Effectiveness of treatment for octogenarians with acute abdominal aortic aneurysm

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.

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.