Elective surgery of abdominal aortic aneurysms in octogenarians: A systematic review

Similar long-term outcomes between endovascular aneurysm repair and open surgical repair for abdominal aortic aneurysms in octogenarian patients: a single-center study

Purpose

Endovascular aneurysm repair (EVAR) has lower perioperative mortality and morbidity rates and shorter hospital stays when compared to open surgical repair (OSR) in octogenarian patients. However, its long-term results remain unclear. Hence, we aimed to analyze and compare the long-term outcomes of OSR and EVAR in this aging population.

Methods

This single-center, retrospective, observational study analyzed the data of patients older than 80 years who underwent primary repair of an abdominal aortic aneurysm (AAA) between 2011 and 2016 in our hospital. The primary outcomes were in-hospital complications and 30-day mortality, while the secondary outcomes included all-cause mortality and reintervention rate.

Results

Among the 48 patients with elective AAA repair, 13 underwent OSR and 35 underwent EVAR. In-hospital complications occurred in 10 patients (20.8%), 5 for OSR (38.5%) and 5 for EVAR (14.3%) with no significant difference between the groups (P = 0.067). In the OSR group, pulmonary complications were the most common events; in the EVAR group, 2 patients had ischemic colitis diagnosed with sigmoidoscopy and recovered by conservative treatment. The 1- and 5-year survival rates were 77.8% and 55.6% in the OSR group, and 66.0% and 54.9% in the EVAR group, respectively. The reintervention rate was 8.6% for the EVAR group; none of the OSR group were readmitted.

Conclusion

The difference in procedures did not affect patient survival. Therefore, OSR does not necessarily have a worse prognosis than EVAR. Individual risk stratification must be preceded before the selection of an appropriate treatment method.

Outcomes of EVAR Conversion in Octogenarians Treated at a High-Volume Aorta Center

INTRODUCTION

Endovascular aortic aneurysm repair(EVAR) is the dominant treatment strategy for infrarenal abdominal aortic aneurysms(AAA) but is especially preferred among octogenarian(age ≥80-years) patients due to concerns surrounding comorbidity severity and physiological frailty. Correspondingly, EVAR failure resulting in subsequent open conversion(EVAR-c) has been increasingly reported in older patients but there is a paucity of literature focusing on outcomes in this subgroup. The purpose of this analysis was to evaluate our experience with EVAR-c in octogenarians(≥80-years) compared to younger patients(age <80-years).

METHODS

A retrospective review of all non-mycotic EVAR-c procedures(2002-2020) at a single high-volume academic hospital with a dedicated aorta center(https://www.uf-health-aortic-disease-center) was performed. Patients(n=162) were categorized into octogenarian(age ≥80; n=43) and non-octogenarian(age<80; n=119) cohorts and subsequently compared. The primary end-point was 30-day mortality. Secondary end-points included complications, 90-day mortality, and overall survival. Cox regression determined effects of selected covariates on mortality risk. Kaplan-Meier methodology estimated survival.

RESULTS

No difference in pre-admission EVAR re-intervention rates was present(octogenerians-42% vs. non-octogenerians-43%;p=1) although time to first re-intervention was greater in octogenarians(41 vs. non-octogenarians, 15-months;p=.01). Concordantly, time to EVAR-c was significantly longer among octogenarian patients(61 vs. non-octogenarians, 39-months;p<.01). No difference in rupture presentation was evident(14% vs. 10%;p=.6); however, elective EVAR-c occurred less frequently(octogenerians-42% vs. non-octogenerians-59%;p=.07). AAA diameter was significantly larger for elective octogenarian EVAR-c(7.8±1.9cm vs. non-octogenarians, 7.0±1.5cm;p=.02) and type 1a endoleak was the most common indication overall(58%;n=91). Among all presentations, a trend in higher 30-day mortality was evident for octogenarian patients(16% vs. non-octogenarians, 7%;p=.06). Similarly 90-day mortality was greater among octogenarians(26% vs. non-octogenarians, 10%;p=.02). However, incidence of any complication(56% vs. 49%;p=.5), readmission(12% vs. 6%;p=.3), unplanned re-operation(10% vs. 5%;p=.5) and LOS(11 vs. 9 days;p=.3) was not significantly different. Age ≥80 was predictive of short-term mortality after non-elective but not elective cases; however, increasing comorbidity number, non-elective admission and renal/mesenteric revascularization had the strongest association with mortality risk. One- and three-year survival was not different between groups when comparing all patients after the first 90-days postoperatively.

CONCLUSION

Although higher unadjusted peri-operative mortality occurred among octogenarian patients, risk-adjusted elective outcomes were comparable to younger EVAR-c subjects when treated at a high-volume aortic surgery center. This underscores the importance of appropriate patient selection and modulation of operative complexity when feasible to achieve optimal results. Providers caring for octogenarian patients with EVAR failure should consider timely elective referral to high-volume aorta centers to reduce resource utilization and frequency of non-elective presentations.

Endovascular Aneurysm Repair Compared With Open Repair Does Not Improve Survival in Octogenarians

BACKGROUND

Not every elderly person is frail, and whether it would be beneficial to perform endovascular aneurysm repair (EVAR) solely because a patient is older is unclear. This study aimed to compare the results of EVAR and open surgical repair (OSR) in elderly individuals.Methods and Results:From May 1998 to March 2021, 828 EVAR patients and 886 OSR patients with abdominal aortic aneurysm (AAA) were reviewed. Patients aged ≥80 years were included among them. After propensity score matching by age, sex, and American Society of Anesthesiologists (ASA) classification, the outcomes were compared between patients who underwent EVAR and OSR. The study cohort was composed of 351 EVAR patients and 90 OSR patients. The groups had similar comorbidities, except that EVAR patients were significantly older and had higher ASA classifications. After propensity score matching, 79 pairs of patients were selected. The 30-day mortality (0 vs. 1.2%) and aneurysm-related death (ARD) rates during follow up (2.3% vs. 2.3%, respectively) were similar between the groups. Kaplan-Meier curves revealed that estimated overall survival and freedom from ARD were also similar.

CONCLUSIONS

This study suggests that EVAR cannot improve survival outcomes compared with OSR if applied solely because a patient is aged ≥80 years. Not only age but also other risk factors and quality of life after surgery need to be further studied.

Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study

OBJECTIVE

Age is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined.

METHODS

All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality.

RESULTS

This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR.

CONCLUSION

Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of psoas muscle area on mortality following elective abdominal aortic aneurysm repair

BACKGROUND

The effect of sarcopenia based on the total psoas muscle area (TPMA) on CT is inconclusive in patients undergoing abdominal aortic aneurysm (AAA) intervention. The aim of this prospective cohort study was to evaluate morphometric sarcopenia as a method of risk stratification in patients undergoing elective AAA intervention.

METHODS

TPMA was measured on preintervention CT images of patients undergoing elective endovascular aneurysm repair (EVAR) or open aneurysm repair. Mortality was assessed in relation to preintervention TPMA using Cox regression analysis, with calculation of hazard ratios at 30 days, 1 year and 4 years. Postintervention morbidity was evaluated in terms of postintervention care, duration of hospital stay and 30-day readmission. Changes in TPMA on surveillance EVAR imaging were also evaluated.

RESULTS

In total, 382 patient images acquired between March 2008 and December 2016 were analysed. There were no significant intraobserver and interobserver differences in measurements of TPMA. Preintervention TPMA failed to predict morbidity and mortality at all time points. The mean(s.d.) interval between preintervention and surveillance imaging was 361·3(111·2) days. A significant reduction in TPMA was observed in men on surveillance imaging after EVAR (mean reduction 0·63(1·43) cm2 per m2 ; P < 0·001). However, this was not associated with mortality (adjusted hazard ratio 1·00, 95 per cent c.i. 0·99 to 1·01; P = 0·935).

CONCLUSION

TPMA is not a suitable risk stratification tool for patients undergoing effective intervention for AAA.

Survival and Reintervention Risk by Patient Age and Preoperative Abdominal Aortic Aneurysm Diameter after Endovascular Aneurysm Repair

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the standard of care for abdominal aortic aneurysm (AAA), but questions remain regarding the benefit in high-risk and elderly patients. The purpose of this study was to examine the effect of age, preoperative AAA diameter, and their interaction on survival and reintervention rates after EVAR.

METHODS

Our integrated health system's AAA endograft registry was used to identify patients who underwent elective EVAR between 2010 and 2014. Of interest was the effect of patient age at the time of surgery (≤80 vs. >80 years old), preoperative AAA diameter (≤5.5 cm vs. >5.5 cm), and their interaction. Primary endpoints were all-cause mortality and reintervention. Between-within mixed-effects Cox models with propensity score weights were fit.

RESULTS

Of 1,967 patients undergoing EVAR, unadjusted rates for survival at 4 years after EVAR was 76.1%, and reintervention-free rate was 86.0%. For mortality, there was insufficient evidence for an interaction between age and AAA size (P = 0.309). Patient age >80 years was associated with 2.53-fold higher mortality risk (hazard ratios [HR] = 2.53; 95% confidence intervals [CI], 1.73-3.70; P < 0.001), whereas AAA > 5.5 cm was associated with 1.75-fold higher mortality risk (HR = 1.75; 95% CI, 1.26-2.45; P = 0.001). For reintervention risk, there were no significant interactions or main effects for age or AAA diameter.

CONCLUSIONS

Age and AAA diameter are independent predictors of reduced survival after EVAR, but the effect is not amplified when both are present. Age >80 years or AAA size >5.5 cm did not increase the risk of reintervention. No specific AAA size, patient age, or combination thereof was identified that would contraindicate AAA repair.

The Obsolete Maximum Diameter Criterion, the Evident Role of Biomechanical (Pressure) Indices, the New Role of Hemodynamic (Flow) Indices, and the Multi-Modal Approach to the Rupture Risk Assessment of Abdominal Aortic Aneurysms

Although the therapeutic management of abdominal aortic aneurysms (AAAs) is currently based on the maximum diameter criterion, this has often proved inaccurate and misleading. Conversely, the biomechanical approach, which takes into account the pressure-induced wall stress exerted at every point throughout the aneurysmal surface, has been proven superior in predicting the rupture risk of AAAs, and its value is being increasingly recognized among physicians. More recently, hemodynamic indices, such as flow-induced wall shear stresses, have been indicated as potentially significant determinants of AAA natural history. Ultimately, a statistical model that takes into account all these factors may be relevant for making a sound prediction of the rupture risk of aneurysms and optimizing the management of these patients.

Prospective cohort 20 years after endovascular treatment for abdominal aortic aneurysm

OBJECTIVE

To describe the factors associated with survival 20 years after endovascular treatment of an abdominal aortic aneurysm (AAA) in a single center.

METHODS

Prospective cohort of asymptomatic patients with an infrarenal aortic aneurysm treated with a bifurcated endovascular graft (Talent) between June 1997 and August 2008. Cox proportional hazard multivariable regression was used for analysis of independent risk factors for survival. Kaplan-Meier curves were done with the long-rank test. P < .05 was considered significant.

RESULTS

We followed 229 patients, 184 without an endoleak and 45 with an endoleak. Ages ranged between 52 and 89 years, and the mean diameter of the aneurysm was 59.51 ± 14.6 mm. Implantation of the endovascular graft was possible in 99% of the patients. The 30-day mortality rate was 3.4%. In the Cox regression, age <73 years (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.27-0.64), aneurysm size ≤55 mm (HR, 0.62; 95% CI, 0.40-0.95), male sex (HR, 0.17; 95% CI, 0.05-0.52), American Society of Anesthesiologists surgical risk category I and II vs III and IV (HR, 0.51; 95% CI, 0.34-0.75), and aneurysm size reduction ≤3 mm after treatment (HR, 2.23; 95% CI, 1.11-4.51) were significantly correlated with the survival of the patients followed in this long-term case series.

CONCLUSIONS

This 20-year prospective cohort included patients with an AAA treated with a bifurcated endovascular graft (Talent) at a university hospital in Brazil. This study supports that sex, age, aneurysm size, aneurysm size reduction, and American Society of Anesthesiologists surgical risk category are significantly correlated with patient survival after endovascular treatment of the AAA.

Endovascular aneurysm repair in the elderly: First do no harm

Endovascular aneurysm repair (EVAR) has become the intervention of choice for supra-threshold aortic aneurysms due to the lower 30-day mortality of EVAR as compared with open surgery, despite no long-term longevity gains. Trials such as EVAR-1 that established the current status of endovascular aortic intervention often excluded participants over the age of 80, and specific studies of EVAR in the elderly reveal higher mortality than accepted averages. Analyses of the cost-effectiveness of EVAR have not demonstrated superiority of endovascular intervention over open repair, in particular when considering complications such as endoleak. Post-intervention surveillance and the frequent need for re-intervention following EVAR has a detrimental impact on quality of life. Taking these factors into consideration, combined with an ageing population and the likely increase in octogenarian endovascular intervention, there is a clear clinical need for appropriate risk-stratification of elderly patients with supra-threshold aneurysms to determine who will benefit from endovascular repair.

Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients

BACKGROUND

Endovascular aneurysm repair (EVAR) is becoming the preferred treatment modality for patients with a ruptured abdominal aortic aneurysm (rAAA). Although the survival advantage of EVAR over open aortic repair (OAR) has been shown in some studies, it is unclear whether this benefit extends to elderly patients. We sought to evaluate the outcomes of rAAA repair in octogenarians.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set (2005-2014) to identify patients older than 80 years who were treated with EVAR and OAR for rAAA. Procedural trends were evaluated during the course of the study period. Perioperative outcomes including mortality, morbidity, and hospital length of stay (LOS) were compared. Multivariable regression models were used to identify predictors of perioperative mortality and morbidity.

RESULTS

Among 1048 elderly patients who underwent rAAA repair, 450 (43%) and 598 (57%) were treated with EVAR and OAR, respectively. The use of EVAR to treat rAAA had increased significantly in this population of patients (0% in 2005 vs 56% in 2014; P < .001). The overall 30-day mortality rate among octogenarians was 41%. The mortality rate was significantly higher among those treated with OAR compared with EVAR (47% vs 33%; P < .001). Pneumonia (21% vs 10%; P < .001), reintubation (14% vs 9%; P < .001), and >48-hour ventilator dependence (43% vs 21%; P < .001) were significantly higher in patients undergoing OAR. Hospital LOS (13 vs 10 days; P < .001) was also longer in the OAR cohort. Compared with EVAR, OAR was independently predictive of 30-day mortality (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.3-2.2; P < .001), pneumonia (AOR, 2.4; 95% CI, 1.7-3.6; P < .001), >48-hour ventilator dependence (AOR, 2.5; 95% CI, 1.8-3.3; P < .001), and longer LOS (adjusted mean ratio, 1.4; 95% CI, 1.2-1.6; P < .001).

CONCLUSIONS

Elderly patients have significant but acceptable perioperative mortality and morbidity after rAAA repair. Use of endovascular repair in the elderly population has increased and is associated with better perioperative survival and 30-day outcomes compared with traditional open repair in this study.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Abdominal aortic aneurysm repair in octogenarians is associated with higher mortality compared with nonoctogenarians

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.

Vascular interventions in the elderly

Overused?

Clinical outcome of early relaparotomy after elective open repair of abdominal aortic aneurysms

Purpose

The aim of this study was to retrospectively evaluate the association of need for early relaparotomy with clinical outcomes after elective open repair of abdominal aortic aneurysms (AAAs).

Methods

A total of 292 consecutive patients who underwent elective open AAA repair at Asan Medical Center from January 2001 to December 2010 were included in this study, and we compared the demographics, clinical characteristics, related risk factors, and clinical outcomes of early relaparotomy versus nonrelaparotomy patients.

Results

The incidence of early relaparotomy during a single hospital stay was 4.1% (n = 12), and the most common causes were bowel ischemia (n = 5, 41.7%) and postoperative bleeding (n = 3, 25.0%). Among the demographics and clinical characteristics significantly associated with relaparotomy were: age (P = 0.025), chronic obstructive pulmonary disease (COPD) (P = 0.010), number of RBC units transfused during the AAA repair (P = 0.022) and in the following week (P = 0.005), and length of intensive care (P < 0.001) and overall hospital stay (P < 0.001). On multivariate analysis, presence of COPD (P = 0.009) and number of RBC units transfused during the AAA repair (P = 0.006) were statistically significantly associated with relaparotomy. Furthermore, early relaparotomy was associated with perioperative (within 30 days) (P = 0.048) and overall in-hospital mortality (P = 0.001).

Conclusion

Early relaparotomy has an adverse effect on clinical outcomes: increased mortality and hospital length of stay. Presence of COPD and need for RBC transfusion are associated with early relaparotomy.

A new risk-scoring model for predicting 30-day mortality after repair of abdominal aortic aneurysms in the era of endovascular procedures

Purpose

To propose a new, multivariable risk-scoring model for predicting 30-day mortality in individuals underwent repair of abdominal aortic aneurysms (AAA).

Methods

Four hundred eighty-five consecutive patients who underwent AAA repair from January 2000 to December 2010 were included in the study. Univariate and multivariate analyses were performed to evaluate the risk factors, and a risk-scoring model was developed.

Results

Multivariate analysis identified three independent preoperative risk factors associated with mortality, and a risk-scoring model was created by assigning an equal value to each factor. The independent predictors were location of the AAA, rupture of AAA, and preoperative pulmonary dysfunction. The multivariable regression model demonstrated moderate discrimination (c statistic, 0.811) and calibration (Hosmer-Lemeshow test, P = 0.793). The observed mortality rate did not differ significantly from that predicted by our risk-scoring model.

Conclusion

Our risk-scoring model has excellent ability to predict 30-day mortality after AAA repair, and awaits validation in further studies.

Development of a scoring system to estimate mortality in abdominal aortic aneurysms management

INTRODUCTION

This study aimed to define risk factors associated with inpatient mortality in patients undergoing elective repair for unruptured abdominal aortic aneurysm and utilize these factors to create a scoring system to estimate risk of mortality.

METHODS

A retrospective analysis was completed using the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent elective abdominal aortic aneurysm repair were identified using ICD-9 codes. Demographics, comorbidities, length of stay, insurance status, and mortality were recorded. Statistically significant variables were identified using a multivariate analysis, and a discriminant analysis was used to identify factors predictive of inpatient mortality.

RESULTS

Over a 14-year period, 28,448 patients underwent elective repair of an unruptured abdominal aortic aneurysm. Independent variables associated with inpatient mortality included: age >60, female gender, congestive heart failure, peripheral artery disease, renal failure, malnutrition, and hypercoagulability. Endovascular aneurysm repair was protective against inpatient mortality. The area under the curve for the discriminant function was 0.83 (95% CI, 0.81-0.85) and successfully classified 87.9% of patients within the Nationwide Inpatient Sample (25,006/28,448 patients).

CONCLUSION

Seven factors that predict an increased risk of mortality and one factor that decreased the risk of mortality were identified. Preoperative risk factor mitigation may improve mortality following elective abdominal aortic aneurysm repair.

In meta-analyses of proportion studies, funnel plots were found to be an inaccurate method of assessing publication bias

OBJECTIVE

To assess the utility of funnel plots in assessing publication bias (PB) in meta-analyses of proportion studies.

STUDY DESIGN AND SETTING

Meta-analysis simulation study and meta-analysis of published literature reporting peri-operative mortality after abdominal aortic aneurysm (AAA) repair. Data for the simulation study were stochastically generated. A literature search of Medline and Embase was performed to identify studies for inclusion in the published literature meta-analyses.

RESULTS

The simulation study demonstrated that conventionally constructed funnel plots (log odds vs. 1/standard error [1/SE]) for extreme proportional outcomes were asymmetric despite no PB. Alternative funnel plots constructed using study size rather than 1/SE showed no asymmetry for extreme proportional outcomes. When used in meta-analyses of the mortality of AAA repair, these alternative funnel plots highlighted the possibility for conventional funnel plots to demonstrate asymmetry when there was no evidence of PB.

CONCLUSION

Conventional funnel plots used to assess for potential PB in meta-analyses are inaccurate for meta-analyses of proportion studies with low proportion outcomes. Funnel plots of study size against log odds may be a more accurate way of assessing for PB in these studies.

A limited and customized follow-up seems justified after endovascular abdominal aneurysm repair in octogenarians

OBJECTIVE

The objective of this study was to determine whether long-term follow-up after endovascular aneurysm repair (EVAR) is justified in octogenarians.

METHODS

Between September 1996 and October 2011, all patients, including octogenarians, treated for an abdominal aortic aneurysm (AAA) by EVAR were included in a prospective database. Patients older than 80 years and with a nonruptured infrarenal aneurysm treated electively or urgently were included in the study (study group [SG]). Patients with ruptured aneurysms and patients who died during surgery or within the first postoperative month were excluded from further analysis. The control group (CG) consisted of patients younger than 80 years, matched for gender and AAA diameter. All patients were evaluated 4 to 8 weeks after EVAR and then annually thereafter. Follow-up data were complemented by review of the computerized hospital registry and charts and by contact of the patient's general practitioner or referring hospital. Primary outcomes were stent- or aneurysm-related complications and interventions. Secondary outcomes were additional surgical complications and patient survival.

RESULTS

A total number of 193 patients (SG, n = 97; CG, n = 96) were included for analysis. Median age was 80 years, and 88.6% were male. Median follow-up time was 33.6 months (interquartile range [IQR], 12.9-68.3). Stent- and procedure-related postoperative complications were comparable between groups (SG, 41.2%; CG, 39.6%; P = .82). Median time to complication was 2.3 months (IQR, 0.2-19.4) in the SG compared with 18.1 months (IQR, 6.8-50.5) in the CG. The 2-year complication-free survival rates were 58% (SG) and 60% (CG). Interventions were performed significantly less frequently in octogenarians (SG, 8.2%; CG, 19.8%; P < .05). Median time to intervention was 11.1 months (IQR, 2.0-31.0) in the SG compared with 54.3 months (IQR, 15.0-93.2) in the CG. The 2-year intervention-free survival rates were 90% (SG) and 92% (CG). During follow-up, 98 patients died (SG, n = 54; CG, n = 44); median time to death was 31.8 months (IQR, 13.3-66.0) in the SG compared with 44.4 months (IQR, 15.0-77.7) in the CG. One aneurysm-related death occurred in the CG. The 2- and 5-year survival rates were 71% and 32% for the SG compared with 77% and 66% for the CG (P < .05).

CONCLUSIONS

Because of the low incidence of secondary procedures and AAA-related deaths in octogenarians, long-term and frequent follow-up after EVAR seems questionable. An adapted and shortened follow-up seems warranted in this patient group.

Measurement science in the circulatory system

The dynamics of the cellular and molecular constituents of the circulatory system are regulated by the biophysical properties of the heart, vasculature and blood cells and proteins. In this review, we discuss measurement techniques that have been developed to characterize the physical and mechanical parameters of the circulatory system across length scales ranging from the tissue scale (centimeter) to the molecular scale (nanometer) and time scales of years to milliseconds. We compare the utility of measurement techniques as a function of spatial resolution and penetration depth from both a diagnostic and research perspective. Together, this review provides an overview of the utility of measurement science techniques to study the spatial systems of the circulatory system in health and disease.

Elective treatment of abdominal aortic aneurysm is reasonable in patients >85 years of age

BACKGROUND

The numbers of patients >85 years of age referred for abdominal aortic aneurysm (AAA) repair have increased in recent decades. With the population aging, increased screening of AAA, and introduction of less invasive surgical techniques, vascular surgeons will be treating more elderly patients. Few data are available for estimating the risks and benefits of prophylactic repair among those with such an advanced age. The aim of this single-center study was to evaluate the short-term to midterm results after AAA repair in patients >85 years of age.

METHODS

Between 2004 and 2012, data of patients >85 years old who required an elective AAA repair at our institution were collected prospectively. According to the current guidelines, patients underwent endovascular aneurysm repair (EVAR) each time the aortic anatomy was suitable. Open repair (OR) was performed in those patients with hostile proximal neck anatomy and/or severe iliac tortuosity. Type of repair (EVAR or OR) and perioperative and midterm outcomes were analyzed. Primary end points were 30-day mortality and midterm survival.

RESULTS

Among 1016 patients undergoing elective AAA repair during the study period, 59 (5.8%) were ≥85 years of age (54 men, mean age 87 ± 2 years), with a mean aneurysm diameter of 61.5 ± 20.3 mm. Thirty-three patients (56%) underwent EVAR and 26 (44%) had an OR. Thirty-day mortality was 6.7% (6% with EVAR and 7.6% with OR, P <0.05). Mean follow-up was 24.7 ± 18 months. Kaplan‒Meier analyses for survival were 85.5%, 64.5%, and 50% at 1, 3, and 5 years, respectively. No aneurysm-related death was observed during follow-up.

CONCLUSION

Elective repair may be proposed in patients >85 years of age in cases of threatening AAA, showing acceptable perioperative mortality and reasonable midterm survival results. Even if EVAR did not seem to offer significant benefits in perioperative mortality in our study, it appears reasonable to suggest this less invasive technique as first-line treatment in cases of suitable anatomy in such an advanced-age population.

Evaluation of four risk-scoring methods to predict long-term outcomes in patients undergoing aorto-bifemoral bypass for aorto-iliac occlusive disease

This study was done to determine the usefulness of the American Society of Anesthesiologists (ASA) classification, the comorbidity Charlson index unadjusted (CCIu),the comorbidity Charlson index adjusted by age (CCIa), and the Glasgow aneurysm score (GAS) for postoperative morbimortality and survival in patients treated with aorto-bifemoral bypass (AFB) for aorto-iliac occlusive disease (AIOD). A series of 278 patients who underwent AFB were restrospectively studied. For the CCIu, CCIa, ASA, and GAS, receiver operating characteristics curve analysis for prediction of morbidity showed area under the curves of 0.61 (p = 0.004), 0.59 (p = 0.026), 0.569 (p = 0.087), and 0.63 (p = 0.001), respectively. Additionally, univariate analysis showed that CCIa (p = 0.016) and GAS (p = 0.006) were associated significantly with an increased risk of developing complications. Furthermore, CCIa (p < 0.001) and GAS (p = 0.001) showed a significant association with survival. Finally, the variable age was related to morbidity (p = 0.004), mortality (p = 0.038), and survival (p < 0.001). The comorbididity and the age should be taken in account in clinical treatment decisions for patients with AIOD. The CCIa and GAS may play a role as predictive factors for postoperative morbidity and survival after AFB.

Identifying patients with AAA with the highest risk following endovascular repair

INTRODUCTION

It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair.

METHODS

We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression.

RESULTS

A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups.

CONCLUSIONS

Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.

Provider volume and long-term outcome after elective abdominal aortic aneurysm repair

Background

Robust risk-adjusted analyses have demonstrated that a reduction in perioperative mortality is associated with the repair of an abdominal aortic aneurysm (AAA) in centres with a high operative caseload (volume). However, the long-term impact of this volume-related effect on mortality remains unknown.

Methods

Demographic and clinical data were extracted from UK Hospital Episodes Statistics for patients undergoing elective repair of an infrarenal AAA from 1 April 2000 to 31 March 2005. The long-term mortality of this cohort was investigated through linkage to the UK Office for National Statistics (ONS) registry. Risk-adjusted survival was analysed using Cox proportional hazards modelling to identify the effect of hospital volume on long-term mortality.

Results

A total of 14 396 patients with mean age of 72 years, of whom 85·7 per cent were men, underwent elective repair of an infrarenal AAA in England. They were linked to follow-up using ONS data. Risk-adjusted analysis of all-cause mortality by Cox proportional hazards modelling demonstrated a significant effect of hospital volume across all quintiles up to 2 years (P = 0·013). Remodelling the data after excluding in-hospital mortality still demonstrated the significant effect of hospital volume on late outcome.

Conclusion

There is a long-term benefit to patients who undergo elective AAA repair in a high-volume hospital.