Influence of frailty on treatment outcomes after revascularization in patients with critical limb ischemia

Objective: It is unclear whether frailty adversely affects treatment outcomes in patients with critical limb ischemia (CLI). The aim of this study was to investigate the influence of frailty on CLI patients after revascularization. Methods: Patients undergoing infrapopliteal revascularization between 2007 and 2015 were retrospectively analyzed. The patient was defined as CLI frail when two or more of the following were present: low Geriatric Nutritional Risk Index, low skeletal muscle mass index, or nonambulatory status. The primary study end point was 2-year amputation-free survival (AFS). To analyze the diagnostic criteria of frailty, the CLI Frailty Index was compared with amodified Frailty Index using a receiver operating characteristic area under the curve. The secondary end points were occurrence of Clavien-Dindo class IV complications and 30-day or hospital mortality. Results: During the study period, 266 patients and 325 limbs underwent infrapopliteal revascularization. The AFS rate 1 year and 2 years after revascularization was 81.8% and 72.9% for the CLI frail - group vs 45.8% and 34.0% for the CLI frail+group (P<.001), respectively. Multivariate analysis revealed that the CLI Frailty Index (hazard ratio [HR], 2.77; 95% confidence interval [CI], 1.78-4.32; P<.001) and hemodialysis (HR, 1.72; 95% CI, 1.11-2.69; P = .02) were risk factors for AFS 2 years after revascularization. The CLI Frailty Index area under the curve was 0.72 compared with 0.63 for the modified Frailty Index (P = .01). Only the CLI Frailty Index was found to be a risk factor for morbidity (HR, 3.21; 95% CI, 1.45-7.27; P = .004) and 30-day or hospital mortality (HR, 6.32; 95% CI, 1.43-43.7; P = .01). Conclusions: The CLI Frailty Index is a risk factor for 2-year AFS in CLI patients after revascularization. This result could prove useful for prognostic prediction and decision-making in selection of bypass surgery or endovascular therapy as a first treatment strategy.