Abstract 4144894: Patient Frailty Rather than Procedural Approach Associated with Loss of Life and Limb

Objectives: Evidence behind frail patients preferentially undergoing endovascular interventions for peripheral arterial disease remains sparse; thus, we evaluated the association of frailty and revascularization-approach with long-term mortality and major adverse limb events (MALE). Methods: VQI-Medicare linked VISION databases were queried for patients who had their first infrainguinal open or endovascular (endo) procedure between 2011-2015 [N=27,200]. Frailty was measured using the VQI-Risk Analysis Index (RAI) and dichotomized into “frail” (RAI≥37) and “non-frail” (RAI<37). The primary endpoints were 4-year mortality and MALE (major amputation and/or reintervention). Associations of frailty and approach were estimated using Kaplan-Meier analysis and multivariable Cox hazards regression using an interaction term and stratified by indication. Results: Frail patients experienced significantly worse mortality and amputation-free survival, but both frail and non-frail patients experienced worse survival following an endo first approach (Figure 1, both log-rank p < 0.001). In adjusted Cox regression, frail patients with CLTI were at significantly increased risk of amputation (HR = 1.36; 95% CI: 1.18-1.56; p <.0001), MALE (HR:1.09, 95% CI:1-1.19; P=.049) and mortality (HR = 2.70; 95% CI: 2.51-2.89; p <.0001); endo approach for CLTI demonstrated a similar pattern of adverse outcomes (Table 1). However, interaction terms were not significant - the effects of frailty and approach did not influence each other. In claudicants, frailty was associated with increased mortality (HR = 3.05; 95% CI: 2.40-3.86; p <.0001) but not MALE, and endo approach was associated with increased MALE but not amputation; again, interaction terms were not significant. Conclusion: Endovascular approach did not mitigate the adverse effects of frailty on life and limb-related outcomes, thereby underscoring the need for frailty screening and accordingly tailoring treatment and managing expectations given their high mortality risk.