Frailty raises amputation, mortality risk after PAD revascularization

Vascular surgeons know that frailty complicates recovery after lower-extremity revascularization. A new study puts precise numbers on exactly how much it costs patients, even after adjusting for age and comorbidities. 

The findings, published in the Journal of Vascular Surgery, come from a retrospective analysis of 11,436 adults who underwent an index lower extremity revascularization for peripheral artery disease (PAD) between 2016 and 2024 across the University of Pittsburgh Medical Center’s (UPMC) multihospital system. Researchers identified frailty using the Risk Analysis Index adapted to standard diagnosis codes already present in a patient’s chart and 17% of the cohort met the threshold.  

Patients were then tracked for hospital-free days (HFDs) over the 90 days after surgery — a measure that treats emergency department visits like hospital stays and assigns zero additional days to any patient who died during that window. 

"After multivariable adjustment, in the 90 days following revascularization, frail patients had fewer HFDs than those without frailty," said lead author Stuthi Iyer, MPH. 

Katherine Reitz, MD, senior author of the study, said the finding reflects a basic reality of caring for older patients with PAD. "When frail patients undergo PAD revascularization, their physiologic reserve to rebound after surgery is low," she said. "HFDs equate to a patient's time alive and out of the hospital, which is something easy for both patients and providers to understand and prioritize." 

Frail patients in the cohort were significantly older (76 years versus 67 years) and more likely to have diabetes, coronary artery disease and chronic lung disease. Their HFDs were lower even before adjustment, a median of 83 days compared with 86 days. 

The breadth of the measure is intentional, Iyer said. "The data point contains a large amount of information that single outcomes, like time to death, can’t capture alone," said Reitz. However, examined individually, the outcomes told a more complicated story. 

"Our secondary outcomes revealed that frailty was associated with a 44% higher risk of major amputation and a 69% higher risk of mortality, but a 22% lower risk of major reintervention — a pattern that held after multivariable modeling," said Iyer. 

Reitz said the lower reintervention rate reflects a familiar calculus in vascular clinics. "These results highlight that patients and their providers understand repeated revascularization attempts are high risk for frail patients," she Reitz. "As we know from clinical practice, an amputation can be a safer outcome for frail patients." 

The authors note that a four-day gap may sound modest against a 90-day window. "The four-day difference in HFDs between frail and non-frail patients may not seem drastically different, but it’s both statistically and clinically meaningful," said Iyer. "The median length of stay for hospitalized PAD patients was found to be four days, indicating one saved hospitalization." 

Reitz said the finding carries a broader lesson: These conversations should happen before surgery, not after a complication. "The more important implication is that patients and providers should have shared decision-making regarding the physiologic stress of reintervention versus the likelihood of ambulating with a prosthesis," she said. 

The study calls for further attention to preoperative communication and planning for frail PAD patients. "For those who decide to pursue surgery, future work in understanding and exploring prehabilitation may provide an avenue for risk reduction," said Reitz. 

Multimodal prehabilitation — pairing supervised exercise with nutrition counseling and smoking cessation — has improved functional capacity and quality-of-life scores in PAD patients and abbreviated three-week versions have reduced complications in patients with chronic limb-threatening ischemia who cannot tolerate longer programs, the authors noted. 

"It would be valuable and practical to conduct future trials on rapid, multimodal prehabilitation among PAD patients and HFDs provide an excellent data point to inform these future studies," said Iyer. "Revascularization of frail patients is resource intensive and such patients should expect increased reliance on the healthcare system following their intervention for PAD."