Endovascular surgery does not mitigate the adverse effects of frailty on the risk of losing life or limb

Sabina M Sorondo; Katherine Arnow; Aditi Kashikar; Arash Fereydooni; Amber W Trickey; Shipra Arya; Elizabeth L George

doi:10.1016/j.jvs.2025.06.050

Endovascular surgery does not mitigate the adverse effects of frailty on the risk of losing life or limb

J Vasc Surg. 2025 Jul 7:S0741-5214(25)01399-0. doi: 10.1016/j.jvs.2025.06.050. Online ahead of print.

Authors

Sabina M Sorondo¹, Katherine Arnow², Aditi Kashikar², Arash Fereydooni¹, Amber W Trickey³, Shipra Arya⁴, Elizabeth L George⁵

Affiliations

¹ Stanford University, Department of Surgery, Division of Vascular & Endovascular Surgery, Palo Alto, CA, USA.
² Stanford University, Stanford-Surgery Policy Improvement Research and Education Center, Palo Alto, CA, USA.
³ Veterans Affairs Palo Alto Health Care System, Surgical Service Line, Palo Alto, CA USA.
⁴ Stanford University, Department of Surgery, Division of Vascular & Endovascular Surgery, Palo Alto, CA, USA; Stanford University, Stanford-Surgery Policy Improvement Research and Education Center, Palo Alto, CA, USA.
⁵ Stanford University, Department of Surgery, Division of Vascular & Endovascular Surgery, Palo Alto, CA, USA; Stanford University, Stanford-Surgery Policy Improvement Research and Education Center, Palo Alto, CA, USA. Electronic address: lizzyg@stanford.edu.

PMID: 40633790
DOI: 10.1016/j.jvs.2025.06.050

Abstract

Objectives: Evidence behind frail patients preferentially undergoing minimally invasive 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: The 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 whether the procedure was performed for claudication or chronic limb threatening ischemia (CLTI).

Results: Frail patients experienced significantly worse mortality and amputation-free survival, but both frail and non-frail patients experienced worse survival following an endovascular first approach (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) and endovascular approach for CLTI demonstrated a similar pattern of adverse outcomes. However, interaction terms were not significant - the effects of frailty and approach did not influence each other. In patients with claudication, frailty was associated with increased mortality (HR = 3.05; 95% CI: 2.40-3.86; p <.0001) but not MALE, and endovascular approach was associated with increased MALE but not amputation; interaction terms were again 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.

Keywords: chronic limb-threatening ischemia; endovascular intervention; frailty; major adverse limb events; peripheral artery disease; procedural approach.