Infrainguinal bypass for limb salvage has comparable mortality and affords a better chance of home discharge than amputation among octogenarians.

Background: Infrainguinal bypass for chronic limb-threatening ischemia (CTLI) in octogenarians is considered a high-risk procedure due to the presumed associated frailty of the patient population. However, the alternative which is major amputation may not be a better option. This study retrospectively compares the outcomes of bypass versus major amputation for functionally independent and partially dependent patients.

Methods: Patients greater than and equal to 80 years old who underwent non-emergent infrainguinal bypasses for CTLI presenting with rest pain/tissue loss were selected from the targeted NSQIP database 2011-2022. Patients with major amputations (CPT codes 27880, 27882, 27590, 27592) for atherosclerosis by ICD9/10 codes were selected from the general database. We stratified the patients based on functional status (independent or partially dependent) and compared outcomes of bypass versus amputation within each group. Multivariable logistic regression was performed for 30-day mortality, major organ dysfunction, length of stay (LOS), and discharge destinations.

Results: There were 2,419 patients who underwent a bypass and 1,326 patients who underwent an amputation in the independent functional group. Patients with bypass were generally healthier. Multivariable analysis revealed that having a bypass was associated with significantly higher major adverse cardiac events (aOR: 1.7; p<0.01), bleeding requiring transfusion (aOR: 4.3; p<0.01), and wound complications (aOR: 1.7; p<0.01). There was no significant difference in mortality, renal complications, or sepsis. Additionally, bypass patients had longer operation time (p<0.01) and return to the operating room (aOR: 2.7; p<0.01). However, bypass patients were more likely to be discharged to home rather than to a facility (aOR: 4.2; p<0.01). Similar outcomes were observed for partially dependent patients, except that bypass patients had a longer LOS (12.40 ± 9.86 vs. 10.78 ± 9.94 days; p<0.01).

Conclusion: Bypass for limb salvage for octogenarians does incur higher morbidities than amputation but does not increase mortality. The immediate higher morbidities of bypass should be weighed against a better chance of home discharge, which could potentially imply less functional decline.