Elective Open Operation for Abdominal Aortic Aneurysm in Octogenarians—Survival Analysis of 105 Patients

Aortic aneurysm trials in octogenarians: Are we really measuring the outcomes that matter?

Purpose

This study is a systematic review to determine the types of outcomes reported in abdominal aortic aneurysm (AAA) studies of patients aged 80 and over. Specifically, it determines the types of patient-centered outcomes reported.

Method

MEDLINE and EMBASE were searched from 2000 to 2014 for studies on AAA surgery with outcome data on patients aged 80 and over. Outcomes were categorized according to Donabedian’s framework for health quality indicators, with further classification as procedural, complication, resource or patient-centered outcome indicators.

Findings

Forty studies were reviewed. Patient-centered outcomes were infrequently reported (13%, n=5), with limited outcomes specifically relevant to older patients. No studies reported physical function, activities of daily living or cognition using validated assessment methods. Short-term mortality (95%, n=38) and complications (85%, n=34) were reported most frequently.

Conclusion

Reporting of aortic surgery outcomes in patients aged 80 and over requires a focus upon outcomes of primary importance to people of this age.

Ten-Year Outcomes after Endovascular Aneurysm Repair (Evar) and Magnitude of Additional Procedures

Background and Aims:

With any new technology complications are possible, and problems with first-generation aortic stentgrafts have been extensively reported. The long-term outcome of this patient population and the magnitude of additional secondary procedures are, however, less well covered.

Materials and Methods:

Between February 1997 and November 1999, 48 patients (44 men and 4 women; mean age 70 years; range 54–85) with AAA (average 57mm, range 40–90mm) were treated with a Vanguard® endoprosthesis. Stentgrafts were sized by CT and angiography-based measurements. Results were continuously assessed using contrast-enhanced CT before discharge, 1, 3, 6 and 12 months after the procedure and thereafter annually. Since 2001 plain abdominal X-rays have been performed annually.

Results:

The technical implant success rate was 100%. Median follow-up was 91 months (range 7.6–120 months). None of the patients was lost during this period. Hospital mortality was 0%. There were 25 subsequent deaths (52%), the most common cause being coronary artery disease. There were ten late conversions to open surgical repair, including three emergency operations: two due to rupture and one to thrombosis. EVAR-related complications were encountered in 43 patients (90%): 12 primary endoleaks (all type II), 36 late endoleaks (16 type I, 2 type II and 18 type III), 22 migrations, 25 row separations, 20 thromboses, one endotension and 3 ruptures of the AAA. Secondary procedures were required in 39 patients (81%): 1 re-endografting by aortoiliac bifurcated graft and 3 with a uni-iliac graft; 33 limb graft repairs were performed and 19 infrarenal cuffs were placed. There were 4 late embolizations and 4 attempts, and 6 thrombolyses, four of which were successful. Further, 9 femoro-femoral crossover by-pass and 2 axillo-femoral by-pass operations and 2 amputations were carried out during the follow-up. Only one patient was alive without complications.

Conclusions:

The impact of long-term follow-up of patients treated with the new technology was emphasized in this patient population. A careful surveillance protocol and active endovascular treatment of complications can yield acceptable results and low AAA rupture and aneurysm mortality rates, also with the first-generation endovascular graft. A new technology, however, may involve unpredictable problems which can magnify the workload and incur high costs over several years after the initial procedure.

Effectiveness of treatment for octogenarians with acute abdominal aortic aneurysm

OBJECTIVE

To investigate whether advanced age may be a reason to refrain from treatment in patients with an acute abdominal aortic aneurysm (AAAA).

METHODS

This was a retrospective cohort study that took place in a tertiary care university hospital with a 45-bed intensive care unit. Two hundred seventy-one patients with manifest AAAA, admitted and treated between January 2000 and February 2008, were included. Six patients died during operation and were included in the final analysis to ensure an intention-to-treat protocol, resulting in 234 men and 37 women with a mean age of 72 ± 7.8 years (range, 54-88 years). Forty-six patients (17%) were 80 years or older. Interventions involved open or endovascular AAAA repair.

RESULTS

Mean follow-up was 33 ± 30.4 months (including early deaths). Mean hospital length of stay was 16.9 ± 20 days for patients younger than 80 and 13 ± 16.7 days for patients older than 80 years of age. Kaplan-Meier survival analysis revealed a significantly better survival for the younger patients (P < .05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 70% for patients younger than 80 and 52% for those older than 80. At 5-year follow-up, these figures were 62% and 29%, respectively. Mean survival in patients older than 80 was 39.8 ± 6.8 months versus 64.5 ± 3.0 months in those younger than 80.

CONCLUSIONS

For octogenarians, our liberal strategy of treating patients with AAAA was associated with satisfactory short- and long-term outcome, with no difference with regard to disease- or procedure-related morbidity between the younger and older group. Assuming an integrated system for managing AAAA is in place, advanced age is not a reason to deny patients surgery.

Systematic review and meta-analysis of sex differences in outcome after intervention for abdominal aortic aneurysm

Background

The aim of this study was to assess possible differences in mortality between men and women with an abdominal aortic aneurysm (AAA) treated either by elective repair or following aneurysm rupture.

Methods

A systematic literature search was performed using the MEDLINE, Cochrane and Embase databases. Data were analysed by means of bivariate random-effects meta-analysis. Data were pooled and odds ratios (ORs) calculated for women compared with men.

Results

Sixty-one studies (516 118 patients) met the predetermined inclusion criteria. Twenty-six reported on elective open AAA repair, 21 on elective endovascular repair, 25 on open repair for ruptured AAA and one study on endovascular repair for ruptured AAA. Mortality rates for women compared with men were 7·6 versus 5·1 per cent (OR 1·28, 95 per cent confidence interval (c.i.) 1·09 to 1·49) for elective open repair, 2·9 versus 1·5 per cent (OR 2·41, 95 per cent c.i. 1·14 to 5·15) for elective endovascular repair, and 61·8 versus 42·2 per cent (OR 1·16, 95 per cent c.i. 0·97 to 1·37) in the group that had open repair for rupture. The group that had endovascular repair for ruptured AAA was too small for meaningful analysis.

Conclusion

Women with an AAA had a higher mortality rate following elective open and endovascular repair.

Laparoscopic abdominal aortic aneurysm repair in octogenarians

OBJECTIVE

Open abdominal aortic aneurysm (AAA) repair in octogenarians is considered to have higher risks of mortality and systemic complications compared with younger patients. The purpose of our work is to present our experience with total laparoscopic repair for AAA in this subset of patients.

METHODS

From February 2002 to February 2008, 29 octogenarian patients underwent total laparoscopic AAA repair. Median age was 82 years (range, 80-85 years). Median aneurysm size was 52 mm (range, 40-85 mm). Disease was classified as American Society of Anesthesiologist (ASA) class II in 12 patients and class III in 17 patients. Ten patients presented with past medical history of myocardial infarct (34.5%).

RESULTS

We implanted 12 tube grafts and 17 bifurcated grafts. Twenty-six procedures were totally laparoscopic (89.6 %). Median operative time and aortic clamping time were 280 min (range, 160-480 min) and 75 min (range, 22-125 min), respectively. Two patients with juxtarenal AAA underwent suprarenal clamping. Median blood loss was 1100 cc (range, 600-3000 cc). Four patients (13.8%) needed adjunctive vascular procedures because of intraoperative complications. Two patients died in the postoperative course (6.9%). Four patients developed severe systemic non-lethal complications (14.8%, pneumopathies). Mild or moderate systemic complications were observed in 14 patients (51.8%) including transient renal insufficiencies without dialysis (13) and cardiac arrhythmia (1). Postoperative creatinine levels returned to baseline before discharge in all patients. Liquid diet was reintroduced after a median duration of 2 days (range, 1-10 days) and most patients were ambulatory by day four (range, 3-30 days). Median stays in intensive care unit and hospital were 72 hours (range, 12-1368 hours) and 11 days (range, 6-74 days), respectively. Sixteen patients (59.2%) were discharged directly to home with complete recovery. After a median follow-up of 24 months (range, 2-48 months), 23 patients are still alive and regained their baseline status. Four patients died after hospital discharge of non-vascular etiologies.

CONCLUSION

Total laparoscopic AAA repair is a worthwhile but challenging procedure in octogenarians. Laparoscopy is complementary to open surgery and EVAR in this subset. These results encourage us to offer laparoscopic AAA repair in good surgical risk octogenarians.

Abdominal aortic aneurysm surgery for octogenarians

PURPOSE

To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians.

METHODS

We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006.

RESULTS

Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B.

CONCLUSIONS

We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.

Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms in High-Risk-Surgical Patients

PURPOSE

Following the publication of a prospective randomized trial (EVAR2) that questioned the benefit of endovascular repair of abdominal aortic aneurysms (AAA) for high-surgical-risk patients, we evaluated our own initial and long-term results with endovascular AAA repair for this patient population.

MATERIAL AND METHODS

Between January 2000 and December 2005, 115 patients with an AAA managed by an aortic endograft were entered in a registry. Data concerning diagnosis, operative risk, treatment, and follow-up were analyzed on an intention-to-treat basis for all patients considered to be poor candidates for surgery. Patients with a ruptured AAA and those who were good surgical candidates were excluded from analysis. The main goal was evaluation of the operative mortality and the long-term survival of these patients. Secondary goals were determination of the frequency of secondary operations, the outcome of the aneurysm sac, and primary and secondary patency rates after aortic endograft placement.

RESULTS

A total of 92 high-surgical-risk patients treated by an endograft were entered in this study. Sixty-seven patients (73%) were classed ASA III and 18 (20%) were ASA IV (20%). Mean aneurysm diameter was 58 mm+/-9 mm. The technical success rate was 99%. Operative mortality was 4.3% (4 cases). Four patients required re-intervention during the mean follow-up of 18 months. The survival rate at 3 yr was 85%. One type I endoleak (1%) and 9 type II endoleaks (9.7%) occurred during the follow-up period. Primary and secondary patency rates at 3 yr were respectively 96% and 100%.

CONCLUSION

Our initial and long-term results with endograft repair of AAA in high-surgical-risk patients were satisfactory. These results appear to justify endovascular repair for this patient population.

Infrarenal Abdominal Aortic Aneurysm Repair: Time-trends during a 20-year Period

BACKGROUND

The goal of the present study was to investigate the number of operations for abdominal aortic aneurysm (AAA) including time-trends in treatment during a 20-year period. Operating time and anesthesia time were also studied.

METHOD

During the period 1983-2002, a total of 1,041 patients with AAA were treated with open surgery (905) or EVAR (136). Number of operations, type of graft, anesthesia time, and operating time were the variables investigated. Data were collected retrospectively from the patients' medical records.

RESULTS

There was an increase in the number of operations both for ruptured and non-ruptured AAA in men during the study period. Among women, an increase was observed only for ruptured aneurysm. Operating time and anesthesia time increased significantly during the 20-year period. The number of patients treated by EVAR increased significantly, beginning in 1995.

CONCLUSIONS

In conclusion, there has been an increase in the number of AAA operations, and the proportion of patients treated with EVAR is increasing. Furthermore, we found an increase in both anesthesia time and operating time. These trends may be important for allocation of resources needed for the treatment of patients with AAA.

Different Disease Profiles for Women and Men with Abdominal Aortic Aneurysms

OBJECTIVE

The overall aim with this study was to investigate causes of death and mortality rates for women and men treated for abdominal aortic aneurysm (AAA) in Sweden.

MATERIALS AND METHOD

All patients treated for ruptured and non-ruptured AAA 1987-2002 in Sweden were identified in national registries (n=12917). Age, sex, diagnosis, surgical procedure and mortality were analysed on a patient specific level. Logistic regression and analysis of standardised mortality rates (SMR) were performed.

RESULTS

Post operative mortality was similar between the sexes. Age (p<0.0001), and surgery for rupture (p=0.0005), but not gender (p=0.65) were significant risk factor for poor long term survival. SMR revealed increased risk for both sexes compared to the population with significantly higher values for women than men (2.26, CI 2.10-2.43 vs. 1.63, CI 1.57-1.68, p<0.0001). The higher risk for women could be explained by the higher risk for aneurysm related death (ie.thoracic or abdominal aorta) compared to men (Hazard ratio 1.57 vs. 1.0, p<0.0001).

CONCLUSION

Women do not have an increased surgical risk compared to men, but treated women have an increased risk of premature death compared to men and women in the population. They also have a higher risk for aneurysm related death compared to men with AAA.

Experience With Endovascular Abdominal Aortic Aneurysm Repair in Nonagenarians

PURPOSE

To report a single-institution experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in nonagenarians.

METHODS

A retrospective review was performed of all patients >90 years old undergoing EVAR over an 8-year period at a major academic medical center. The patient population was investigated for the presence of various comorbidities, initial aneurysm size, successful aneurysm exclusion, perioperative complications, disposition, endoleaks, secondary interventions, and overall survival.

RESULTS

EVAR was performed in 18 male nonagenarians (mean age 92.4 years, range 90- 95). Mean aneurysm diameter was 7.3 cm (range 5.5-9.8). The cohort had an average of 3.2 comorbid conditions. Sixteen patients were treated electively, while 2 patients underwent emergent repair for contained rupture and bleeding aortoenteric fistula, respectively. Immediate technical success was 100%. Perioperative local/vascular complications occurred in 4 (22%) patients. Perioperative systemic complications occurred in 3 (17%) patients. There were 2 (11%) perioperative (<30 days) deaths. Three (17%) patients required secondary interventions. Mean survival in patients who expired during the follow-up period beyond the first 30 days was 34 months (range 8-78). Mean survival in 8 patients who are still alive is 17.4 months (range 9-39).

CONCLUSION

Endovascular AAA repair in nonagenarians is associated with a high rate of technical success and relatively low morbidity rate. Survival times following successful hospital discharge are significant. Suitable patients over 90 years of age may benefit from an endovascular AAA repair.

Endovascular repair of abdominal aortic aneurysm in octogenarians: an analysis based on EUROSTAR data

PURPOSE

To investigate the early and late outcome after endovascular treatment of abdominal aortic aneurysm (EVAR) in octogenarians compared with patients aged < 80 years.

METHODS

Patients treated for abdominal aortic aneurysm (AAA) with endovascular repair during the period 1996 to 2004 were collated in the EUROSTAR registry. This study group consisted of 697 patients aged > or = 80 years. Comparison was made with 4198 patients aged < 80 years with regard to the incidence of preoperative characteristics and outcomes of the procedure.

RESULTS

The proportion of octogenarians treated by EVAR increased during the study period, from 11% in the first year to 18% in the last year. Octogenarians more frequently had cardiac disease, impaired renal function, and pulmonary disease (P = .03, P < .0001 and P = .0001). Thirty-two percent of the octogenarians were recorded unfit for open surgery as opposed to 22% in younger patients (P < .0001); they also had a larger aneurysm diameter (62 vs 58 mm, respectively; P < .0001). The 30-day and in-hospital mortality in octogenarians was 5% vs 2% in the younger group (P < .0001). More device-related complications and systemic complications, including cardiac disease, were noted in octogenarians (7% vs 5% and 19% vs 11%, P = .03 and P < .0001, respectively). This group of patients also had a higher incidence of postoperative hemorrhagic complications, including hematoma (7% vs 3%, P < .0001, respectively). No differences in conversion to open repair and post-EVAR rupture rate were observed. Aneurysm-related mortality and late all-cause mortality was 7% vs 3% and 10% vs 7%, both P < .0001.

CONCLUSION

Our study supports that EVAR might be considered when treating elderly patients, provided their aneurysms are anatomically suited for the endovascular technique. The risk for late complications compared with open repair may be outweighed by a lower early mortality as well as a shorter time for physical recovery.