“Outpatient Arteriography and Arterial Intervention in Octogenarians. Is It Safe?” George G. Hartnell Baystate Medical Center Springfield, MA Safe at Any.

““Outpatient Arteriography and Outpatient Arteriography and Arterial Intervention in Arterial Intervention in

Octogenarians. Is It Safe?”Octogenarians. Is It Safe?” George G. HartnellGeorge G. Hartnell

Baystate Medical CenterBaystate Medical CenterSpringfield, MASpringfield, MA

Safe at Any Age? Safe at Any Age?

Octogenarians Do As Well as Younger Patients Octogenarians Do As Well as Younger Patients With Interventional Radiology Arterial Procedures.With Interventional Radiology Arterial Procedures.

Abstract #131, SIR 2008Abstract #131, SIR 2008

PerceptionsPerceptions

‘I’m too old.’

‘Its what you expect when you’re my age.’

‘Can he/she manage it?’

‘Isn’t it dangerous?’

‘What about my heart/kidneys?’

Outpatient Arteriography and ArterialOutpatient Arteriography and ArterialIntervention in Octogenarians. Is It Safe?Intervention in Octogenarians. Is It Safe?

Introduction:Introduction:It has been said by many that very elderly subjects (VES; aged 80 years or older) constitute a special population as they frequently have multiple diseases (polypathology). It is often felt that any procedure, including diagnostic arteriography and arterial interventions for peripheral vascular disease (PVD), is associated with increased risk in the very elderly. Some research protocols have deliberately or unconsciously excluded or minimized the participation of the very elderly. The very elderly may be denied treatment due to the perception that the risks of PVD procedures are too high.

Is It Safe?Is It Safe?Some suggest that octogenarians requiring arteriography or arterial Some suggest that octogenarians requiring arteriography or arterial intervention should be admitted to the hospital. Many admit patients intervention should be admitted to the hospital. Many admit patients requiring arterial interventions, irrespective of age. Even with the routine requiring arterial interventions, irrespective of age. Even with the routine use of closure devices following outpatient arterial intervention, use of closure devices following outpatient arterial intervention, admission for complications has been reported in up to 10%. admission for complications has been reported in up to 10%.

I reviewed my experience of outpatient arteriography and arterial I reviewed my experience of outpatient arteriography and arterial interventions in octogenarians to determine if this approach is safe. interventions in octogenarians to determine if this approach is safe.

Data on arterial procedures and complications were collected over a Data on arterial procedures and complications were collected over a period of 36 months (2005-2007) for VES and a contemporary period of 36 months (2005-2007) for VES and a contemporary comparison group aged 50-79. Patients for arterial procedures who did comparison group aged 50-79. Patients for arterial procedures who did not require admission for scheduling reasons or other procedures were not require admission for scheduling reasons or other procedures were routinely evaluated and treated as outpatients, irrespective of age. routinely evaluated and treated as outpatients, irrespective of age. Procedures and immediate complications were compared.Procedures and immediate complications were compared.

84 year old man presents with severe right leg pain walking 84 year old man presents with severe right leg pain walking fewer than 200 yards. He also has coronary artery disease, fewer than 200 yards. He also has coronary artery disease, high blood pressure, high cholesterol, diabetes and chronic high blood pressure, high cholesterol, diabetes and chronic renal insufficiency. Previously he had carotid artery and renal insufficiency. Previously he had carotid artery and coronary artery bypass surgery.coronary artery bypass surgery.

Digital angiogram shows a Digital angiogram shows a complete blockage (complete blockage (…..….. between between arrows) of the femoral artery. This arrows) of the femoral artery. This was over three inches long.was over three inches long.

The blockage (A) was crossed and treated initially by balloon dilatation (B). The blockage (A) was crossed and treated initially by balloon dilatation (B). Because of the length of the blockage, it was decided to treat the opened Because of the length of the blockage, it was decided to treat the opened area with a 10 cm flexible stent (C and D). The pulse in his foot returned area with a 10 cm flexible stent (C and D). The pulse in his foot returned and he was discharged home that evening. Since then he has done well and he was discharged home that evening. Since then he has done well with significant improvement in symptoms. A pulse is still felt below the with significant improvement in symptoms. A pulse is still felt below the stent. ABI five months later 0.92; he is still doing well after 9 months.stent. ABI five months later 0.92; he is still doing well after 9 months.

(A).(A). (B).(B). (C).(C). (D).(D).

““Fragile” 80 year old lady complained of worsening right leg pain on walking Fragile” 80 year old lady complained of worsening right leg pain on walking and had developed pain at rest, especially at night. There were ischemic and had developed pain at rest, especially at night. There were ischemic changes in the right foot (blue discoloration, no ulceration). She also has changes in the right foot (blue discoloration, no ulceration). She also has high blood pressure and high cholesterol.high blood pressure and high cholesterol.

DSA shows stenosis of superficial femoral artery (A) and DSA shows stenosis of superficial femoral artery (A) and tibio-peroneal trunk (B) with poor distal run off (C, D).tibio-peroneal trunk (B) with poor distal run off (C, D).

(A)(A) (B)(B) (D)(D)(C)(C)

Balloon cryoplasty was performed (PolarCath, Boston Balloon cryoplasty was performed (PolarCath, Boston Scientific Corporation, Natick MA). The superficial femoral Scientific Corporation, Natick MA). The superficial femoral artery stenosis was dilated to 4 mm (A->B) and the tibio-artery stenosis was dilated to 4 mm (A->B) and the tibio-peroneal trunk to 2.5 mm (C->D). She was discharged peroneal trunk to 2.5 mm (C->D). She was discharged home the same day. She is doing well five months later.home the same day. She is doing well five months later.

(A)(A) (C)(C)(B)(B) (D)(D)

81 year old woman complained of worsening right leg pain on walking 81 year old woman complained of worsening right leg pain on walking and had developed pain at rest, especially at night. She also suffers and had developed pain at rest, especially at night. She also suffers from high blood pressure, high cholesterol and diabetes. MRA showed from high blood pressure, high cholesterol and diabetes. MRA showed multiple narrowings of the right femoral artery with only one vessel multiple narrowings of the right femoral artery with only one vessel supplying the calf (the other two calf arteries being blocked).supplying the calf (the other two calf arteries being blocked).

Digital angiogram showed Digital angiogram showed narrowing of the arteries at several narrowing of the arteries at several levels in the femoral (A) and levels in the femoral (A) and popliteal artery (A and B).popliteal artery (A and B).

(A)(A) (B)(B)

The femoral artery blockage was treated with balloon dilatation using a The femoral artery blockage was treated with balloon dilatation using a freezing balloon (PolarCath, Boston Scientific Corporation, Natick MA). freezing balloon (PolarCath, Boston Scientific Corporation, Natick MA). The narrowings in the popliteal artery were treated in the same way. The narrowings in the popliteal artery were treated in the same way. The result shown on the final angiogram (C) was excellent. She went The result shown on the final angiogram (C) was excellent. She went home after six hours of bed rest later that evening.home after six hours of bed rest later that evening.

Digital Angiogram (C) shows Digital Angiogram (C) shows relief of all the stenoses relief of all the stenoses (arrows) treated by cryoplasty.(arrows) treated by cryoplasty.

(A)(A) (B)(B) (C)(C)

ProceduresProceduresAge ≥80Age ≥80 Age 50-79Age 50-79

Patient Episodes Patient Episodes 91 91 260260Age range; meanAge range; mean 80-92; mean 83.880-92; mean 83.8 Mean 67.6Mean 67.6GenderGender Female 52Female 52 Female 120 Female 120 Diagnostic ArteriographyDiagnostic Arteriography 25 (27%)25 (27%) 112 (43%)112 (43%)

RenalRenal 10 (11% total)10 (11% total) 30 (11% total)30 (11% total)FemoralFemoral 14 (15% total)14 (15% total) 46 (17% total)46 (17% total)Carotids/UECarotids/UE 1 (1% total)1 (1% total) 31 (12% total)31 (12% total)MesentericMesenteric 00 7 (3% total)7 (3% total)

Angioplasty/Cryoplasty Angioplasty/Cryoplasty 19 (21%)19 (21%) 26 (10%)26 (10%)

Stent +/- AngioplastyStent +/- Angioplasty 46 (51%)46 (51%) 119 (46%)119 (46%)(Multivessel stenting)(Multivessel stenting) (9; 20% stents)(9; 20% stents) (34; 29% stents) (34; 29% stents)

Thrombolysis Thrombolysis (Mechanical)(Mechanical) 1 (1%)1 (1%) 1 (0.4%)1 (0.4%)

Reported ComplicationsReported Complications Age ≥80 Aged 50-79

All Recorded Events 5/91 (5.5%) 15/260 (5.7%)

Major Events 2 (2.2%) 2 (2.2%) 3 (6*; 2.3%)3 (6*; 2.3%) (Admissions) (1)(1) (3)(3)

False Aneurysm 11 0

Worsening Limb Ischemia 0 3* (1.1%)3* (1.1%)(limited adverse outcomes)

Hematoma (admission) 11 2 (0.8%)2 (0.8%)

>3cm Hematoma (no action) 3 (3.3%) 6 (2.3%)

CHF 0 1 (0.4%)1 (0.4%)

Death 0 0

Standards for Complications ofStandards for Complications ofPercutaneous Renal RevascularizationPercutaneous Renal Revascularization

Major Complications for Percutaneous Renal RevascularizationMajor Complications for Percutaneous Renal RevascularizationComplicationComplication Reported Rate (%)Reported Rate (%) Threshold (%)Threshold (%)30-day mortality 30-day mortality 1 1 11Secondary nephrectomy Secondary nephrectomy 1 1 11Surgical salvage operation Surgical salvage operation 1 1 22Symptomatic embolization Symptomatic embolization 3 3 33Main renal artery occlusion Main renal artery occlusion 2 2 22Branch renal artery occlusion Branch renal artery occlusion 2 2 22Access site hematoma Access site hematoma requiring surgery, transfusion,requiring surgery, transfusion,or prolonged hospital stayor prolonged hospital stay 5 5 55

Acute renal failure Acute renal failure 2 2 22Worsened chronic renal failure Worsened chronic renal failure requiring increased carerequiring increased care 2 2 55

Table 4. Angioplasty Standards of Practice: SIR Standards of Practice Committee. Table 4. Angioplasty Standards of Practice: SIR Standards of Practice Committee. J Vasc Interv Radiol 2003J Vasc Interv Radiol 2003;14:S219–S221.;14:S219–S221.

ConclusionsConclusionsDiagnostic arteriography and percutaneous arterial Diagnostic arteriography and percutaneous arterial

interventions for PVD can be safely performed as interventions for PVD can be safely performed as outpatient procedures in stable patients.outpatient procedures in stable patients.

The risk of major complications is low (1-2%).The risk of major complications is low (1-2%).

The routine or frequent use of closure devices is not The routine or frequent use of closure devices is not necessary. necessary.

Octogenarians seem to tolerate arteriography and Octogenarians seem to tolerate arteriography and arterial interventions as well as younger arterial interventions as well as younger

patients. patients.

Octogenarians do not need hospital admission for Octogenarians do not need hospital admission for elective diagnostic arteriography or arterial elective diagnostic arteriography or arterial interventions for PVD.interventions for PVD.