Download this article's Factoid (PDF & PPT for Gold Subscribers)

Contemporary endovascular intervention in elderly patients with lower-extremity vascular disease generally is successful, with an acceptable safety profile and low in-hospital mortality, according to a registry study published in the June 2011 issue of JACC: Cardiovascular Interventions.

A research team led by P. Michael Grossman, MD, of the University of Michigan (Ann Arbor, MI), analyzed data from 7,769 patients who underwent lower-limb peripheral vascular intervention at 18 Michigan centers from 2001 through 2008. All were prospectively enrolled in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention (BMC2 PVI) registry. The number of procedures performed at the individual centers ranged from 5 to 2,381.

Patients were divided into 3 age categories:

• Less than 70 years (n = 4,017)
• 70 to 80 years (n = 2,350)
• 80 years or older (n = 1,402)

Elderly patients (≥ 80 years) were more likely to be female, have a normal or lean BMI, be anemic, and have a history of hypertension, congestive heart failure, cardiovascular disease, or TIA but were less likely to be current smokers. In addition, the elderly more frequently presented with severe PAD and underwent more femoropopliteal, below-the-knee, and multivessel interventions. Younger patients, meanwhile, were more likely to be revascularized for aortoiliac disease.

Intervention Mostly Successful Despite More Severe PAD

Rates of both technical and procedural success were higher in the 2 younger groups than in the elderly group (table 1).

Table 1. Technical, Procedural Success by Age Group

Although, overall, retrograde access was more prevalent than antegrade access (83% vs. 17%), which is technically more challenging and precludes the use of vascular closure devices, the 2 younger groups received more retrograde access than did elderly patients. In addition, elderly patients more often underwent balloon angioplasty only or atherectomy only, whereas younger patients were more likely to receive stents (table 2).

Table 2. Access Type, Device Use by Age Group

 
Elderly patients were also less likely than the younger groups to receive, either before treatment or at discharge, lipid-lowering drugs, ACE inhibitors, or dual antiplatelet therapy (P < 0.0001 for all comparisons).

The oldest patients experienced higher rates of contrast-induced nephropathy (P < 0.001), access site complications (P < 0.001), and amputation. But despite a higher MACE (death, MI, and stroke/TIA) rate in the elderly (P < 0.01), individual MACE components were uncommon and similar for all age groups, as was the need for reintervention.

In multivariate analysis, older age (here both groups ≥ 70 years) only predicted increased vascular access complications (OR 2.2; 95% CI 1.2-3.9; P = 0.003).

In subgroup analyses, the pattern of complications across the 3 age groups was the same for patients with diabetes or chronic renal failure as for the overall study cohort, the authors report.

Dr. Grossman and colleagues write, “[C]ontrary to the higher risks associated with surgical revascularization of PAD in elderly patients, we found that for patients undergoing [peripheral vascular intervention], advanced age may not be a significant predictor of in-hospital adverse events.”

In an accompanying editorial, Christopher J. White, MD, of the Ochsner Clinic Foundation (New Orleans, LA), and president of the Society for Cardiovascular Angiography and Interventions, suggests that the slightly lower success rates in elderly patients may be attributable to the excess of 2 related variables in that group: (1) more complex, below-the-knee procedures and (2) mostly as a result, more use of antegrade access.

‘Endovascular-First’ Approach Becoming the Norm

Overall, however, “the data support a trend in clinical practice of adopting an ‘endovascular-first’ approach to patients with [lower-extremity peripheral vascular disease] requiring revascularization,” Dr. White writes.

In a telephone interview with TCTMD, William A. Gray, MD, of Columbia University Medical Center (New York, NY), agreed. “This registry provides a snapshot of current practice and tells us that today success rates are reasonable enough that, based on the [observed] morbidity and mortality, there is no reason not to be doing endovascular procedures [in elderly patients],” he said. In fact, according to a recent study (Egorova NN, et al. J Vasc Surg. 2010;51:878-885), over the past decade the endovascular approach has surpassed surgery as the primary treatment for lower-extremity PAD, Dr. Gray reported.

The only characteristic that tends to be more prominent in elderly than younger patients and gives interventionalists pause is severe calcification, he noted. “If a person has a severely calcified popliteal vessel, it’s tough to get that vessel open and get full stent expansion,” Dr. Gray said. “The bottom line is that patients who have severe calcification and a limb [at risk of amputation] ought to have bypass surgery because they don’t do that well with intervention. But that’s a relatively small proportion of patients. [On the other hand,] I’m not sure there’s any justification for surgery for claudication in patients over 80.”

In a telephone interview, Dr. Grossman likewise acknowledged that there are certain angiographic characteristics that may make a vascular specialist hesitate to adopt an endovascular-first approach. “[For example,] patients with long segments or total occlusions might be better served by an open surgical revascularization,” he said.

“But one of the important features of our registry is that it is multidisciplinary, including not only interventional cardiologists but also interventional radiologists and almost 30% vascular surgeons,” he continued. “And yet across the board, the endovascular-first approach is being used more and more.”

Later Surgery Usually Not Precluded

In addition, there is no drawback to an endovascular-first strategy since typically such intervention does not preclude surgery later if necessary, Dr. Grossman said. “And as we gain experience and work more closely [with our vascular surgery colleagues] to understand both what we can and what we shouldn’t do, including the vascular beds where we may want to be more careful about [implanting] a stent that may limit surgical options down the road, I think an endovascular-first approach is quite reasonable.”

Moreover, beyond procedural safety, studies have shown that lower-extremity patients—who tend to be quite impaired—reap significant improvement in quality of life from endovascular intervention, Dr. Grossman said, adding that he is currently analyzing data to specifically compare very old with younger patients in that regard.

“The power of [the BMC2 PVI registry] is that we collect very accurate data from everybody [in the collaborative] who is doing endovascular procedures,” Dr. Grossman said. “And because this is a physician-level registry, the data go from the physicians back to the physicians, who then engage in benchmarking and quality improvement based on their own data.”

Study Details

Vascular access complications were defined as a composite of retroperitoneal hematoma, pseudoaneurysm, hematoma requiring transfusion or associated with a decrease in hemoglobin ≥ 3 g/dL, arteriovenous fistula demonstrated by arteriography or ultrasound, acute thrombosis, or need for surgical repair of the access site.

 

---

Sources:
1. Plaisance BR, Munir K, Share DA, et al. Safety of contemporary percutaneous peripheral arterial interventions in the elderly: Insights from the BMC2 PVI (Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention) registry. J Am Coll Cardiol Intv. 2011;4:694-701.

2. White CJ. A “win-win” for peripheral vascular intervention. J Am Coll Cardiol Intv. 2011;4:702-703.

 

 

Related Stories:

• Rise in Endovascular Therapy for PAD Parallels Improved Outcomes
• PCI for PAD Grows as Surgery Declines: A Boon for Patients?
• Endovascular Approach Compares Well with Surgery for Aorto-Iliac Disease