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Vikan KK, Seternes A, Nilsen LH, Pettersen EM, Altreuther M. Peri-Operative Mortality and Survival After Repair of Abdominal Aortic Aneurysm in Advanced Age Patients: A National Study from the Norwegian Registry for Vascular Surgery Focused on Nonagenarians. Eur J Vasc Endovasc Surg 2024; 67:427-433. [PMID: 37778499 DOI: 10.1016/j.ejvs.2023.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/08/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Treatment of abdominal aortic aneurysm (AAA) in nonagenarians has become more frequent. This national observational cohort study aimed to investigate peri-operative mortality and survival after AAA surgery in nonagenarians in Norway. METHODS All AAA repairs registered in the Norwegian Registry for Vascular Surgery from 2015 to 2021 were identified and stratified into nonagenarians > 90 years old (n = 77), octogenarians 80 - 89 years old (n = 1 362), and patients < 80 years old (n = 4 590). The patient characteristics and comorbidities were recorded, and the 30 and 90 day mortality rates were calculated. Kaplan-Meier analysis was performed to obtain the estimated median survival and survival curves. RESULTS In the nonagenarians, the 30 day mortality rates were 2.5% in asymptomatic patients, 33.3% in symptomatic patients, and 59.1% in the patients with a ruptured AAA (rAAA). The estimated median survival (years) were 3.3 (95% confidence interval [CI] 1.95 - 4.59) for asymptomatic AAA, 2.9 (interquartile range [IQR] 2.82, 5.80) for symptomatic AAA, and 0.1 for rAAA (IQR 0.01, 3.04). For nonagenarians surviving the first 90 days, the estimated median survival (years) were 4.2 (95% CI 2.56 - 5.88) for asymptomatic AAA, 3.4 (IQR 2.86, 5.80) for symptomatic AAA, and 3.8 (IQR 1.49, 4.85) for rAAA. The 90 day mortality rates were 100.0%, 80.0%, and 62.5% for asymptomatic, symptomatic, and rAAA, respectively, after open surgical repair (OSR), and 5.1%, 10.0%, and 50.0%, respectively, after endovascular aortic repair (EVAR). CONCLUSION Peri-operative mortality and survival results after AAA surgery in nonagenarians support treatment of selected asymptomatic patients. The 90 day survivors had an expected survival of more than three years, enabling balanced decision making regarding surgical vs. conservative treatment options in this challenging cohort. EVAR is the treatment method of choice for AAA in nonagenarians because most of them would probably live longer untreated than if treated by OSR.
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Affiliation(s)
- Kristin K Vikan
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway.
| | - Arne Seternes
- Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Linn Hege Nilsen
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway
| | - Erik Mulder Pettersen
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Surgery, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | - Martin Altreuther
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Kumar M, Long GW, Major M, Gates E, Studzinski DM, Callahan RE, Brown OW, Welsh RJ. Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: analysis of the National Surgical Quality Improvement Program dataset. J Vasc Surg 2021; 75:1223-1233. [PMID: 34634420 DOI: 10.1016/j.jvs.2021.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR). METHODS Patients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days. RESULTS A total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001). CONCLUSIONS Nonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.
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Affiliation(s)
- Mohineesh Kumar
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Graham W Long
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich.
| | - Matthew Major
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Elizabeth Gates
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Diane M Studzinski
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Rose E Callahan
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - O William Brown
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Robert J Welsh
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
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3
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Prendes CF, Dayama A, Panneton JM, Stana J, Rantner B, Álvarez Marcos F, Mani K, Wanhainen A, Tsilimparis N. Endovascular Aortic Repair in Nonagenarian Patients. J Am Coll Cardiol 2021; 77:1891-1899. [PMID: 33858626 DOI: 10.1016/j.jacc.2021.02.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/16/2020] [Accepted: 02/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The increasing proportion of elderly patients being treated for abdominal aortic aneurysm (AAA) in the endovascular era is controversial. OBJECTIVES This study compared 30-day outcomes of endovascular aortic repair (EVAR) in nonagenarians (NAs) with non-nonagenarians (NNAs). METHODS This retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database included EVAR procedures performed from 2011 to 2017. Multivariate logistic regression in the unadjusted cohort, followed by propensity-score matching (PSM), was performed. Primary outcomes were 30-day mortality and 30-day major adverse events. RESULTS A total of 12,267 patients were included (365 NAs). Ruptured aneurysms accounted for 6.7% (n = 819): 15.7% (n = 57) in NAs versus 6.5% (n = 762) in NNAs (p < 0.001). Mean aneurysm diameter was 6.5 ± 1.8 cm in NAs versus 5.8 ± 1.7 cm in NNAs (p < 0.001). The unadjusted 30-day mortality was 9.9% in NA versus 2.2% in NNAs (p < 0.001). Multivariate analysis revealed age ≥90 years (odds ratio [OR]: 3.36), male sex (OR: 1.78), functional status (OR: 4.22), pre-operative ventilator dependency (OR: 3.80), bleeding disorders (OR: 1.52), dialysis (OR: 2.56), and ruptured aneurysms (OR: 17.21) as independent predictors of mortality. After PSM, no differences in 30-day mortality (intact AAA [iAAA]: 5.3% NA vs. 3% NNA [p = 0.15]; ruptured AAA [rAAA]: 38% NA vs. 28.6% NNA [p = 0.32]) or 30-day major adverse events (iAAA: 7% NA vs. 4.6% NNA [p = 0.22]; rAAA: 28% NA vs. 36.7% NNA [p = 0.35]) were observed. CONCLUSIONS Age was identified as an independent predictor of 30-day mortality after EVAR on multivariate analysis. However, no differences were found after PSM, suggesting that being ≥90 years of age but with similar comorbidities to younger patients is not associated with a higher short-term mortality after EVAR. Age ≥90 years alone should not exclude patients from EVAR, and tailored indications and carefully balanced risk assessment are advised.
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Affiliation(s)
- Carlota F Prendes
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany.
| | - Anand Dayama
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | - Jan Stana
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Barbara Rantner
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
| | | | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital, Munich, Germany
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Bellamkonda KS, Kim T, Rosenthal R, Dardik A, Nassiri N. Endovascular abdominal aortic aneurysm repair in a centenarian. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:361-364. [PMID: 32715172 PMCID: PMC7371717 DOI: 10.1016/j.jvscit.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/14/2020] [Indexed: 11/18/2022]
Abstract
As the general population ages, there will be an increasing number of vascular patients in their 90s and older. However, geriatric patients have historically been turned down for abdominal aortic aneurysm repair despite high aneurysm-related mortality in the unrepaired. Herein, we describe the perioperative considerations and the successful, uncomplicated operative course of a 100-year-old woman who underwent an elective endovascular aortic aneurysm repair for an expanding 5.3-cm abdominal aortic aneurysm. Given a suitable patient, there is acceptable risk profile of an endovascular approach, even in centenarians.
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Affiliation(s)
- Kirthi S Bellamkonda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Tanner Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | | | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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Kim TI, Brahmandam A, Skrip L, Sarac T, Dardik A, Ochoa Chaar CI. Surgery for the Very Old: Are Nonagenarians Different? Am Surg 2020. [DOI: 10.1177/000313482008600129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.
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Affiliation(s)
- Tanner I. Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anand Brahmandam
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Laura Skrip
- Yale School of Public Health, New Haven, Connecticut; and
| | - Timur Sarac
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University School of Medicine, Columbus, Ohio
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Mwipatayi BP, Oshin OA, Faraj J, Varcoe RL, Wong J, Becquemin JP, Riambau V, Böckler D, Verhagen HJ. Analysis of Midterm Outcomes of Endovascular Aneurysm Repair in Octogenarians From the ENGAGE Registry. J Endovasc Ther 2020; 27:836-844. [PMID: 32436808 DOI: 10.1177/1526602820923827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess periprocedural results and secondary endovascular procedure outcomes over 5 years in patients aged ≥80 vs <80 years undergoing endovascular aneurysm repair (EVAR). MATERIALS AND METHODS Data from the Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE) were used for the analyses. A total of 1263 consecutive patients were enrolled in the prospective, observational, single-arm registry and divided into 2 groups according to age: ≥80 years (290, 22.9%) and <80 years (973, 77.1%). Baseline patient characteristics, risk scores according to the Society for Vascular Surgery (SVS) reporting standards, American Society of Anesthesiologists (ASA) classification, quality of life assessments [EuroQol 5 (EQ5D) index], and treatment outcomes, including all-cause mortality, aneurysm-related mortality, major adverse events, secondary endovascular procedures, and endoleaks were compared between groups. RESULTS Octogenarians were classified into the highest category of the SVS risk stratification system; however, this did not result in a significant difference in the 30-day mortality [1.4% (4/290) vs 1.2% (12/973) for controls; p=0.85] or major adverse event rates [5.2% (15/290) vs 3.6% (35/973), p=0.23]. Multivariable analysis confirmed that age ≥80 years, pulmonary disease, large aneurysm diameter, and renal insufficiency were significantly associated with all-cause mortality, whereas diameter was the only parameter associated with increased aneurysm-related mortality. The differences in freedom from secondary endovascular procedures over 5 years between octogenarians and controls did not reach statistical significance (88.5% vs 83.2%, p=0.07). CONCLUSION EVAR can be performed in individuals aged ≥80 years with no statistically significant difference in midterm aneurysm-related deaths compared with younger patients. The findings in this elderly patient cohort show that EVAR can be safely performed with acceptable morbidity rates in octogenarians.
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Affiliation(s)
- Bibombe P Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Surgery, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Olufemi A Oshin
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Joseph Faraj
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital and the University of New South Wales, Sydney, Australia
| | - Jackie Wong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Vincente Riambau
- Division of Vascular Surgery, Thorax Institute, Hospital Clinic, University of Barcelona, Spain
| | - Dittmar Böckler
- Division of Vascular Surgery, University Hospital Heidelberg, Germany
| | - Hence J Verhagen
- Division of Vascular and Endovascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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Posso M, Quintana MJ, Bellmunt S, Martínez García L, Escudero JR, Viteri-García A, Valli C, Bonfill X. GRADE-Based Recommendations for Surgical Repair of Nonruptured Abdominal Aortic Aneurysm. Angiology 2019; 70:701-710. [PMID: 30961349 DOI: 10.1177/0003319719838892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to provide evidence-based recommendations for endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) for patients with a nonruptured abdominal aortic aneurysm (AAA). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement and adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Both low- and high surgical risk patients treated with EVAR showed decreased 30-day mortality, but the low-risk group had no differences in 4-year mortality. Compared with friendly anatomy, patients with hostile anatomy had an increased risk of type I endoleak. Young patients may prefer OSR. Endovascular aneurysm repair was not cost-effective in Europe. Four conditional recommendations were formulated: (1) OSR for low-risk patients up to 80 years old, (2) EVAR for low-risk patients older than 80 years, (3) EVAR for high-risk patients as long as is anatomically feasible, and (4) OSR in patients in whom it is not anatomically feasible to perform EVAR. Based on GRADE criteria, either OSR or EVAR can be suggested to patients with nonruptured AAA taking into account their surgical risk, hostile anatomy, and age. Given the weakness of the recommendations, personal preferences are determinant.
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Affiliation(s)
- Margarita Posso
- 1 Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau IIB Sant Pau, Barcelona, Spain.,2 Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain
| | - M Jesús Quintana
- 1 Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau IIB Sant Pau, Barcelona, Spain.,3 CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Sergi Bellmunt
- 4 Department of Angiology, Vascular and Endovascular Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,5 Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | | | - José R Escudero
- 6 Joint Service of Angiology, Vascular and Endovascular Surgery, Sant Pau-Dos de Mayo Hospital, Barcelona, Spain.,7 Autonomous University of Barcelona, Barcelona, Spain.,8 CIBER of Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Andrés Viteri-García
- 9 Faculty of Health Sciences "Eugenio Espejo," Clinical Epidemiology and Public Health Research Centre (CISPEC), Universidad UTE, Quito, Ecuador
| | - Claudia Valli
- 2 Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain
| | - Xavier Bonfill
- 1 Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau IIB Sant Pau, Barcelona, Spain.,2 Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain.,3 CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,7 Autonomous University of Barcelona, Barcelona, Spain
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8
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Perioperative Outcome in Geriatric Patients. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Racial disparities in outcomes after intact abdominal aortic aneurysm repair. J Vasc Surg 2017; 67:1059-1067. [PMID: 29074109 DOI: 10.1016/j.jvs.2017.07.138] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/28/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We aimed to compare perioperative morbidity and mortality and late survival among black, white, and Asian patients undergoing intact abdominal aortic aneurysm (AAA) repair. METHODS We identified all patients undergoing intact, infrarenal AAA repair in the Vascular Quality Initiative (VQI) from 2003 to 2017. We compared in-hospital outcomes by race using the Fisher exact and Kruskal-Wallis tests. Multivariable logistic and linear regression models of perioperative outcomes adjusted for differences in demographics, comorbidities, hospital volume, and procedure. We used Cox regression to evaluate late survival by race. RESULTS In the cohort, 21,961 (94%) patients were white, 1215 (5.2%) were black, and 318 (1.4%) were Asian. Black patients were more likely to be symptomatic (black, 16%; white, 9.1%; Asian, 11%; P < .001) and to undergo endovascular aneurysm repair (EVAR; black, 87%; white, 83%; Asian, 84%; P < .001). There were no differences in 30-day mortality after EVAR (black, 1.1%; white, 1.1%; Asian, 0.8%; P = .80) or open repair (black; 4.3%; white, 2.6%; Asian, 1.9%; P = .33). However, black patients were more likely to receive new postoperative dialysis (black, 1.6%; white, 0.8%; Asian; 0.7%; P = .01) and to return to the operating room (black, 4.3%; white, 2.9%; Asian, 0.9%; P < .01). Mean hospital length of stay was longer in black patients after EVAR (black, 3.3 days; white, 2.6 days; Asian, 2.6 days; P < .001) and in Asian and black patients after open repair (black, 10.5 days; white, 8.5 days; Asian, 13.0 days; P < .001). After multivariable adjustment, black patients were more likely than white patients to have postoperative dialysis (odds ratio, 2.2; 95% confidence interval [CI], 1.3-3.6; P < .01) and return to the operating room (odds ratio, 1.6; 95% CI, 1.2-2.2; P < .01). Five-year survival was highest for Asian patients (black, 84%; white, 85%; Asian, 92%), even in the adjusted Cox model (Asian: hazard ratio, 0.6; 95% CI, 0.4-0.97; P = .04). CONCLUSIONS Although perioperative mortality is comparable across races after AAA repair, black patients are more likely than white or Asian patients to develop new postoperative renal failure and return to the operating room, even after adjusting for differences in comorbidities, operative variables, and hospital volume. In addition, whereas Asian patients have the highest rate of postoperative myocardial infarction, they also have the highest late survival. Further studies are warranted to elucidate the mechanism of these disparities.
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10
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Predicting failure to rescue after abdominal aortic aneurysm repair in elderly patients. J Surg Res 2017; 217:265-270. [DOI: 10.1016/j.jss.2017.06.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 05/24/2017] [Accepted: 06/15/2017] [Indexed: 11/19/2022]
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Crespy V, Salomon du Mont L, Kaladji A, Bartoli M, Gouëffic Y, Abello N, Magnan PE, Cardon A, Chaillou P, Steinmetz E. Endovascular Treatment of Asymptomatic Abdominal Aortic Aneurysms in Octogenarians: Factors Influencing Long-term Survival. Ann Vasc Surg 2017; 45:199-205. [PMID: 28651997 DOI: 10.1016/j.avsg.2017.05.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 05/07/2017] [Accepted: 05/09/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Valentin Crespy
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France.
| | - Lucie Salomon du Mont
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France
| | - Adrien Kaladji
- Unité de chirurgie vasculaire, Vascular Surgery Department, CHU Rennes, Rennes, France
| | - Michel Bartoli
- Service de chirurgie vasculaire, Vascular Surgery Department, Hôpital de la Timone, Marseille, France
| | - Yann Gouëffic
- Service de chirurgie vasculaire, Vascular Surgery Department, Institut du Thorax, CHU Nantes, Nantes, France
| | - Nicolas Abello
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France
| | - Pierre-Edouard Magnan
- Service de chirurgie vasculaire, Vascular Surgery Department, Hôpital de la Timone, Marseille, France
| | - Alain Cardon
- Unité de chirurgie vasculaire, Vascular Surgery Department, CHU Rennes, Rennes, France
| | - Philippe Chaillou
- Service de chirurgie vasculaire, Vascular Surgery Department, Institut du Thorax, CHU Nantes, Nantes, France
| | - Eric Steinmetz
- Service de chirurgie cardiovasculaire et thoracique, Cardiovascular and Thoracique Surgery Department, CHU Francois Mitterrand, Dijon, France
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Uehara K, Matsuda H, Inoue Y, Omura A, Seike Y, Sasaki H, Kobayashi J. Is Conventional Open Repair for Abdominal Aortic Aneurysm Feasible in Nonagenarians? Ann Vasc Dis 2017; 10. [PMID: 29147161 PMCID: PMC5684160 DOI: 10.3400/avd.oa.17-00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients. Methods and Results: Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51). Conclusion: Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.
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Affiliation(s)
- Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
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Abdominal aortic aneurysm repair in octogenarians is associated with higher mortality compared with nonoctogenarians. J Vasc Surg 2016; 64:956-965.e1. [PMID: 27364946 DOI: 10.1016/j.jvs.2016.03.440] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/17/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Age is a well-known independent risk factor for death after abdominal aortic aneurysm (AAA) repair. However, there is significant debate about the utility of AAA repair in older patients. In this study, mortality outcomes after endovascular AAA repair (EVAR) and open AAA repair (OAR) in octogenarians (aged ≥80 years) were compared with younger patients (aged <80 years). METHODS All patients recorded in the Vascular Quality Initiative database (2002-2012) who underwent infrarenal AAA repair were included. Univariable and multivariable statistics were used to compare perioperative (30-day) and 1-year mortality outcomes between octogenarians vs nonoctogenarians for OAR and EVAR. RESULTS During the study period, 21,874 patients underwent AAA repair (OAR, 5765; EVAR, 16,109), including 4839 octogenarians (OAR, 765; EVAR, 4074) and 17,035 nonoctogenarians (OAR, 5000; EVAR, 12,035). Octogenarians (mean age, 83.0 ± 0.1 years) were less frequently male (66% vs 75%) and had a higher prevalence of congestive heart failure (9.9% vs 7.1%), chronic renal insufficiency (12.2% vs 7.5%), and a history of aortic surgery (14.3% vs 7.7%) compared with nonoctogenarians (P < .01 for all). Intraoperative use of blood transfusions and vasopressors was more common in octogenarians for OAR (blood: 3.3 ± 4.4 vs 1.8 ± 3.7 units; vasopressors: 45.2% vs 32.8%) and EVAR (blood: 0.43 ± 1.7 vs 0.31 ± 1.6 units; vasopressors: 7.6% vs 5.7%; P < .01 for all). Contrast dye volumes used during EVAR were similar in octogenarians and nonoctogenarians (108 ± 71 vs 107 ± 68 mL; P = .18). Perioperative mortality after OAR was 20.1% in octogenarians compared with 7.1% in nonoctogenarians (P < .01). Perioperative mortality after EVAR was 3.8% in the octogenarians compared with 1.6% in nonoctogenarians (P < .01). One-year mortality among octogenarians vs nonoctogenarians was 26% vs 9.7% for OAR and 8.9% vs 4.3% for EVAR (log-rank test, P < .01 for both). Multivariable analysis controlling for baseline and intraoperative differences between groups demonstrated that age ≥80 years increased the risk of 30-day and 1-year mortality after AAA repair by 223% and 187%, respectively (P < .01 for both). CONCLUSIONS AAA repair should be approached with extreme caution in octogenarians. Perioperative and 1-year mortality rates after OAR are particularly high in the older population, suggesting that the appropriate aneurysm size threshold for OAR might be larger due to the greater operative risk in octogenarian patients.
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Perioperative Letalität bei der Versorgung abdomineller Aortenaneurysmen in Deutschland. Chirurg 2015; 86:1041-50. [DOI: 10.1007/s00104-015-0087-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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