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Informal caregivers play a significant role in providing care for older, often vulnerable, patients, and supporting them as they live with chronic diseases. Due to the rising prevalence of older vascular patients and their use of healthcare, the role of their informal caregivers will become more important. However, little is known about the experiences of informal caregivers of patients with critical limb-threatening ischemia and the impact of informal care on different aspects of these caregivers' lives. In addition, literature does not describe the burden this role brings with it, or lack thereof. Therefore a qualitative study using a phenomenological approach, specifically interpretive phenomenological analysis, was used to gain insight into the experiences of the primary informal caregivers of patients with chronic limb-threatening ischemia. Data were collected via semi-structured interviews and focus groups discussions. Fifteen primary informal caregivers of patients with critical limb-threatening ischemia under the care of the vascular surgeon at a tertiary teaching hospital in the Netherlands were included. Data analysis yielded three themes: the perceived identity of this group of caregivers; the varying intensity of informal care; and the collaboration between informal carers, their care recipients and the professional care provider within the vascular surgery department. In contrast to carers of other chronic diseases, the shifting intensity of care that informal caregivers of critical limb-threatening ischemia patients experience seems to prevent long-term overload. Adapting to that fluctuating situation requires flexibility from healthcare providers within the vascular surgery department. In addition, professionals need to involve informal caregivers in the patient's decision-making process and recognize their role in that process., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 van Gorkom et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) are both associated with a decreased health status and possibly quality of life (QOL). A better understanding of the differences in QOL between patients with IC and CLTI could be of additional value in shared decision-making. The aim of this study was to compare the QOL at baseline between patients with IC and patients with CLTI., Methods: The study population was based on 2 study cohorts, 1 cohort consisted of patients with IC (ELECT registry) and the other cohort of patients with CLTI (KOP-study). Patients with an age of ≥70 years were included. QOL at baseline was measured by the WHOQOL-BREF questionnaire. Nonresponders were excluded from data analyses. Student's t-tests and analysis of covariance (ANCOVA) analyses were used to compare QOL between the 2 groups. Outcomes of the ANCOVA analyses were expressed as estimated marginal means., Results: In total, 308 patients were included, 115 patients with IC and 193 patients with CLTI. Patients with CLTI were older (median age 80 years vs. 75 years, P < 0.001) and had more comorbidities. Patients with IC had a statistically significant higher QOL regarding physical health (mean 13.7 [standard deviation (SD) 2.3] vs. 10.8 [SD 2.8], P < 0.001), psychological health (mean 15.3 [SD 2.1] vs. 14.1 [SD 2.4], P < 0.001), environment (mean 16.3 [SD 2.4] vs. 15.5 [SD 2.0], P < 0.002), and the overall domain (mean 3.5 [SD 0.7] vs. 3.1 [SD 0.9], P < 0.001). After correcting for the confounding effect of age and sex, patients with IC still had a statistically significant higher QOL in the physical, psychological, environment, and overall domain., Conclusions: Patients with IC had a significantly higher QOL in the physical, psychological, environment, and overall domains of the WHOQOL-BREF questionnaire compared with patients with CLTI. This underlines the importance of strategies that reduce disease progression as disease progression is associated with a decrease in QOL., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To aid physicians in the process of shared decision-making, many predictive models for critical limb ischemia (CLI) have been constructed. However, none of these models is in widespread use. Predicting survival outcomes for a specific individual may be used to guide treatment selection. The aim of this study was to construct a 6-month survival-predicting model representative of elderly patients with CLI undergoing surgical or endovascular treatment., Methods: An observational cohort study including all patients with CLI aged ≥65 years who underwent surgical or endovascular treatment of CLI between January 2013 and June 2018 was conducted. The model to predict survival at 6 months was based on a multivariable Cox proportional hazards regression model and a penalized likelihood method. The performance of the model was judged by means of the area under the receiver operating characteristic curve., Results: In total, 449 patients were included in the study population. The median age was 76 years (range, 65-97 years), and 52.8% of the population was male. Surgical treatment was performed in 303 patients (67.5%), and 146 underwent endovascular treatment (32.5%). The estimated 30-day survival was 92.7% (standard error [SE], 1.2%); 6-month survival, 80% (SE, 1.9%); and 12-month survival, 71% (SE, 2.1%). Variables with the strongest association with 6-month mortality were age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class. The area under the receiver operating characteristic curve of the 6-month mortality model was 0.81 (95% confidence interval, 0.76-0.85; P < .001)., Conclusions: A prediction model constructed for 6-month mortality of elderly patients undergoing surgical or endovascular treatment of CLI showed that age, living in a nursing home, physical impairment, and American Society of Anesthesiologists class have the highest association with an increase in mortality. These factors may be used to identify patients at risk for mortality in shared decision-making., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Delirium is associated with adverse outcomes, such as increased mortality and prolonged hospital stay. Information on the risk factors for delirium in elderly patients with critical limb ischaemia (CLI) is scarce. The aim of this study was to analyse the incidence of delirium and to identify risk factors for delirium in elderly patients undergoing surgical or endovascular treatment., Methods: A retrospective cohort study was conducted including patients aged ≥ 65 years undergoing surgical or endovascular treatment for CLI between January 2013 and June 2018. Delirium was scored using the DOSS (Delirium Observation Screening Scale) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. Risk factors for delirium were analysed using logistic regression. The discriminative ability of the model was calculated using the area under the receiver operating characteristics (AUROC) curve., Results: In total, 392 patients were included, of which 70 (17.9%) developed delirium. Factors associated with an increased risk of delirium were: age, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.0-1.1), history of femoral endarterectomy, OR 4.7 (95% CI 1.5-15), physical impairment, OR 2.2 (95% CI 1.1-4.5), history of delirium, OR 2.7 (95% CI 1.4-5.3), general anaesthesia, OR 2.6 (95% CI 1.2-5.7) and pre-operative anaemia, OR 5.9 (95% CI 2.3-15). The AUROC was .82 (95% CI 0.76-0.87, p < .001). Delirium was associated with more respiratory, renal and surgical complications, as well as a prolonged hospital stay and a more frequent discharge to a nursing home., Conclusion: Delirium occurs frequently in patients with critical limb ischaemia undergoing any type of invasive treatment. This study identified multiple risk factors for delirium that may be helpful to delineate patients susceptible to its development., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed., Methods: An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model., Results: In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4)., Conclusion: Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The treatment of critical limb ischemia (CLI), with the intention to prevent limb loss, is often an intensive and expensive therapy. The aim of this study was to examine the cost-effectiveness of endovascular and conservative treatment of elderly CLI patients unsuitable for surgery., Methods: In this prospective observational cohort study, data were gathered in two Dutch peripheral hospitals. CLI patients aged 70 years or older were included in the outpatient clinic. Exclusion criteria were malignant disease, lack of language skills, and cognitive impairment; 195 patients were included and 192 patients were excluded. After a multidisciplinary vascular conference, patients were divided into three treatment groups (endovascular revascularization, surgical revascularization, or conservative therapy). Subanalyses based on age were made (70-79 years and ≥80 years). The follow-up period was 2 years. Cost-effectiveness of endovascular and conservative treatment was quantified using incremental cost-effectiveness ratios (ICERs) in euros per quality-adjusted life-years (QALYs)., Results: At baseline, patients allocated to surgical revascularization had better health states, but the health states of endovascular revascularization and conservative therapy patients were comparable. With an ICER of €38,247.41/QALY (∼$50,869/QALY), endovascular revascularization was cost-effective compared with conservative therapy. This is favorable compared with the Dutch applicable threshold of €80,000/QALY (∼$106,400/QALY). The subanalyses also established that endovascular revascularization is a cost-effective alternative for conservative treatment both in patients aged 70 to 79 years (ICER €29,898.36/QALY; ∼$39,765/QALY) and in octogenarians (ICER €56,810.14/QALY; ∼$75,557/QALY)., Conclusions: Our study has shown that endovascular revascularization is cost-effective compared with conservative treatment of CLI patients older than 70 years and also in octogenarians. Given the small absolute differences in costs and effects, physicians should also consider individual circumstances that can alter the outcome of the intervention. Cost-effectiveness remains one of the aspects to take into consideration in making a clinical decision., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Critical limb ischemia (CLI) patients are often of advanced age with reduced health status (HS) and quality of life (QoL) at baseline. Physical health is considered as the most affected domain due to reduced mobility and ischemic pain. QoL and HS are often used interchangeably in the current literature. HS refers to objectively perceived physical, psychological, and social functioning and in assessing QoL, change is measured subjectively and can only be determined by the individual since it concerns patients' evaluation of their functioning. It is important to distinguish between QoL and HS, especially in the concept of shared decision-making when the opinion of the patient is key. Goal of this study was to examine and compare QoL and HS in elderly CLI patients in relation to the used therapy, with a special interest in conservatively treated patients., Methods: Patients suffering from CLI and ≥70 years old were included in a prospective study with a follow-up period of 1 year. Patients were divided into three groups; endovascular revascularization, surgical revascularization, and conservative therapy. The WHOQoL-Bref was used to determine QoL, and the 12-Item Short Form Health Survey was used to evaluate HS at baseline, 5-7 days, 6 weeks, 6 months, and 1 year., Results: Physical QoL of endovascularly and surgically treated patients showed immediate significant improvement during follow-up in contrast to delayed increased physical HS at 6 weeks and 6 months ( P <0.001). Conservatively treated patients showed significantly improved physical QoL at 6 and 12 months ( P =0.02) in contrast to no significant improvement in physical HS., Conclusion: This study demonstrates that QoL and HS are indeed not identical concepts and that differentiating between these two concepts could influence the choice of treatment in elderly CLI patients. Discriminating between QoL and HS is, therefore, of major importance for clinical practice, especially to achieve shared decision-making., Competing Interests: Dr Stijn L Steunenberg reports grants from Nuts Ohra, during the conduct of the study. The other authors report no conflicts of interest in this work.

Purpose: Despite high amputation rates, data on patient-reported outcomes is scarce in the elderly population with critical limb ischemia. The aim of this study was to provide mortality rates and long-term changes of the following patient-reported outcomes in elderly critical limb ischemia amputees: quality of life (QoL), health status (HS), and symptoms of depression., Patients and Methods: In this prospective observational cohort study, amputated critical limb ischemia patients ≥70 years were included. The follow-up period was two years. Within the follow-up period patients completed the following questionnaires: the World Health Organization Quality Of Life -abbreviated version of the WHOQOL 100 (WHOQOL-BREF), the 12-Item Short Form Health Survey, and the Center for Epidemiological Studies Depression Scale., Results: A total of 49 elderly patients with critical limb ischemia had undergone major limb amputation within two years after inclusion. In these patients, the one-year mortality rate was 39% and the two-year mortality rate was 55%. The physical QoL was the only domain of the WHOQOL-BREF that improved significantly across time after amputation (p≤0.001). In the long-term, there was no difference in the ability to enjoy life (p=0.380) or the satisfaction in performing daily living activities (p=0.231) compared to the scores of the general elderly population. After amputation, the physical HS domain (p≤0.001) and the mental HS domain (p=0.002) improved. In the first year, amputees experienced less symptoms of depression (p=0.004)., Conclusion: Elderly critical limb ischemia amputees are a fragile population with high mortality rates. Their QoL and HS increased after major limb amputation as compared to the baseline situation and they experienced less symptoms of depression. Moreover, our results show that, in the long-term, major limb amputation in the elderly patients with critical limb ischemia shows an acceptable QoL, which, in some aspects, is comparable to the QoL of their peers. These results can improve the shared-decision making process that does not delay the timing of major limb amputation., Competing Interests: The authors report no conflicts of interest in this work.

Background: In patients with critical limb ischemia, an association is assumed between depression and worse outcome for morbidity, such as major limb amputation. After major amputation, anxiety and depression are common. We aimed to determine the association of depressive and anxiety symptoms in the elderly with critical limb ischemia, especially after major limb amputation., Methods: Patients with critical limb ischemia aged ≥70 years were included in this prospective observational cohort study between January 2012 and February 2016 in 2 Dutch hospitals. After a multidisciplinary vascular conference, patients were divided into 4 treatment groups: endovascular revascularization, surgical revascularization, conservative therapy, and primary major amputation. In a 1-year follow-up period, depression and anxiety were measured 4 times using the Dutch versions of the Center for Epidemiological Studies Depression Scale and the State-Trait Anxiety Inventory., Results: One Hundred eighty-seven patients were included. Within 1 year, 44 patients underwent a major limb amputation. Lower amputation-free survival did not differ significantly for patients with versus without greater anxiety (X 2 [1] = 0.689, P = 0.407) and also not for patients with versus without more depressive symptoms (X 2 [1] = 0.614, P = 0.433). For both groups, there were no significant changes in anxiety scores over time. After a median follow-up time of 336.5 days and 365 days, depressive symptoms significantly decreased in amputees, respectively, 8.5 vs. 4.5 (95% CI 1.76-7.48, P = 0.002) and 8.5 vs. 4.3 (95% CI 0.61-9.82, P = 0.027) when compared to the baseline measurement. Similarly, nonamputees had significantly lower overall score for depressive symptoms after a median follow-up time of 365 days (10.1 vs. 4.1, 95% CI 4.49 to 6.90, P < 0.001)., Conclusions: In the opinion of the medical health care provider, amputation is a severe and unwanted end phase of critical limb ischemia. However, depressive symptoms seem to decrease over time and anxiety symptoms do not seem to be affected in patients after major limb amputation. In addition, patients with greater trait anxiety or more depressive symptoms at baseline did not have significantly higher amputation rates. These findings are similar to the course of depressive and anxiety symptoms for the elderly patients without major limb amputation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: A patient-oriented appraisal of treatment has become extremely important, particularly in elderly patients with critical limb ischaemia (CLI). Quality of life (QoL) is an important patient-reported outcome in vascular surgery. Frequently, the physical domain of QoL questionnaires represents an 'objective' evaluation of performing activities, which is expected to be impaired after major limb amputation. However, an objective appraisal of physical function is an assessment of health status (HS) and not of QoL. Little is known about the subjective appraisal of physical health (QoL). The goal of this study was to evaluate, prospectively, QoL in relation to HS in elderly CLI patients undergoing major limb amputation., Methods: Patients suffering from CLI aged 70 years or older were included in a prospective observational cohort study with a follow-up period of 1 year. Patients were divided according to having had an amputation or not. The World Health Organization Quality Of Life-BREF (WHOQOL-BREF) was used to asses QoL. The 12-Item Short Form Health Survey (SF-12) was used to measure HS. These self-reported questionnaires were completed five times during follow-up., Results: Two-hundred patients were included of whom 46 underwent a major limb amputation within one year. Amputees had a statistically significant improvement of their physical QoL after six months (14.0 vs. 9.0 (95% CI -7.84;-1.45),p = 0.005) and after a one-year follow-up (14.0 vs. 9.0 (95% CI -9.58;-1.46),p = 0.008). They did not however show any statistically significant difference in HS. For non-amputees, both physical QoL and HS improved. An instant statistically significant improvement of the physical QoL appeared 1 week after inclusion (12.0 vs. 10.9 (95% CI -1.57;-0.63),p<0.001). Similarly, statistically significant improvement in the physical HS first occurred at 1 week follow-up (29.0 vs. 28.9 (95% CI -5.78; -2.23),p = 0.003)., Conclusions: There is a clear difference between patients' functioning (HS) and the patients' appraisal of functioning (QoL). In elderly CLI patients, this study clearly suggests a discrepancy between the physical QoL (WHOQOL-BREF) and HS (SF-12) measurements in vascular amputees. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. Individual treatment goals should be kept in mind when assessing the HS or QoL outcome of patients undergoing hospital care. With respect to shared decision making, distinctive and subjective QoL questionnaires, like the WHOQOL-BREF, provide a very important outcome measurement and should be used in future research., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Endovascular-first strategy for critical limb ischemia is widely accepted, especially in elderly patients, because of the increasing patency rates and minimally invasive character. Nonetheless, the impact of reinterventions because of endovascular treatment failure in this population is not well known. The aim of this study was to evaluate the reintervention rate and outcomes following reinterventions., Methods: Patients aged >70 years with critical limb ischemia as a result of aortoiliac, femoropopliteal, and/or crural disease, treated by "endovascular-first strategy" between 2006 and 2013, were retrospectively analyzed. Follow-up was until 31 December 2014. Primary end point was freedom from reintervention or major amputation. Secondary outcome measures were limb salvage and mortality after reintervention. Reintervention was defined as endovascular or surgical re-revascularization and categorized into early reintervention (<3 months) and late reintervention (>3 months)., Results: In total, 263 patients were treated by endovascular revascularization. The majority (60%) of the treated lesion was located in the femoropopliteal segment. In total, a reintervention was performed in 32%, with 48% performed within 3 months. Freedom from reintervention or major amputation at 1 and 3 years was 0.71 ± 0.03 and 0.61 ± 0.03, respectively. The 1-year Kaplan-Meier estimate amputation-free survival was 0.35 ± 0.06 in the early reintervention group, compared with 0.73 ± 0.06 in the late reintervention group and 0.71 ± 0.04 in the no reintervention group (P < 0.001; log rank). The 1-year mortality in the early reintervention group was 0.35 ± 0.06, compared with 0.14 ± 0.05 in the late reintervention group and 0.29 ± 0.04 in the group who did not require reintervention (P = 0.047; log rank)., Conclusions: Endovascular revascularization first strategy for critical limb ischemia results in high reintervention rates in elderly patients. Failure of the endovascular revascularization requiring early reintervention is associated with lower amputation-free survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Revascularization to relieve ischemic pain and prevent limb loss is the cornerstone of critical limb ischemia (CLI) treatment; however, not all elderly patients are deemed fit for revascularization. Patient-related outcome measurements are important in these patients. Quality of life (QoL) results regarding the effect of endovascular, surgical, and conservative treatment on the QoL in the elderly are scarce in the current literature. The goal of this study was to explore the outcomes of the different treatment modalities in elderly patients suffering from CLI, with a specific focus on QoL., Methods: A total of 195 CLI patients ≥70 years were prospectively included between January 2012 and February 2016 and divided into 6 groups (endovascular revascularization, surgical revascularization, and conservative treatment). Two age groups (70-79 and >80 years) were analyzed. Follow-up was performed at 5-7 days, 6 weeks, and 6 months. World Health Organization Quality of Life-BREF questionnaire was used to determine QoL. The Vascular-Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity score was noted. QoL was used as the primary end point, with mortality and limb salvage as the secondary end points., Results: Six-month mortality was significantly lower in surgically treated patients aged 70-79 years (4%) as compared with endovascular (24%, P = 0.001) or conservative treatment (25%, P = 0.02). There was no significant difference in 6-month mortality in patients >80 years among endovascularly (38%), surgically (15%), and conservatively treated patients (27%). QoL significantly increased at all follow-up moments in surgically treated patients between 70 and 79 years and at 6 months in endovascularly treated patients. Conservatively treated patients did not improve their QoL in this age group. All patients aged >80 years, including conservatively treated patients, showed significantly improved QoL results at 6 months., Conclusions: Elderly patients judged fit for surgery may benefit the most from surgical revascularization, reporting low mortality rates, low adverse events and significantly gained QoL in multiple domains. However, all 3 treatment modalities have significantly increased physical health at 6 months. Conservative therapy seems to be an acceptable treatment option in patients unfit for revascularization with gained physical health at 6 months., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The treatment of critical limb ischemia (CLI) in the elderly patients is challenging because of the comorbidity and fragility of these patients. We analyzed survival in relation to different treatment options and estimated life expectancy of our study group by age and gender., Methods: All patients aged ≥70 years, presenting with chronic CLI, between 2006 and 2013 were included. The treatment was conservative, endovascular, surgical, or by primary major amputation. The interest was in the effect of conservative versus nonconservative treatment on survival. Furthermore, we compared mortality and life expectancy between the study population to the overall Dutch population by age and gender., Results: In total, 686 legs in 651 patients were treated. Initial treatment of patients was conservative (n = 181), endovascular (n = 259), surgical (n = 169), or amputation (n = 42). The overall 1-year mortality was 29%. Patients were stratified by age: 70-79 (n = 350) years and ≥80 (n = 301) years. Higher mortality rate ratios (RR) were found in octogenarians compared with patients aged 70-79 years, in the endovascular (P < 0.001) and surgical (P < 0.001) group. The mortality RRs of conservative relatively to nonconservative treatment was 0.84 (95% confidence interval: 0.65-1.09; P = 0.19), not significantly differing between both age groups (P = 0.74). The mortality RR of 3.72 of our study population to the Dutch general population was high, with an excess mortality of 272%. Life expectancy at the age of 70 years was substantially decreased by 9 and 8 years for, respectively, the male and female population., Conclusions: Mortality rates in elderly patients with CLI are high, corresponding with a decreased life expectancy, regardless of the type of intervention. Revascularization is associated with high periprocedural mortality, especially in octogenarians. Conservative treatment is noninferior to nonconservative treatment in terms of mortality and should be considered as the treatment in octogenarians with substantial comorbidity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Owing 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., Methods: From 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)., Results: In 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., Conclusion: Despite 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., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Critical limb ischemia (CLI) is a disease that is most prevalent in the elderly population. This group of patients includes patients suffering from comorbidities such as dementia. Mortality rates of both CLI and dementia are higher when compared with the nonaffected population. These demented vascular patients are often deemed unfit for surgery and at risk of respiratory and cardiovascular adverse events. Unfortunately, current literature is lacking in to determining the optimal treatment for demented patients suffering from CLI. The purpose of this study is to determine the prevalence of dementia in patients suffering from CLI, with special interest in the mortality rates of these patients., Methods: Between January 2012 and October 2015, all patients aged over 70 and suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients with diagnosed dementia before admission by a geriatrician were included in this study. Baseline characteristics were retrieved from patients' medical charts. Primary end point of this study is mortality and the secondary end points include adverse events, reinterventions, and limb salvage., Results: A total of 369 patients suffering from CLI were diagnosed between January 2012 and October 2015. Thirty-one patients (8%) diagnosed with both dementia and CLI were included in this study with a mean age of 82 years old. Conservative therapy was selected as the therapy of choice in 61% of the patients. There was a mortality rate of 32% after 6 months, increasing to 52% after 1 year and 92% after 2 years. Limb salvage rates after 30 days were 84%, dropping to 77% after 6 months., Conclusions: Eight percent of CLI patients aged above 70 years old are suffering from dementia. Demented patients suffering from CLI are a frail group of elderly patients with a high mortality rate of 52% after 1-year follow-up. Therapy of choice should probably be selected following mutual agreement between vascular surgeons, individual patients, and their families, taking postoperative quality of life, life expectation, and anatomical arterial lesions into account., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Various treatment options exist for patients suffering from critical limb ischemia (CLI). These options consist of endovascular procedures, surgical revascularization, primary amputation, or conservative therapy. The effect of the treatment is traditionally focused on outcomes, such as primary patency and limb salvage, though quality of life (QoL) is considered an important additional primary end point in a more patient-oriented healthcare system. The aim of this systematic review is to explore the best clinical decision making possible, to increase QoL in CLI patients., Methods: This review is based on a systematic electronic literature search using the PubMed and EMBASE databases. Articles evaluating QoL in patients with CLI were selected for further analysis. Only prospective studies, written in English, describing QoL and health status (HS) after endovascular or surgical revascularization, amputation or conservative therapy were considered for inclusion. Treatment results were divided into short-term (≤3-month follow-up) and long-term results (≥1-year follow-up) to achieve a clear view of the QoL in patients suffering for CLI patients., Results: Twenty-five articles describing HS in patients suffering from CLI were included. It was found that while most of these articles reported HS of patients, rarely did they report on QoL. As a result, it is difficult to determine the best treatment to increase HS as studies that focus on the comparison of treatment modalities are lacking. All 4 treatment modalities can raise HS in the short and the long terms; however, endovascular and surgical revascularization seem to positively effect HS the most. QoL results are lacking in both the short and long terms., Conclusions: All treatment methods included in the study resulted in an increase in patients' HS in both short and long terms. More comparative studies with inclusion of all different treatments of CLI are needed to assist in clinical decision making and perform tailored interventions for the individual patient. QoL and HS are confusingly used in current international literature with abundant HS research. To take patients individual opinions more into account, focus on QoL research is needed to designate the superior treatment in patients suffering from CLI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Peripheral arterial disease has become an increasing problem in the aging population of the western world with a prevalence of 10-14%. This will result in a growing group of nonagenarians being referred to vascular surgeons, with an estimated growth of 2.5 times the number of nonagenarians between 2015 and 2040. Outcome results of nonagenarians suffering from critical limb ischemia (CLI) are scarce, which can cause difficulties in choosing superior therapy options. We propose that the life expectancy of nonagenarians suffering CLI compared to the overall population of nonagenarians is valuable information required in clinical decision-making., Methods: Between January 2012 and October 2015, all patients suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients aged ≥90 years at admission were exclusively included. The main outcome result of this study is the life expectancy of nonagenarians suffering from CLI. Closely related to life expectancy is the primary end point of mortality. Secondary end points were adverse events, reoperations, and limb salvage., Results: A total of 36 patients were included in this study of which 27 were women. The median age was 92 years. Conservative therapy was performed in 61% of the patients. Based on 24 deaths (of which 19 were women), the mortality rate ratio of the study group relative to the Dutch population was 3.13 (95% confidence interval [CI], 2.00-4.66; P < 0.000001), adjusted for age and gender. Life expectancy in years of the total Dutch population at age 90 years in 2013 was 3.83 for men and 4.54 for women in contrast to, respectively, 1.23 (95% CI, 0.50-5.69) and 2.70 (95% CI, 1.76-3.74) years in our patient group., Conclusions: CLI is a severe disease in nonagenarians with a dreadful life expectancy of 1.23 and 2.7 years for men and women, respectively, corresponding with an age- and gender-adjusted mortality rate ratio of 3.13 relative to the Dutch population. Individual factors such as preoperative status, arterial occlusive lesion, and especially predicted postoperative quality of life are important parameters in clinical decision-making. Results of conservative therapy might be acceptable in selected patients, but more focus on quality of life is needed to be conclusive., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The primary objective was to identify possible risk factors for delirium in patients with critical limb ischemia undergoing surgery. The secondary objective was to study the effect of delirium on complications, the length of hospital stay, health care costs, and mortality., Methods: All patients 65 years or older with critical limb ischemia undergoing surgery from February 2013 to July 2014 at Amphia Hospital, were included and followed up until December 31, 2014. Delirium was scored using the Delirium Observation Screening Scale (DOSS). Perioperative risk factors (age, comorbidity, factors of frailty, operation type, hemoglobulin, and transfusion) were collected and analyzed using logistic regression. Secondary outcomes were the number of complications, total hospital stay, extra health care costs per delirium, and mortality within 3 months and 6 months of surgery., Results: We included 92 patients with critical limb ischemia undergoing surgery. Twenty-nine (32%) patients developed a delirium during admission, of whom 17 (59%) developed delirium preoperatively. After multivariable analysis, only diabetes mellitus (odds ratio [OR] =6.23; 95% confidence interval [CI]: 1.11-52.2; P=0.035) and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ-RC) ≥3 (OR =5.55; 95% CI: 1.07-42.0; P=0.039) was significantly associated with the onset of delirium. Delirium was associated with longer hospital stay (P=0.001), increased health care costs, and higher mortality after 6 months (P<0.001)., Conclusion: Delirium is a common adverse event in patients with critical limb ischemia undergoing surgery with devastating outcome in the long term. Most patients developed delirium preoperatively, which indicates the need for early recognition and preventive strategies in the preoperative period. This study identified undernourishment and diabetes mellitus as independent risk factors for delirium.

Objective: To assess the outcome of conservative treatment of severe critical limb ischemia (CLI) classified as Rutherford 5/6., Background: The preferred therapy for CLI is either endovascular revascularization or bypass surgery. With a growing aged population with more serious comorbidities, these therapies are not always a viable option. Primary amputation leads to decreased mobility and a reduced quality of life. There is a lack of literature regarding the outcome of conservative therapy., Methods: Hospital charts were reviewed of all patients who were diagnosed with Rutherford classification 5-6 and received conservative treatment and lacked interventional options. Outcome measures were mortality, complete wound closure, and limb salvage rate., Results: 38 patients were included with a median age of 80 years (range 57-97). The amputation rate during follow-up was 16%. In 58% of patients, complete wound closure was achieved. All-cause mortality was 58% with a 2-year survivability rate of 55%., Conclusions: Conservative management in our selected patients with CLI results in a moderate rate of wound closure and acceptable amputation rates albeit with a high mortality rate. For patients not eligible for endovascular revascularization or bypass surgery, conservative treatment could be a viable option besides primary limb amputation.

Background: To assess the outcome and the occurrence and consequences of adverse events (AEs) after treatment of acute limb ischemia (ALI)., Methods: Retrospective analysis on intra-arterial thrombolysis (group I) and thromboembolectomy (group II). Outcome measures were primary patency and limb salvage rates. AEs and consequences were registered during admission and 30 days after discharge., Results: A total of 238 procedures were included (group I, 173 vs. group II, 65). The primary patency (P = 0.144) and limb salvage rates (P = 0.166) were not significantly different between both groups. A total of 195 AEs were registered. Most AEs were procedure related and resulted in surgical reintervention (77% vs. 76%). Some AEs resulted in irreversible physical damage (15% vs. 25%) and death (6% vs. 12%)., Conclusions: Both, intra-arterial thrombolysis and thromboembolectomies are adequate therapies; however, they result in a wide variety of AEs resulting in serious morbidity and even death., (Copyright © 2015 Elsevier Inc. All rights reserved.)