Endovascular Surgery Fails to Offset High Risks in Frail PAD Patients, Study Finds
USA: A recent study led by Dr. Elizabeth L. George and colleagues from the Division of Vascular & Endovascular Surgery at Stanford University has found that endovascular procedures do not reduce the heightened risk of mortality or limb-related complications associated with frailty in patients undergoing revascularization for peripheral artery disease (PAD). The findings were published in the Journal of Vascular Surgery.
The study aimed to evaluate whether frail patients—who are often directed toward minimally invasive procedures due to perceived safety advantages—benefit from endovascular surgery in terms of long-term survival and limb preservation. The research team conducted a single-center retrospective cohort study using the VQI-Medicare linked VISION database, analyzing data from 27,200 patients who underwent their first infrainguinal revascularization (either open or endovascular) between 2011 and 2015.
Frailty was measured using the VQI-Risk Analysis Index (RAI), categorizing patients into frail (RAI ≥ 37) and non-frail (RAI < 37). The researchers looked at two primary outcomes over four years: all-cause mortality and major adverse limb events (MALE), which include major amputations or the need for repeat interventions.
The results highlighted significant concerns for frail individuals, and the key findings were as follows:
- In patients with chronic limb-threatening ischemia (CLTI), frailty was associated with a higher risk of amputation (hazard ratio [HR] 1.36).
- Frailty also increased the risk of major adverse limb events (MALE) in CLTI patients (HR 1.09).
- The risk of mortality was significantly higher in frail patients with CLTI (HR 2.70).
- Among patients with claudication, frailty raised the risk of death (HR 3.05) but did not significantly impact limb-related outcomes.
- Endovascular procedures did not reduce the adverse effects of frailty on survival or limb outcomes.
- Both frail and non-frail individuals undergoing endovascular surgery experienced poor survival outcomes.
- The interaction between frailty and the type of revascularization approach was not statistically significant, indicating that frailty independently influenced patient outcomes regardless of the surgical method.
These findings suggest that simply choosing a less invasive technique does not compensate for the physiological vulnerabilities associated with frailty. Dr. George and her team emphasize the need for routine frailty screening in clinical settings and for treatment decisions to be tailored accordingly.
“Frail patients face high risks regardless of whether they undergo open or endovascular revascularization,” the authors noted. “Identifying these individuals early and managing expectations realistically is essential to improving long-term outcomes.”
The authors concluded, "The study highlights a critical gap in current PAD management: while minimally invasive options are often preferred, they may not deliver the desired benefit in high-risk populations. Personalized care plans that account for frailty could help optimize outcomes and reduce avoidable complications in these vulnerable patients."
Reference:
Sorondo, S. M., Arnow, K., Kashikar, A., Fereydooni, A., Trickey, A. W., Arya, S., & George, E. L. (2025). Endovascular surgery does not mitigate the adverse effects of frailty on the risk of losing life or limb. Journal of Vascular Surgery. https://doi.org/10.1016/j.jvs.2025.06.050
