Outcome of Ruptured Abdominal Aortic Aneurysm Repair in Octogenarians: A Systematic Review and Meta-Analysis

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, age is on par with other medical comorbidities and therefore should not be a strict exclusion criterion for F/BEVAR procedures, rather considered in the global context of patient's aortic anatomy, health, and functional status.

Outcomes of Endovascular Aneurysm Repair (EVAR) Compared to Open Repair in Abdominal Aortic Aneurysm: An Umbrella Meta-Analysis

This umbrella meta-analysis aims to investigate two surgical treatments for abdominal aortic aneurysm (AAA): endovascular aneurysm repair (EVAR) and open surgery repair (OSR). Our study aims to elucidate the 30-day mortality rate, reintervention rates, and aneurysm-related mortality in EVAR versus OSR for AAA.  We conducted a comprehensive assessment of meta-analyses (n = 34 articles) comparing EVAR and OSR for AAA. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and considered statistical significance at P ≤ 0.05. For the 30-day mortality rate, a pooled odds ratio (pOR) of 0.59 (95% confidence interval [CI] 0.45-0.77, P = 0.0001, and I2 = 98%) indicates that EVAR was associated with a lower risk of mortality compared to OSR. For reintervention rates, a pOR of 1.33 (95% CI = 0.98-1.82, P = 0.11, and I2 = 90%). In aneurysm-related mortality, a pOR of 0.78 (95% CI = 0.63-0.97, P = 0.03, and I2 = 43%). In postoperative rupture of aneurysm, a pOR of 3.28 (95% CI = 2.16-4.98, P < 0.00001, and I2 = 50%). Furthermore, when analyzing systemic complications, only for visceral ischemia, significant results showed lower odds for EVAR, with a pOR of 0.57 (95% CI = 0.40-0.80, P = 0.001, and I2 = 0%) was found.  EVAR is better in terms of short-term mortality rate and aneurysm-related mortality. Furthermore, EVAR is still a safer procedure in elective settings, as the studies we included recruited patients for this setting. However, given the high reintervention rates and recent developments in surgical techniques and materials, more recent data and extensive research are needed.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

Eleven-Year Outcomes of a Screening Project for Abdominal Aortic Aneurysm (AAA) in 65-Year-Old Men

Objective

Since 2011, the Department of Vascular Surgery at Oslo University Hospital has offered screening for abdominal aortic aneurysm (AAA) to 65-year-old men living in Oslo, Norway. The aim of this study was to evaluate the effect of the screening project on AAA-related mortality and rupture and repair rates in the screened population.

Methods

This cohort study included men that participated in AAA screening at the Department of Vascular Surgery at Oslo University Hospital in the period May 2011 to September 2019. All men with screen-detected AAA (aortic diameter ≥30 mm) and subaneurysmal aortic dilatation (aortic diameter 25-29 mm) were included. A stratified (1:1 with the subaneurysm group), randomized selection of men with normal aortic diameter (<25 mm) upon screening was also included. The follow-up data on events (ruptures, repairs, and deaths) after screening were collected retrospectively from patient electronic medical records at Oslo University Hospital, the National Population Register and the Norwegian Cause of Death Registry (CoDR).

Results

In total, 2048 men were included, with a median follow-up time of 7.1 years (IQR 3.8). Among men with screen-detected AAA, 0.6% died of AAA-related causes (0.9 AAA-related deaths per 1000 person-years). The rupture rate was 0.3% among men with screen-detected AAA or subaneurysmal aortic dilatation, giving an incidence of 0.5 ruptures per 1000 person-years. The overall repair rate in the AAA group was 20.6% (36.1 repairs per 1000 person-years) and 0.6% (0.9 repairs per 1000 person-years) in the subaneurysm group.

Conclusion

In a population screened for AAA, the incidence of rupture and the AAA-related mortality was very low. Almost one-fifth of the participants with screen-detected AAA underwent elective repair, representing a group that might have presented with rupture if untreated. These results indicate that screening is valuable in preventing AAA rupture and AAA-related mortality.

Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic Aneurysms

PURPOSE

Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data.

METHODS

All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians.

RESULTS

The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8).

CONCLUSION

Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.

Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021

Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. Methodology: All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. Results: From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. Conclusions: This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.

Center Volume and Failure to Rescue after Open or Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

BACKGROUND

The correlation between center volume and elective abdominal aortic aneurysm(AAA) repair outcomes is well established; however, these effects for either endovascular(EVAR) or open(OAR) repair of ruptured AAA(rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities following elective procedures; however, there is a paucity of data surrounding non-elective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue(FtR) after EVAR and OAR of rAAA.

METHODS

All consecutive endovascular and open rAAA repairs from 2010-2020 in the Vascular Quality Initiative were examined. Annual center volume(procedures/year per center) was grouped into quartiles: EVAR-Q1[<14](3.4%), Q2[14-23](12.8%), Q3[24-37](24.7%), Q4[>38](59.1%); OAR-Q1[<3](5.4%), Q2[4-6](12.8%), Q3[7-10](22.7%), Q4[>10](59.1%). The primary end-point was FtR, defined as in-hospital death after experiencing one of six major complications(cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for inter-group comparisons was completed using multivariable logistic regression.

RESULTS

The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR(n=1,439/3,188) and 70% of OAR(n=1,366/1,961) patients with corresponding FtR rates of 14%(EVAR) and 26%(OAR). For OAR, Q4-centers had a 43% lower FtR risk(OR 0.57, 95%CI 0.4-0.9;p=.017) compared to Q1 centers. Centers performing >5 OARs/year had a 43% lower risk(OR 0.57, 95%CI 0.4-0.7;p<.001) of FtR and this decreased 4% for each additional 5 procedures performed annually(95%CI .93-.991;p=.013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures(OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication;p<.0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality(OR 4.1, 95%CI 1.1-4.8;p=.034), while no specific type of complication increased FtR risk after EVAR.

CONCLUSIONS

FtR occurs commonly after EVAR and OAR of rAAA within VQI centers. Importantly, increasing center volume was associated with reduced FtR risk after OAR but not EVAR. Complication pattern and frequency predicted FTR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.

[Abdominal aortic aneurysms-open vs. endovascular treatment : Decision-making from the perspective of the vascular surgeon]

CLINICAL/METHODICAL ISSUE

In the last 20 years, the treatment of abdominal aortic aneurysms has essentially evolved from surgical to minimally invasive endovascular treatment.

ACHIEVEMENTS

There are still a number of clinical situations that make surgical intervention useful or even necessary. This underlines the importance of interdisciplinary vascular centers for the treatment of complex aortic pathologies and their sequelae.

PRACTICAL RECOMMENDATIONS

In the following article, the arguments for the choice of procedure for the treatment of infrarenal aortic aneurysms are discussed and the recommendations of various guidelines are compared.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Screening for Abdominal Aortic Aneurysms and Risk Factors in 65-Year-Old Men in Oslo, Norway

Purpose

To investigate the prevalence of and risk factors for abdominal aortic aneurysm (AAA) in 65-year-old men in Oslo, Norway.

Materials and Methods

From May 2011, until September 2019, the annual population of 65-year-old men living in Oslo were invited to an ultrasonographic screening of the abdominal aorta. Candidates received a one-time invitation by mail, including a questionnaire on possible risk factors and comorbidities. Abdominal aortic outer-to-outer diameter and ankle-brachial index were measured by the screening team. Participants were allocated into three groups: non-, sub- and aneurysmal aorta. Written information on recommended follow-up regime was given to participants with an aortic diameter ≥25 mm. Univariate and multivariate analyses of potential risk factors were performed, in addition to descriptive analyses and significance testing.

Results

In total, 19,328 were invited, 13,215 men were screened, of which 12,822 accepted inclusion in the study. Aortic diameter was registered for 12,810 participants and 330 men had aortic diameter ≥30 mm, giving a prevalence of AAA of 2.6% (95% confidence interval (CI) 2.31-2.86). We identified 4 independent risk factors for AAA: smoking (OR = 3.64, 95% CI 2.90-4.58), hypertension (OR = 1.87, 95% CI 1.49-2.35), BMI >30 (OR = 1.02, 95% CI 1.00-1.03), and diabetes mellitus (OR = 0.52, 95% CI 0.35-0.79), the latter showing an inverse association with AAA growth. A subgroup of 862 men with aortic diameters 25-29 mm had a significantly higher prevalence of BMI >25, smoking and family history of AAA, compared to participants with aortic diameter <25 mm.

Conclusion

Among the participants in this study, the prevalence of abdominal aortic aneurysms was 2.6%. Participants with AAA more frequently reported cardiovascular risk factors, and less frequently diabetes mellitus.

Endovascular Aortic Repair in Nonagenarian Patients

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.

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.

Survival and Living Situation After Ruptured Abdominal Aneurysm Repair in Octogenarians

OBJECTIVE

To determine the 30 day and one year mortality and post-operative living situation in octogenarians treated for ruptured abdominal aortic aneurysm (rAAA).

METHODS

A retrospective study was performed at four centres in the Netherlands. All consecutive patients aged ≥80 years, presenting with a rAAA between January 2013 and October 2018, were included. The primary outcomes were post-operative living situation and one year mortality.

RESULTS

In total, 157 patients were included. Forty-seven received palliative care and 110 patients had surgery. After endovascular or open repair, the one year mortality rate was 50.0%. The 30 day mortality rate was 40.8% (95% confidence interval [CI] 27-55) and 31.7% (95% CI 20-44), for endovascular and open repair, respectively (p = .32). Sixty-five per cent of survivors were discharged home, while 34.8% went to a nursing home for rehabilitation. Of the surviving patients, 82.6% went back to living in their pre-rupture home situation. Of the investigated variables, only a high body mass index proved a significant predictor of death at 30 days and one year. Compared with operated patients, patients turned down for surgery were older (mean age 87.5 ± 3.8 vs. 84.0 ± 3.5; p < .001), lived significantly more often in a nursing home (odds ratio 1.02, 95% CI 1.00-1.03; p < .001), were more often dependent (odds ratio 3.69, 95% CI 2.31-5.88; p < .001) and had a lower Glasgow Coma Scale score on arrival (odds ratio 0.42, 95% CI 0.25-0.69; p = .002). All palliative patients died within three days.

CONCLUSION

Overall treatment outcomes showed that octogenarians should not be denied surgery based on age alone, as half of the octogenarians that undergo surgical treatment are still alive one year after rAAA repair. In addition, > 80% returned to their own home after rehabilitation.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.

Correlation of intracranial and aortic aneurysms: current trends and evidence

The correlation between intracranial and aortic aneurysms remains elusive. Data in the literature are scattered, and outcome reporting is swamped with heterogeneity and single-center bias. This calamity is adding to confusion on decision-making and delays the instigation of appropriate clinical applications. This literature review delves into the abyss of the lack of clinically driven scientific input, and highlights the trends explored thus far.

Nationwide Analysis of Ruptured Abdominal Aortic Aneurysm in Portugal (2000-2015)

OBJECTIVE

Ruptured abdominal aortic aneurysm (rAAA) is a lethal condition that requires acute repair to prevent death. This analysis aims to assess the nationwide trends in rAAA admission, repair and mortality in a country, Portugal, without national screening for AAA.

METHODS

rAAA registered in the hospital administrative database of the National Health Service and all nationally registered deaths due to rAAA based on death certificate data were analysed. Three time periods (2000-2004, 2005-2009, and 2010-2015) were compared in patients ≥ 50 years old to assess the variations over time.

RESULTS

A total of 2 275 patients ≥50 years old with rAAA were identified in the two databases from 2000 to 2015. The age standardised incidence of rAAA was 2.78 ± 0.24/100 000/year in 2000-2004, 3.17 ± 0.39/100 000/year in 2005-2009 and 3.21 ± 0.28/100 000/year in 2010-2015 (p < .001). When comparing the time periods 2000-2004 to 2005-2009, the age standardised rate of admission (n = 1460) increased from 1.57 ± 0.25/100 000/year to 2.24 ± 0.32/100 000/year (p < .001). The operative mortality rates decreased during this time period (from 55.3 ± 4.7% to 48.8 ± 4.7%, p < .001). In 2010-2015, the age standardised rate of admissions due to rAAA decreased (1.98 ± 0.22/100 000/year). Operative mortality remained stable (48.9 ± 6.2%). The rate of patient deaths outside the hospital decreased from the first to the second period (1.21 ± 0.10/100 000/year and 0.93 ± 0.29/100 000/year, respectively) but later increased (1.14 ± 0.22/100 000/year). This resulted in a higher overall rAAA related mortality in Portugal in the third period (2.20 ± 0.18/100 000/year, 2.21 ± 0.27/100 000/year and 2.26 ± 0.26/100 000/year in 2000-2004, 2005-2009, and 2010-2015, respectively, p < .001).

CONCLUSION

Overall, the incidence of rAAA in Portugal has been stable over the past 10 years. The rates of admission, repair, and death due to rAAA repair seem to have reached an inflection point and are now decreasing. Mortality outside the hospital remains a matter of concern, warranting further planning of streamlined transfer networks and vascular surgical departments.