Statewide study supports PAD interventions in older patients

Quality improvement network yields many important PAD findings

P. Michael Grossman, M.D.,
associate professor of internal
medicine and interventional
cardiologist

The elderly may no longer need to be excluded from undergoing minimally invasive procedures to treat peripheral arterial disease because of their age.

A statewide study from the Michigan Cardiovascular Consortium showed elderly patients were no more likely than younger patients to suffer major complications or deaths after endovascular procedures such as angioplasty or stents to restore blood flow in the lower extremities.

More than 4 million American adults, nearly 15 percent of those over age 70, have peripheral arterial disease, or PAD. PAD affects circulation in the legs, patient mobility and sometimes lead to amputation.

"A patient's age may not be the significant predictor of whether they'll experience complications from endovascular procedures," says study lead author P. Michael Grossman, M.D., an interventional cardiologist at the University of Michigan Cardiovascular Center and VA Ann Arbor Healthcare System, and associate professor of internal medicine at the U-M Medical School. U-M coordinates the Michigan Cardiovascular Consortium, which is funded by Blue Cross Blue Shield of Michigan and includes physicians and hospitals statewide.

The severity and location of blockages may determine whether physicianss use a less invasive endovascular procedure or open surgery to treat PAD. But the recent study supports the 'endovascular-first' approach that's emerging in medical care, particularly for older patients who often have other medical conditions that may increase the risk of major complications associated with open surgery.

In addition, there is no drawback to an endovascular-first strategy since typically such an intervention does not preclude surgery later, Grossman says.

"And as we gain experience and work more closely with our vascular surgery colleagues to understand both what we can and what we shouldn't do - including the vascular beds where we may want to be more careful about implanting a stent that may limit surgical options down the road - I think an endovascular-first approach is quite reasonable," Grossman says.

In general, the study's authors write, "the findings may support the notion of using peripheral vascular interventions as a preferred strategy in the treatment of severe PAD in the elderly."

Data from 18 Michigan hospitals were used in the research published in the Journal of the American College of Cardiology: Cardiovascular Interventions.

Major findings:

• Success rates of lower extremity intervention decreased in the elderly - but were still strong
• Older patients undergoing endovascular procedures are more likely to have vascular access complications
• Most other complication rates, including in-hospital mortality,were similar among older and younger patients

The hospitals in the study are part of the Blue Cross Blue Shield of Michigan Cardiovascular Consortium-Peripheral Vascular Intervention, a statewide collaborative effort focused on improving patient safety and quality of care. The U-M is the coordinating center for the consortium and its registry of patients who have had vascular interventions at Michigan hospitals.

In this study, 7,779 patients with PAD were divided into three age groups: less than 70 years old, 70 to 80 years old, and 80 years and older.

Endovascular interventions were mostly successful despite more severe PAD. Technical success was highest in the youngest age group -- 85 percent compared to 82 percent among 70 to 80-year-olds and 78.2 percent in those over 80 years old. But older age was not associated with an increased risk of major complications such as death, heart attack, stroke, transfusion, or amputation.

PAD can develop as a result of smoking, diabetes, elevated cholesterol, hypertension, obesity or a family history of cardiac or vascular disease. Some patients have no symptoms. But for others, PAD can cause severe leg pain and numbness and be a limb - or even life-threatening condition.

"Patients with PAD of the legs can be quite impaired, but after these procedures, these patients can experience improvements in their quality of life," Grossman says.

For patients like Colbert Smith, 79, it means enjoying family time during his retirement. Even after working for years in factories and spending years cooking in the kitchens of Ann Arbor's beloved diners, still wanted to be on his feet - this time for walks in the woods on a Rails to Trails path with his wife Thelma.

"But my legs would go numb. I could walk 75 to 100 yards and then I wouldn't be able to get them to work," says Smith, who lives in Stockbridge, Mich. Smith knew that his diabetes could affect circulation throughout his body, but members of the U-M Multidisciplanary PAD Program found severe blockages in his leg vessels. Smith had an endovascular procedure by Jon Eliasion, M.D., vascular surgeon at the U-M Cardiovascular Center. The result has been better blood flow in his legs and a return to the woods.

"There's a trail next to an old railroad track where my wife likes to walk. I'm doing all I can to be able to take those walks with her," Smith says.

U-M Multidisciplinary PAD program

The U-M's PAD program delivers care with a team of physicians specializing in interventional cardiology, interventional radiology, cardiovascular medicine, vascular medicine and vascular surgery. The U-M uses traditional therapies like lifestyle changes and medications as well as procedures and surgical interventions to provide relief for patients and reduce their risk for heart attack and stroke.

FOR MORE INFORMATION:

University of Michigan Cardiovascular Center PAD program

Blue Cross Blue Shield Michigan Cardiovascular Consortium Peripheral Vascular Intervention