Results of F-EVAR in Octogenarians

Age is not a sole predictor of outcomes in octogenarians undergoing complex endovascular aortic repair

OBJECTIVE

To examine the perioperative, postoperative, and long-term outcomes of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in octogenarians compared with nonoctogenarians.

METHODS

A multicenter, retrospective cohort study was conducted using the Vascular Quality Improvement database, which prospectively captures information on patients who undergo vascular surgery across 1021 academic and community hospitals in North America. All patients who underwent F/BEVAR endovascular aortic repair from 2012 to 2022 were included. Patients were stratified into two groups: those aged <80 years and those aged ≥80 years at the time of the procedure. The preoperative, intraoperative, and postoperative factors were compared between the two groups. The primary outcome was long-term all-cause mortality; secondary outcomes included aortic-specific mortality and aortic-specific reintervention.

RESULTS

A total of 6007 patients (aged <80 years, n = 4860; aged ≥80 years, n = 1147) who had undergone F/BEVAR procedures were included. No significant difference was found in technical success, postoperative length of stay, length of intensive care unit stay, postoperative bowel ischemia, and spinal cord ischemia. After adjustment for baseline covariates, octogenarians were more likely to suffer from a postoperative complication (odds ratio [OR]: 1.16; [95% confidence interval (CI): 0.98-1.37], P < .001) and be discharged to a rehabilitation center (OR: 1.60; [95% CI: 1.27-2.00], P < .001) or nursing home (OR: 2.23; [95% CI: 1.64-3.01], P < .001). Five-year survival was lower in octogenarians (83% vs 71%, hazard ratio [HR]: 1.70; [95% CI: 1.46-2.0], P < .0001). Multivariate Cox proportional hazard analysis demonstrated that age was associated with increased all-cause mortality (HR: 1.72, [95% CI: 1.39-2.12], P < .001) and aortic-specific mortality (HR: 1.92, [95% CI: 1.04-3.68], P = .038). Crawford extent II aortic disease was associated with an increase in all-cause mortality (HR 1.49; [95% CI: 1.01-2.19], P < .001), aortic-specific mortality (HR: 5.05; [95% CI: 1.35-18.9], P = .016), and aortic-specific reintervention (HR: 1.91; [95% CI: 1.24-2.93], P = .003). Functional dependence was associated with increased all-cause mortality (HR: 2.90; [95% CI: 1.87-4.51], P < .001) and aortic-specific mortality (HR: 4.93; [95% CI: 1.69-14.4], P = .004).

CONCLUSIONS

Our findings suggest that octogenarians do have a mildly increased mortality rate and rate of adverse events after F/BEVAR procedures. Despite this, when adjusted for other risk factors, on par with other medical comorbidities and therefore age should be strict exclusion criterion for F/BEVAR procedures, rather age should be considered in the global context of patient's aortic anatomy, health, and functional status.

Systematic review of the results of fenestrated endovascular aortic repair in octogenarians

INTRODUCTION

With the increasing life expectancy of Western populations, more octogenarians are presenting with large abdominal aortic aneurysm (AAA). Endovascular repair offers a less invasive alternative and older patients who may not have been offered open repair in the past are now being considered for elective repair with this approach. Age in isolation may not be the only consideration in recommending elective aneurysm repair. We aimed to review the literature on complex endovascular AAA repairs (mainly fenestrated endovascular aortic repair [FEVAR]) in octogenarians.

METHODS

A literature search was conducted using the Ovid Medline®, Embase® and Cochrane Library databases for articles published up to January 2022. All English language publications from 1995 onwards were eligible for inclusion. Search terms included: "FEVAR", "F-EVAR", "fenestrated EVAR", "fenestrated endovascular aortic repair", "fenestrated endovascular aneurysm repair", "fenestrated AAA repair", "fenestrated endograft", "fenestrated stent graft", "fenestrated", "endograft", "EVAR", "octogenarian", "elderly", "above 80" and "over 80".

METHODS

The literature search identified 134 potential articles. Following qualitative assessment by two independent appraisers, this was refined to 11 studies, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement.

RESULTS

The primary outcome measure was 30-day mortality, which was highly variable, ranging from 0% to 9% in octogenarians and from 0% to 5% in non-octogenarians. However, these differences were only found to be statistically significant in two studies. The secondary outcome measures included technical success rates, major adverse events, reintervention rates, freedom from reintervention, target vessel patency, freedom from target branch instability, and length of hospital and intensive care unit stay. No statistically significant differences were found between octogenarians and non-octogenarians. Long-term survival was significantly lower for octogenarians in two studies.

CONCLUSIONS

The perioperative outcomes of FEVAR in octogenarians are comparable with those of younger patients. FEVAR therefore appears to be an acceptable option for complex endovascular aneurysm repairs in carefully selected octogenarians. Nevertheless, this review highlights the paucity of published data on the outcomes of endovascular repair of complex aneurysms in octogenarians.

The Effect of Age on Peri-Operative Outcomes after FEVAR

INTRODUCTION

Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor.

METHODS

A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest.

RESULTS

During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest.

DISCUSSION

In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.

Outcomes in octogenarians after thoracoabdominal and juxtarenal aortic aneurysm repair using fenestrated-branched devices justifies treatment

OBJECTIVE

To compare outcomes between octogenarians and nonoctogenarians undergoing thoracoabdominal aortic aneurysm repair and juxtarenal aortic aneurysm repair using branched and/or fenestrated endovascular devices (F/BEVAR) and compare octogenarian survival to population survival statistics from Ontario, Canada.

METHODS

Patients who underwent F/BEVAR at a single institution between 2007 and 2020 were retrospectively reviewed with a median follow-up of 3.3 years (interquartile range, 1.6-5.3). The median survival of an average 84-year-old Ontarian from Canada, adjusted for a male:female ratio of 4:1, was retrieved from publicly available Statistics Canada data.

RESULTS

In total, 68 octogenarians (25.8%) and 196 nonoctogenarians (74.2%) were included (mean age, 83.5 ± 3.0 vs 71.9 ± 5.8 years; P ≤ .001). The maximum aneurysm size was significantly larger in octogenarians (68.9 ± 11.4 mm vs 65.4 ± 10.0 mm; P = .017). No differences in the number of thoracoabdominal aortic aneurysm repairs (29.4% vs 38.3%; P = .19) or operative technical success (92.6% vs 85.7%; P = .136) were observed between the two cohorts. Postoperatively, no significant differences in overall in-hospital mortality (7.3% vs 5.1%; P = .49), elective in-hospital mortality (6.1% vs 4.4%; P = .49), stroke (1.5% vs 3.6%; P = .384), or spinal cord ischemia (2.9% vs 9.2%; P = .094) were seen between octogenarians and nonoctogenarians. There was no difference in survival at 4 years between the two cohorts (62.9% vs 71.1%; P = .22), however, survival at 6 years was significantly lower for octogenarians (44.5% vs 64.1%; hazard ratio, 1.96; P = .02). The cumulative rate of reintervention (44.1% vs 41.3%; P = .84) and freedom from branch instability (67.6% vs 73.5%; P = .33) at 6 years were not different between the two groups. When comparing octogenarians who survived to discharge from index hospitalization after F/BEVAR with 84-year-old Ontarians unmatched for comorbidities, a survival difference of 4.8% and 11.1% was noted at 4 and 6 years, respectively.

CONCLUSIONS

F/BEVAR in octogenarians is associated with no differences in technical success or postoperative adverse outcomes when compared with their younger counterparts. Octogenarians had increased mortality after 4 years and their survival at 4 years was comparable with that of an 84-year-old Ontarian. F/BEVAR was safe and effective in octogenarians deemed fit for intervention. Further research into preoperative patient selection and improving perioperative outcomes is needed.

Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared with nonoctogenarians

OBJECTIVE

Open repair of complex aortic aneurysms is frequently not an option for octogenarians because of prohibitive surgical risks. This study aimed to analyze the outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) in octogenarians (≥80 years old) compared with nonoctogenarians (<80 years old).

METHODS

We reviewed 893 patients with pararenal or extent I to V thoracoabdominal aneurysms, enrolled in six prospective physician-sponsored investigational device exemption studies from 2012 to 2018. All patients were treated with either company-manufactured off-the-shelf or patient-specific F-BEVAR stent grafts. Data analyzed included demographics, cardiovascular risk factors, history of active cancer, American Society of Anesthesiologists classification, aortic anatomy characteristics, and procedural data. End points included mortality, major adverse events (all-cause mortality, stroke, paralysis, acute kidney injury [RIFLE criteria], dialysis, myocardial infarction, respiratory failure, and bowel ischemia), technical success, hospital length of stay, target artery instability (occlusion/stenosis, endoleak, rupture or death), and secondary interventions.

RESULTS

During the study period, 195 octogenarian patients (22%) and 698 (78%) nonoctogenarian patients were treated with F-BEVAR. Octogenarians presented more frequently with a history of cancer (17% vs 11%; P = .01), whereas nonoctogenarians more frequently had hyperlipidemia (76% vs 65%; P = .003), chronic obstructive pulmonary disease (42% vs 33%; P = .04) and American Society of Anesthesiologists class III to V (78% vs 70%; P = .02). Male sex was similar between groups (68% [octogenarians] vs 70% [nonoctogenarians]; P = .62). Octogenarians had a larger mean aneurysm diameter (67 ± 1 mm vs 65 ± 1 mm; P = .002). The thoracoabdominal classification and the use of upper extremity access were similar between groups. Estimated blood loss was also similar (484 ± 454 mL [octogenarian] vs 416 ± 457 mL [nonoctogenarian]; P = .07). Octogenarians had an increased mean number of vessels incorporated into the repair (3.1 ± 1.4 vs 2.7 ± 1.7; P < .001). The technical success rate was 99% for octogenarians and 97% for nonoctogenarians (P = .19). The 30-day mortality rate was 0.5% for octogenarians and 1.3% for the nonoctogenarians (P = .70). Major adverse events (9.2% vs 9.7%), types I/III endoleak (4.6% vs 2.4%) access complication (3.1% vs 3.3%), and length of stay (8.2 ± 27 days vs 5.7 ± 6.3 days) were all similar between the groups. Freedom from target artery instability and freedom from secondary interventions at 3 years were similar between the groups. Octogenarian survival was lower at 3 years compared with nonoctogenarians on univariate analysis (log-rank P < .01) and on multivariable analysis after adjusting for history of active cancer, hyperlipidemia, and chronic obstructive pulmonary disease.

CONCLUSIONS

Despite small differences in demographics, anatomic factors, and procedural data, F-BEVAR was safe and effective with nearly identical early outcomes in octogenarians in these experienced aortic centers. More extensive clinical experience and longer follow-up are needed to better delineate factors impacting longer term mortality.

Predictors of Survival in Patients Over 80 Years Old Treated with Fenestrated and Branched Endograft

BACKGROUND

Fenestrated and branched endovascular aneurysm repair endograft (f/bEVAR) allows the endovascular repair of thoracoabdominal and juxtarenal and pararenal abdominal aortic aneurysms (T-J-P-AAAs); however, given their high cost and complexity, their use should be limited to patients with life expectancy >2 years. Nevertheless, the number of patients older than 80 years treated by f/bEVAR is growing, with no hard evidence of the real efficacy in this context. The aim of the present study is to analyze the survival of ≥80-year-old patients treated with f/bEVAR, and to identify possible predictors of late mortality.

METHODS

An analysis of clinical, anatomical, and technical characteristics of patients treated with f/bEVAR for J-, P-, and T-AAA from 2010 to 2019 in a single academic center was performed. Follow-up data were collected prospectively with clinical visit and computed tomography angiography at discharge, after 6 months, and yearly thereafter. Survival after 2 years was evaluated by Kaplan-Meier analysis. Possible predictors of mortality were evaluated by univariable/multivariable analysis.

RESULTS

In the study period, a total of 243 f/bEVARs were considered: 83 for TAAA (34%) and 160 for J/PAAA (66%). Mean age was 73 ± 6 years, with 35 (14%) patients ≥80 years old; 209 patients (86%) were male and 78 (39%) had an American Society of Anesthesiology score IV. The 30-day and 2-year survival were 96% and 80 ± 3%, respectively. At a mean follow-up of 36 ± 25 months, independent predictors of late mortality by Cox regression analysis were chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF), and ≥80 years old (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.02-3.2, P = 0.05; HR 1.7, 95% CI 1.01-3.4, P = 0.04; HR 3.1, 95% CI 1.5-6.3, P = 0.002, respectively). Preoperative clinical characteristics were similar in ≥80 years old versus younger patients, except for the prevalence of TAAA (14% vs. 38%, P = 0.04). The technical success and 30-day mortality were similar in ≥80 vs. <80-year-old patients (93% vs. 96%, P = 0.31; 7% vs. 3.5%, P = 0.60, respectively). The 2-year survival estimation was significantly lower in ≥80 years old compared with younger patients (62 ± 10% vs. 82 ± 3%, P = 0.003). The association of COPD and CRF significantly affects the 2-year survival in ≥80-year-old patients (no patients survived at 2 years) and was significantly different compared with the survival in ≥80-year-old patients without these risk factors (70 ± 11%, P = 0.001).

CONCLUSIONS

The early mortality rate and the 2-year survival after f/bEVAR justify this type of treatment in patients ≥80 years old; however, the presence of comorbidities such as COPD and CRF significantly reduces mid-term survival in this group and should be taken into consideration in the indication to f/bEVAR.

The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review

INTRODUCTION

Open repair (OR), fenestrated endovascular aneurysm repair (fEVAR) and endovascular exclusion using parallel graft (chEVAR) are complementary procedures used for treatment of juxtarenal abdominal aortic aneurysm (jrAAA). The aim of our study was to assess available literature and analyze dispersion of OR, fEVAR and chEVAR procedures among reported papers related to treatment of jrAAA.

EVIDENCE ACQUISITION

The PubMed database was systematically searched using predefined strategy and key words related to treatment of jrAAA on September 28th, 2019. Studies were assessed for eligibility using the inclusion and exclusion criteria with at least five patients treated with at least one of the procedures while systematic reviews, meta-analysis, reviews, comments, editorials and letters were excluded as well as studies without clear classification of the location of the aneurysm, studies not specifying the number of patients treated with each of the techniques or not discriminated between aortic pathologies (juxtarenal, paravisceral and thoracoabdominal), hybrid procedures, endoanchors or with branched stent-graft.

EVIDENCE SYNTHESIS

Overall, 1533 papers were identified while papers that met inclusion criteria were either representing experience of single institution (87 papers) or from multicenter studies (6 papers), national or international registries (18 papers). In the period between January 1977 and December 2017, treatment of 5664 patients with jrAAA was reported in 87 papers as a single institution report. Out of them 2531 (45%) were treated with OR, 2592 (46%) with fEVAR and 541 (9%) with chEVAR. Out of 29 institutions reporting OR, there were 11 (37.9%) with more than 100 treated patients while 21 (41.1%) out of 51 institutions that reported more than 50 jrAAA treated with fEVAR. Only four institutions reported results of all three treatment modalities.

CONCLUSIONS

Based on the results reported in the literature, regardless of its complexity and costs, fEVAR for jrAAA has been accepted in substantial number of hospitals worldwide, while number of reported procedures is reaching OR.

Endovascular Treatment of Asymptomatic Abdominal Aortic Aneurysms in Octogenarians: Factors Influencing Long-term Survival

BACKGROUND

Beyond the age of 80 years, the preventive treatment of an asymptomatic abdominal aortic aneurysm (AAA) has to be decided in light of the life expectancy which it is difficult to evaluate, but it is important to determine who in this population will benefit from it. The objective of our study was to determine the factors influencing short-term mortality and long-term survival in patients aged 80 years and older after the endovascular treatment of AAAs (EVAR).

MATERIAL AND METHODS

We present a retrospective analysis of the prospective databases of 4 French academic departments of vascular surgery, bringing together the data of all the patients presenting an AAA who were treated by EVAR between 1998 and 2011. Logistic regression and multivariate analysis with a Cox survival model were used to determine the factors influencing perioperative and long-term mortality. The cumulative rate of events for the measurement of survival was calculated with the technique of Kaplan-Meier.

RESULTS

We treated 345 octogenarians and 339 younger patients. The average follow-up was 40 months. Average survival was 75% at 36 months and 49% at 60 months. There was no evidence of any risk factor influencing mortality at 30 days in the octogenarians. However, chronic kidney disease (odds ratio [OR] = 3.95, P <0.001) and chronic respiratory failure (OR = 2.62, P <0.001) proved to be independent factors of a poor long-term prognosis.

CONCLUSIONS

The treatment by stent graft in octogenarians is effective in the long term. The presence of an impaired renal function or respiratory failure in this population could put into question the operative indication.

Treatment of complex aortic aneurysms with fenestrated endografts and chimney stent repair: Systematic review and meta-analysis

Objective

We reviewed data pertaining to fenestrated endograft technique and chimney stent repair of complex aortic aneurysm for comparative analysis of the outcomes.

Methods

A comprehensive search of relevant databases was conducted to identify articles in English, related to the treatment of complex aortic aneurysm with fenestrated endovascular aneurysm repair and chimney stent repair, published until January 2015.

Results

A total of 42 relevant studies and 2264 patients with aortic aneurysm undergoing fenestrated endovascular aneurysm repair and chimney stent repair were included in our review. A total of 4413 vessels were involved in these processes. The cumulative 30-day mortality was 2.4% and 3.2% ( p = 0.459). The follow-up aneurysm-related mortality was 1.4% and 3.2% ( p = 0.018), and target organ dysfunction was 5.0% and 4.0% in fenestrated endovascular aneurysm repair and chimney stent repair, respectively ( p = 0.27). A total of 156 vessels showed restenosis or occlusion after primary intervention (3.6% and 3.4% in fenestrated endovascular aneurysm repair and chimney stent repair, respectively, p = 0.792). The cumulative type I endoleak was 2.0% (38/1884) after fenestrated endovascular aneurysm repair compared with 3.4% (13/380) after chimney stent repair ( p = 0.092), and the type II endoleak was 5.4% (102/1884) and 5.3% (20/380), respectively ( p = 0.905). Approximately, 1.1% and 1.6% increase in aneurysm was observed following fenestrated endovascular aneurysm repair and chimney stent repair, respectively ( p = 0.437). The re-intervention frequency was 205 and 19 cases after fenestrated endovascular aneurysm repair and chimney stent repair, respectively (11.7%, 5.6%, p = 0.001).

Conclusions

Fenestrated endovascular aneurysm repair and chimney stent repair are safe and effective in treating patients with complex aortic aneurysm. A higher aneurysm-related mortality was observed in chimney stent repair while fenestrated endovascular aneurysm repair was associated with a higher re-intervention rate.

Fenestrated endovascular repair of abdominal aortic aneurysms: a less invasive option for the treatment of juxtarenal aortic aneurysms

Endovascular aortic aneurysm repair has become the predominant surgical therapy for abdominal aortic aneurysms. Whereas anatomical limitations had become the major contraindication to endovascular treatment, fenestrated stent grafts were developed to overcome such obstacles. Fenestrated endovascular aortic aneurysm repair now provides an additional treatment option for patients felt to be unsuitable for an invasive open repair whose anatomy is not compatible with more traditional stent grafts. We review the evolution of fenestrated endovascular aortic aneurysm repair and compare its safety and efficacy to other endovascular options.