“ Outpatient Arteriography and Arterial Intervention in Octogenarians. Is It Safe?” George G. Hartnell Baystate Medical

1. “Outpatient Arteriography and Arterial Intervention in Octogenarians. Is It Safe?”George G. HartnellBaystate Medical CenterSpringfield, MA • Safe at Any Age? • Octogenarians Do As Well as Younger Patients With Interventional Radiology Arterial Procedures. Abstract #131, SIR 2008

2. Perceptions ‘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?’

3. Outpatient Arteriography and ArterialIntervention in Octogenarians. Is It Safe? • Introduction: • It has been said by many that very elderly subjects (VES; aged 80 years orolder) 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.

4. Is It Safe? • Some suggest that octogenarians requiring arteriography or arterial intervention should be admitted to the hospital. Many admit patients requiring arterial interventions, irrespective of age. Even with the routine use of closure devices following outpatient arterial intervention, admission for complications has been reported in up to 10%. • I reviewed my experience of outpatient arteriography and arterial interventions in octogenarians to determine if this approach is safe. • Data on arterial procedures and complications were collected over a period of 36 months (2005-2007) for VES and a contemporary comparison group aged 50-79. Patients for arterial procedures who did not require admission for scheduling reasons or other procedures were routinely evaluated and treated as outpatients, irrespective of age. Procedures and immediate complications were compared.

5. 84 year old man presents with severe right leg pain walking fewer than 200 yards. He also has coronary artery disease, high blood pressure, high cholesterol, diabetes and chronic renal insufficiency. Previously he had carotid artery and coronary artery bypass surgery. Digital angiogram shows a complete blockage (….. between arrows) of the femoral artery. This was over three inches long.

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

7. “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 changes in the right foot (blue discoloration, no ulceration). She also has high blood pressure and high cholesterol. DSA shows stenosis of superficial femoral artery (A) and tibio-peroneal trunk (B) with poor distal run off (C, D). (A) (B) (C) (D)

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

9. 81 year old woman complained of worsening right leg pain on walking and had developed pain at rest, especially at night. She also suffers from high blood pressure, high cholesterol and diabetes. MRA showed multiple narrowings of the right femoral artery with only one vessel supplying the calf (the other two calf arteries being blocked). (A) (B) Digital angiogram showed narrowing of the arteries at several levels in the femoral (A) and popliteal artery (A and B).

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

11. Procedures Age ≥80 Age 50-79 Patient Episodes 91 260 Age range; mean 80-92; mean 83.8 Mean 67.6 Gender Female 52 Female 120 Diagnostic Arteriography 25 (27%) 112 (43%) Renal 10 (11% total) 30 (11% total) Femoral 14 (15% total) 46 (17% total) Carotids/UE 1 (1% total) 31 (12% total) Mesenteric 0 7 (3% total) Angioplasty/Cryoplasty 19 (21%) 26 (10%) Stent +/- Angioplasty 46 (51%) 119 (46%) (Multivessel stenting) (9; 20% stents) (34; 29% stents) Thrombolysis (Mechanical) 1 (1%) 1 (0.4%)

12. Reported Complications Age ≥80 Aged 50-79 All Recorded Events 5/91 (5.5%) 15/260 (5.7%) Major Events 2 (2.2%) 3 (6*; 2.3%) (Admissions) (1) (3) False Aneurysm 1 0 Worsening Limb Ischemia 0 3* (1.1%) (limited adverse outcomes) Hematoma (admission) 1 2 (0.8%) >3cm Hematoma (no action) 3 (3.3%) 6 (2.3%) CHF 0 1 (0.4%) Death 0 0

13. Standards for Complications ofPercutaneous Renal Revascularization Major Complications for Percutaneous Renal Revascularization Complication Reported Rate (%) Threshold (%) 30-day mortality 1 1 Secondary nephrectomy 1 1 Surgical salvage operation 1 2 Symptomatic embolization 3 3 Main renal artery occlusion 2 2 Branch renal artery occlusion 2 2 Access site hematoma requiring surgery, transfusion, or prolonged hospital stay 5 5 Acute renal failure 2 2 Worsened chronic renal failure requiring increased care 2 5 Table 4. Angioplasty Standards of Practice: SIR Standards of Practice Committee. J Vasc Interv Radiol 2003;14:S219–S221.

14. Conclusions • Diagnostic arteriography and percutaneous arterial interventions for PVD can be safely performed as outpatient procedures in stable patients. • The risk of major complications is low (1-2%). • The routine or frequent use of closure devices is not necessary. • Octogenarians seem to tolerate arteriography and arterial interventions as well as younger patients. • Octogenarians do not need hospital admission for elective diagnostic arteriography or arterial interventions for PVD.