MALNUTRITION-INFLAMMATION-ATHEROSCLEROSIS (MIA) SYNDROME IS A MAJOR FACTOR TO AFFECT PROGNOSIS OF ELDERLY PATIENTS WITH CHRONIC LIMB-THREATENING ISCHEMIA AFTER ENDOVASCULAR THERAPY

BackgroundEndovascular therapy (EVT) for acute ischemic stroke (AIS) can be challenging in older patients with supra-aortic tortuosity. Rescue carotid puncture (RCP) can be an alternative in case of supra-aortic catheterization failure by femoral access, but data regarding RCP are scarce. We sought to investigate the feasibility, effectiveness and safety of RCP for AIS treated by EVT.MethodsPatients treated by EVT with RCP were included from January 2012 to December 2019 in the Endovascular Treatment in Ischemic Stroke (ETIS) multicentric registry. Main outcomes included reperfusion rates (≥TICI2B), 3 month functional outcome (modified Rankin Scale) and 3 month mortality. We also performed an additional systematic review of the literature according to the PRISMA checklist to summarize previous studies on RCP.Results25 patients treated by EVT with RCP were included from the ETIS registry. RCP mainly concerned elderly patients (median age 85 years, range 73–92) with supra-aortic tortuosity (n=16 (64%)). Intravenous thrombolysis (IVT) was used for nine patients (36%). Successful reperfusion was achieved in 64%, 87.5% of patients were dependent at 3 months, and 3 month mortality was 45.8%. The systematic review yielded comparable results. In pooled individual data, there was a shift toward better functional outcome in patients with successful reperfusion (median (IQR) 4 (2–6) vs 6 (4–6), p=0.011).ConclusionRCP mainly concerned elderly patients admitted for AIS with anterior LVO with supra-aortic tortuosity. The procedure seemed feasible, notably for patients treated with IVT, and led to significant reperfusion rates at the end of procedure, but with pronounced unfavorable outcomes at 3 months. RCP should be performed under general anesthesia to avoid life-threatening complications and ensure airways safety. Finally, RCP led to low rates of closure complications, emphasizing that this concern should not withhold RCP, if indicated.

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Impact of Frailty and Age on Clinical Outcomes in Patients Who Underwent Endovascular Therapy

Journal of Endovascular Therapy ◽

10.1177/15266028211067729 ◽

2021 ◽

pp. 152660282110677

Author(s):

Ken Nishikawa ◽

Soichiro Ebisawa ◽

Takashi Miura ◽

Tamon Kato ◽

Kanzaki Yusuke ◽

...

Keyword(s):

Elderly Patients ◽

Endovascular Therapy ◽

Young Patients ◽

The Elderly ◽

Cardiovascular Death ◽

Major Amputation ◽

Clinical Frailty Scale ◽

Treatment Indications ◽

Artery Disease ◽

The Impact

Purpose: Information on the relationship between frailty and the outcome of endovascular therapy (EVT) in elderly patients with lower extremity peripheral artery disease (PAD) is scarce. This study aimed to reveal the impact of frailty on the prognosis of super-elderly patients who underwent EVT. Materials and Methods: From August 2015 to August 2016, 335 consecutive patients who underwent EVT were enrolled in the I-PAD registry from 7 institutes in Nagano prefecture. Among them, we categorized 323 patients into 4 groups according to age and the presence or absence of frailty as follows: elderly with frailty (age ≥ 75, Clinical Frailty Scale [CFS] ≥ 5), elderly without frailty (age ≥ 75, CFS ≤ 4), young with frailty (age < 75, CFS ≥ 5), and young without frailty (age < 75, CFS ≤ 4); we analyzed them accordingly. The primary endpoints were major adverse cardiovascular and limb events (MACLE), defined as a composite of cardiovascular death, myocardial infarction, stroke, admission for heart failure, major amputation, and revascularization. The secondary endpoint was cardiovascular death. Results: The median follow-up period was 2.7 years. In the elderly with frailty, elderly without frailty, young with frailty, and young without frailty groups, the freedom rates from MACLE were 34.9%, 55.7%, 35.4%, and 63.0%, respectively (p<0.001) and from all-cause death were 43.5%, 73.4%, 50.7%, and 90.9%, respectively (p<0.001). The freedom rates from MACLE were significantly higher among elderly patients with frailty than among young patients without frailty (55.7% vs 35.4%, p=0.01). In multivariate analysis, frailty was independently associated with MACLE incidence. Conclusion: Frailty as defined by CFS might be a predictor of MACLE incidence in patients with PAD who underwent EVT. By considering treatment indications for patients with PAD by focusing on frailty rather than age, we may examine whether EVT policies are appropriate and manage patient and caregiver expectations for potential improvement in functional outcomes. Further studies are expected to investigate whether changes in frailty after EVT change prognosis.

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Abstract WMP5: Endovascular Therapy Stroke Outcome in Very Elderly: Meta-analysis

Stroke ◽

10.1161/str.47.suppl_1.wmp5 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Michelle P Lin ◽

David S Liebeskind ◽

Steven Cen ◽

William J Mack ◽

Arun P Amar ◽

...

Keyword(s):

Ischemic Stroke ◽

Elderly Patients ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Endovascular Therapy ◽

Odds Ratio ◽

Age Groups ◽

Large Vessel ◽

Very Elderly

Introduction: Very elderly (age ≥80yo) individuals account for about one-third of all stroke admissions with mixed literature demonstrating relative poor stroke outcomes. With overwhelming recent evidence supporting the use of intra-arterial thrombectomy in addition to IV thrombolysis for large-vessel occlusive stroke, we conducted a metaanalysis to assess long-term functional outcome following mechanical thrombectomy in very elderly. Hypothesis: Very elderly patients with acute ischemic stroke treated with thrombectomy have equally favorable long-term functional outcomes to their younger counterparts Methods: Stroke endovascular trials published in New England Journal of Medicine 2014-2015 were included if they reported odds ratio of good functional outcome (improvement in modified Rankin score, mRS) comparing thrombectomy vs IV-tPA dichotomized by age groups (age ≤ 80yo vs >80yo, 2 studies dichotomized age at 70yo). Multivariate adjusted odds ratios and the corresponding standard errors were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates with 95% confidence interval were compared between elderly and younger age groups. Forest plots constructed. Results: Of the 5 recent intraartrial thrombectomy trials, 4 studies reported subgroup analysis by age with 1,206 participants, 28% (N=334) were above the age of 80yo, 72% (N=872) were ≤80yo. Among very elderly patients undergoing thrombectomy, the pooled odds ratio of good functional outcome at 3 months was 1.91 (1.13-3.24), in the younger group the pooled odds ratio was 1.95 (1.50-2.53). Conclusions: Endovascular therapy was an effective therapy for very elderly individuals presenting with acute ischemic stroke caused by large vessel occlusive disease. Future studies are needed to further assess the safety and effectiveness of thrombectomy in this growing population.

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Proximal direct endarterectomy combined with simultaneous distal endovascular therapy for chronic full-length occlusion of the superficial femoral artery in elderly patients

Asian Journal of Surgery ◽

10.1016/j.asjsur.2012.11.006 ◽

2013 ◽

Vol 36 (3) ◽

pp. 104-110 ◽

Cited By ~ 1

Author(s):

Mitsuyuki Nakayama ◽

Fumikazu Sakamoto

Keyword(s):

Elderly Patients ◽

Endovascular Therapy ◽

Femoral Artery ◽

Superficial Femoral Artery ◽

Full Length

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Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012313 ◽

2016 ◽

Vol 9 (3) ◽

pp. 324-328 ◽

Cited By ~ 5

Author(s):

Kimon Bekelis ◽

Dan Gottlieb ◽

Yin Su ◽

Nicos Labropoulos ◽

George Bovis ◽

...

Keyword(s):

Elderly Patients ◽

Endovascular Treatment ◽

Endovascular Therapy ◽

Instrumental Variable ◽

Cerebral Aneurysms ◽

Treatment Method ◽

Surgical Clipping ◽

Unmeasured Confounding ◽

Hospital Referral ◽

Unruptured Cerebral Aneurysms

BackgroundThe cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association between treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients.MethodsWe performed a cohort study of 100% Medicare fee-for-service claims data for elderly patients who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding we used multivariable regression analysis with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method.ResultsDuring the study period 8705 patients underwent treatment for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46 800 (IQR $31 000–$74 400) for surgical clipping and $48 100 (IQR $34 500–$73 900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3527 (95% CI $972 to $5736) and increased 1-year Medicare expenditures by $15 984 (95% CI $9017 to $22 951).ConclusionsIn a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures compared with endovascular treatment.

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