., over the life of the patient. Figures are approximately £17,500 for reconstruction and £38,000 for amputations. What initially seems to be the cheaper and quicker option of amputation, in reality is not. Long-term prognosis of patients with peripheral vascular disease is known to be poor [14]. Quality of life is worse for an amputee, at 6 months’ 58% are institutionalized compared with 12% of those undergoing vascular reconstruction [5]. Therefore reconstruction should be considered in all patients regardless of age just on these two points alone.
Conclusion The data suggest that age should not be seen as a contraindication to reconstructive surgery. An aggressive approach to revascularization results in a CARDIOVASCULAR SURGERY
JANUARY 1999 VOL 7 NO 1
Reconstruction for lower limb occlusive disease in the elderly: J. J. Smith et al.
high limb salvage rate, acceptable mortality, reduced total costs and a high likelihood of maintaining an independent life.
References
9.
1. Craig, J., The growth of the elderly population. Office of Population Censuses and Surveys Population Trends, Vol. 32, HMSO, London, HMSO, London, 1983, pp. 28–33. 2. Williams, J. and Collin, J., Surgical care of patients over 80: a predictable crisis at hand. British Journal of Surgery, 1988, 75, 371–373. 3. Andrews, K., Demographic changes and resources for the elderly. British Medical Journal, 1985, 290, 1023–1024. 4. Fowkes, F. G., Epidemiology of atherosclerotic arterial disease in the lower limbs. European Journal of Vascular Surgery, 1988, 2, 283–289. 5. Hosie, K. B., Kockelberg, R., Newbury-Ecob, R. A. et al., A retrospective review of the outcome of patients over 70 years of age considered for vascular reconstruction in a district general hospital. European Journal of Vascular Surgery, 1990, 4, 313–315. 6. Nehler, M. R., Monetta, G. L., Edwards, J. et al., Surgery for chronic lower extremity ischemia in patients eighty or more years of age: operative results and assessment of post-operative independence. Journal of Vascular Surgery, 1993, 18, 618–626. 7. Houghton, A. D., Taylor, P. R., Thurlow, S. et al., Success rates
CARDIOVASCULAR SURGERY
8.
JANUARY 1999 VOL 7 NO 1
10. 11. 12.
13. 14. 15.
of rehabilitation of vascular amputees: implications for preoperative assessment and amputation level. British Journal of Surgery, 1992, 79(8), 753–755. Michaels, J. A. and Galland, R. B., Case mix and outcome of patients referred to the vascular serviceat a district general hospital. Annals of the Royal College of Surgeons, England, 1993, 75, 358–361. Mitchell, J. R. and Schwartz, C. J., Arterial Disease. Blackwell, Oxford, 1965. Michaels, J. A. and Galland, R. B., General practitioner referral of patients with symptoms of peripheral vascular disease. Journal of the Royal College of Surgeons, Edinburgh, 1994, 39, 103–105. Section 7.3. Social Trends. Central Statistical Office, UK, 1996. Michaels, J. A. and Galland, R. B. Overview of data relevant to decision making in vascular surgery. In Clinical Problems in Vascular Surgery, Ch. 27, ed. R. B. Galland and C. A. Clyne. Edward Arnold, 1994, pp. 247–258. Humphreys, W. V., An audit of the results of reconstructive vascular surgery or amputation for critical lower limb ischaemia. ChM thesis, Manchester University, 1994. Hoofwijk, A., The fate of the patient with critical limb ischaemia. Critical Ischaemia, 1991, 1(8), 15–21. O’Brien, T. S., Lamont, P. M., Crow, A. et al., Lower limb surgery in the octogenarian: is limb salvage surgery worthwhile. Annals of the Royal College of Surgeons, England, 1993, 75, 445– 447.
Paper accepted 2 February 1998
61