BackgroundOwing to the aging population, the number of elderly patients with critical limb ischemia (CLI) has increased. The consequence of amputation is immense. However, at the moment, information about the mortality after amputation in the elderly vascular patients is unknown. For this reason, this study evaluated mortality rates and patient-related factors associated with mortality after a major amputation in elderly patients with CLI.MethodsFrom 2006 to 2013, we included patients aged >70 years who were treated for chronic CLI by primary or secondary major amputation within or after 3 months of initial therapy (revascularization or conservative management). Outcome measurements were mortality after major amputation and factors associated with mortality (age, comorbidity and timing of amputation).ResultsIn total, 168/651 patients (178 legs; 26%) underwent a major amputation. Patients were stratified by age: 70–80 years (n=86) and >80 years (n=82). Overall mortality after major amputation was 44%, 66% and 85% after 1, 3 and 5 years, respectively. The 6-month and 1-year mortality in patients aged 80 years or older was, respectively, 59% or 63% after a secondary amputation <3 months versus 34% and 44% after a secondary amputation >3 months. Per year of age, the mortality rate increased by 4% (P=0.005). No significant difference in mortality after major amputation was found in the presence of comorbidity or according to Rutherford classification.ConclusionDespite developments in the treatment of CLI by revascularization, amputation rates remain high and are associated with tremendous mortality rates. Secondary amputation after a failed attempt of revascularization causes a higher mortality. Further research concerning timing of amputation and patient-related outcome is needed to evaluate if selected patients might benefit from primary amputation.

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H.J.M. Verhagen is a consultant to Medtronic and WL Gore & Associates and received an unrestricted educational grant from Abbott. MGM Hunink receives Royalties from Cambridge University Press for her textbook on Medical Decision Making, reimbursement of expenses from the European Society of Radiology (ESR) for work on the ESR guidelines for imaging referrals, reimbursement of expenses from the European Institute for Biomedical Imaging Research (EIBIR) for membership of the Scientific Advisory Board, and research funding from the American Diabetes Association, the Netherlands Organization for Health Research and Development, the German Innovation Fund, Netherlands Educational Grant ("Studie Voorschot Middelen"), and the Gordon and Betty Moore Foundation. Authors contribution: Sanne Klaphake, MD, contribution to the concept and design of the ERASE study acquisition of data analysis an interpretation of data participate in drafting the article and revising it critically give final approval of the version to be published Farzin Fakhry, MD, contribution to the concept and design of the ERASE study acquisition of data analysis an interpretation of data participate in drafting the article and revising it critically give final approval of the version to be published EllenV. Rouwet, MD, PhD, contribution to the concept and design of the ERASE study acquisition of data analysis an interpretation of data participate in drafting the article and revising it critically give final approval of the version to be published Lijckle van der Laan, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Jan J. Wever, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Joep A. W. Teijink, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Wolter H. Hoffmann, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Andre S. van Petersen, MD, acquisition of data participate in revising it critically give final approval of the version to be published Jerome P. van Brussel, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Guido N. M. Stultiens, MD, acquisition of data participate in revising it critically give final approval of the version to be published Alex Derom, MD, acquisition of data participate in revising it critically give final approval of the version to be published P. Ted den Hoed, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Gwan H. Ho, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Lukas C. van Dijk, MD, PhD, acquisition of data participate in revising it critically give final approval of the version to be published Nicole Verhofstad, PhD, acquisition of data parti...

Guidelines recommend supervised exercise therapy (SET) as first-line treatment for intermittent claudication. However, the use of revascularization is widespread. We addressed the effectiveness of preventing (additional) invasive revascularization after primary SET or revascularization based on lesion and patient characteristics. In this single-center, retrospective, cohort study, 474 patients with intermittent claudication were included. Patients with occlusive disease of the aortoiliac tract and/or common femoral artery (inflow) were primarily considered for revascularization, while patients with more distal disease (outflow) were primarily considered for SET. In total, 232 patients were referred for SET and 242 patients received revascularization. The primary outcome was freedom from (additional) intervention, analyzed by Kaplan–Meier estimates. Secondary outcomes were survival, critical ischemia, freedom from target lesion revascularization (TLR), and an increase in maximum walking distance. In the SET-first strategy, 71% of patients had significant outflow lesions. Freedom from intervention was 0.90 ± 0.02 at 1-year and 0.82 ± 0.03 at 2-year follow-up. In the primary revascularization group, 90% of patients had inflow lesions. Freedom from additional intervention was 0.78 ± 0.03 at 1-year and only 0.65 ± 0.04 at 2-year follow-up, despite freedom from TLR of 0.91 ± 0.02 and 0.85 ± 0.03 at 1- and 2-year follow-up, respectively. In conclusion, SET was effective in preventing invasive treatment for patients with mainly outflow lesions. In contrast, secondary intervention rates following our strategy of primary revascularization for inflow lesions were unexpectedly high. These findings further support the guideline recommendations of SET as first-line treatment for all patients with intermittent claudication irrespective of level of disease.

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