Vascular surgeons face increasingly challenging patients as the general population is growing older. The prevalence of peripheral artery disease (PAD) increases with age and so does the burden of comorbidities. At the extreme of the PAD clinical spectrum lies chronic limb-threatening ischemia (CLTI). Nonagenarians with CLTI represent a particularly challenging group and only few studies have addressed the vascular outcomes in this population. This study aimed to investigate survival and amputation free survival rates (AFS) in nonagenarians presenting with CLTI. Moreover, we assessed retrospectively the differences in 1-year and 5-year survival and AFS between a conservative versus a revascularization approach. Finally, we studied what factors could impact on the final outcomes.

Data from a ten-year period (January 2008 - October 2018) were retrieved using the hospital database. All patients treated for CLTI who were at least 90 years old at the time of diagnosis were included. Patients were divided in two groups: those who were offered revascularization and those who were offered conservative treatment. The reason for withholding revascularization was recorded when available. Dependency and autonomy were valuated measuring the Parker score. The primary endpoints were 1-year and 5-year survival and AFS. Kaplan-Meier method was used to calculate survival and AFS rates. Cox regression multivariate analysis was used to assess risk factors associated with the studied outcomes.

A total of 188 patients and 188 limbs were included in the study. Characteristics of the enrolled patients are outlined in Table 1. The overall survival at 1 year was 55.9 % and the median survival time was 14.4 months (95% confidence interval (95% CI) = 10.8-18.1). Survival for the revascularization group was 69.1% at 1 year, while patients in the conservative group had a 1-year survival of 30.8% (Figure 1). 5 years after initial presentation, the calculated survival was 20.8% for the revascularization group, while no patient in the conservative group was alive. The early mortality for the revascularization group was 11.2%. The overall AFS at 1-year was 77.1% (Figure 2). The AFS at 1 year was 85,9% in the revascularization group, while 55% of patients treated conservatively was free from amputation 1 year after presentation (Figure 2). The nonagenarians offered revascularization had an AFS of 76.6% at 5 years. The Cox regression multivariated analysis showed that age, (hazard ratio (HR) [95% CI] = 1.16 [1.03 - 1.30] per year increase in age; p = 0.017), and diabetes (HR [95% CI] = 2.46 [1.25 - 4.85]; p= 0.0090) were important predictors of amputation free survival (Table 2). Age (HR [95% CI] = 1.09 [1.02-1.16] per year increase in age; p = 0.0012), diabetes (HR [95% CI] = 1.48 [1.05-2.09]; p = 0.026) and severe renal insufficiency (HR [95% CI] = 3.01 [1.86-4.88]; p < 0.001) were important predictors of survival (Table 2).

Nonagenarians offered revascularization had markedly better 1-year survival and AFS rate. The majority of our patients were treated with an endovascular approach. Vascular outcomes after revascularization in nonagenarians were comparable with reported results from octogenarians with CLTI. Overall survival is still understandably poor among the very old, nevertheless, acceptable long term AFS rate could suggest that advanced age is not a reason to withhold intervention in elderly patients. In conclusion, it is important to identify the patients whose life expectancy is poor and will not benefit from revascularization and consider preferably endovascular treatment for very elderly patients with CLTI.

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