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 Knowing that so-called lower extremity revascularization may not
improve mobility allows doctors, patients and families to have more
realistic discussions about outcomes of the operation, said Dr.
Emily Finlayson, the study’s senior author from the Philip R. Lee
Institute for Health Policy Studies at the University of California,
San Francisco.
“I think the importance of the study is that people can be sanguine
of the benefits of this operation in this population,” said
Finlayson.
The nearly 11,000 nursing home residents in the study had a problem
called peripheral artery disease, which results when arteries in the
legs are clogged and blood flow is reduced. Pain, trouble walking,
poor wound healing, and even gangrene can result.
To treat the condition, the residents underwent lower extremity
revascularization between 2005 and 2009, at an average age of 82.
Surgeons replaced or reopened their leg arteries with a small
balloon to improve blood flow.
Before surgery, three quarters of the residents could not walk, and
40 percent had experienced a decline in overall function, the
authors reported in JAMA Internal Medicine.
A year after surgery, more than half the people had died. Rates of
death or immobility were 63 percent among patients who were able to
walk before the operation, and 89 percent among those who couldn’t
walk before surgery.
Also at one year, a third had a steady decline in function.
Being 80 years old or older, having cognitive impairment, congestive
heart failure, kidney failure, needing emergency surgery, not being
able to walk before surgery or declining activities of daily living
were each tied to an increased risk of dying or not being able to
walk after lower extremity revascularization, the researchers write.
By traditional measures, such as the ability to walk, the surgeries
were largely unsuccessful, said Finlayson. But she said the results
should be interpreted with caution.
“You have to back up and think of the other potential goals of the
operation,” she said.
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For example, the goal of the operation may be to relieve severe pain
in a patient who has a limited life expectancy.
As an alternative, some people may do better with skilled wound
care, Finlayson said. Or in some cases an amputation may be a better
choice.
“These are all things that should be on the table when you’re
discussing options to treat this condition in this population,” she
said.
In an editorial, Dr. William Hall of the University of Rochester
School of Medicine in New York noted that many of the nursing home
residents in the study’s dataset could not walk before the surgery.
He wrote that “most of the procedures were probably performed for
relief of symptoms secondary to ischemic leg pain, non-healing
wounds or worsening gangrene.”
In those cases, the procedure can be viewed as a way to relieve pain
or discomfort – not a way to extend life or improve the ability to
walk.
Finlayson said the information in the new study can be used to help
patient make decisions and receive care that’s in line with their
goals.
SOURCE: http://bit.ly/1Gi7iWO
and http://bit.ly/1Gi7mG8 JAMA
Internal Medicine, online April 6, 2015.
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