EVAR Conversion is an Increasingly Common Indication for Open AAA Repair

Impact of frailty on adverse outcomes in patients with abdominal aortic aneurysm undergoing surgery: a systematic review and meta-analysis

OBJECTIVE

To explore the prognostic role of frailty in patients with abdominal aortic aneurysm (AAA) by conducting this systematic review and meta-analysis METHODS: We conducted an extensive literature search on PubMed, Web of Sciences, and Embase databases to identify studies that reported the association of frailty with postoperative complications, reintervention, or all-cause mortality in patients with AAA after surgery. Short-term mortality was defined by a combination of in-hospital and 30-day death.

RESULTS

Seven cohort studies reporting on 9 articles with 323,788 AAA patients were included. The reported prevalence of frailty in AAA patients ranged between 2.3% and 34.6%. Pooling the results revealed that frailty was significantly associated with a higher risk of short-term all-cause mortality (adjusted risk ratios [RR] 3.20; 95% confidence intervals [CI] 1.95-5.26), long-term all-cause mortality (adjusted RR 2.86; 95% CI 2.57-3.17), and postoperative complications (adjusted RR 2.19; 95% CI 1.50-3.20) compared to non-frail individuals. However, there was no clear association between frailty and reintervention (HR 1.44; 95% CI 0.97-2.16).

CONCLUSIONS

Frailty independently predicts the short and long-term survival as well as postoperative complications in patients with AAA undergoing surgery. Assessing frail status may potentially enhance surgical decision-making for these patients.

Ultrasound elastography to quantify average percent pressure-normalized strain reduction associated with different aortic endografts in 3D-printed hydrogel phantoms

Objective

Strain has become a viable index for evaluating abdominal aortic aneurysm stability after endovascular aneurysm repair (EVAR). In addition, literature has shown that healthy aortic tissue requires a degree of strain to maintain homeostasis. This has led to the hypothesis that too much strain reduction conferred by a high degree of graft oversizing is detrimental to the aneurysm neck in the seal zone of abdominal aortic aneurysms after EVAR. We investigated this in a laboratory experiment by examining the effects that graft oversizing has on the pressure-normalized strain (ε ρ + ¯ /pulse pressure [PP]) reduction using four different infrarenal EVAR endografts and our ultrasound elastography technique. Approximate graft oversizing percentages were 20% (30 mm phantom-graft combinations), 30% (28 mm phantom-graft combinations), and 50% (24 mm phantom-graft combinations).

Methods

Axisymmetric, 10% by mass polyvinyl alcohol phantoms were connected to a flow simulator. Ultrasound elastography was performed before and after implantation with the four different endografts: (1) 36 mm polyester/stainless steel, (2) 36 mm polyester/electropolished nitinol, (3) 35 mm polytetrafluoroethylene (PTFE)/nitinol, and (4) 36 mm nitinol/polyester/platinum-iridium. Five ultrasound cine loops were taken of each phantom-graft combination. They were analyzed over two different cardiac cycles (end-diastole to end-diastole), yielding a total of 10 maximum mean principal strain (ε ρ + ¯ ) values.ε ρ + ¯ was divided by pulse pressure to yield pressure-normalized strain (ε ρ + ¯ /PP). An analysis of variance was performed for graft comparisons. We calculated the average percentε ρ + ¯ /PP reduction by manufacturer and percent oversizing. These values were used for linear regression analysis.

Results

Results from one-way analysis of variance showed a significant difference inε ρ + ¯ /PP between the empty phantom condition and all oversizing conditions for all graft manufacturers (F(3, 56) = 106.7 [graft A], 132.7 [graft B], 106.5 [graft C], 105.7 [graft D], P < .0001 for grafts A-D). There was a significant difference when comparing the 50% condition with the 30% and 20% conditions across all manufacturers by post hoc analysis (P < .0001). No significant difference was found when comparing the 20% and 30% oversizing conditions for any of the manufacturers or when comparingε ρ + ¯ /PP values across the manufacturers according to percent oversize. Linear regression demonstrated a significant positive correlation between the percent graft oversize and the all-graft average percentε ρ + ¯ /PP reduction (R 2  = 0.84, P < .0001).

Conclusions

This brief report suggests that a 10% increase in graft oversizing leads to an approximate 5.9% reduction inε ρ + ¯ /PP on average. Applied clinically, this increase may result in increased stiffness in axisymmetric vessels after EVAR. Further research is needed to determine if this is clinically significant.

Systematic Review and Meta-Analysis of Elective Open Conversion versus Fenestrated and Branched Endovascular Repair for Previous Non-Infected Failed Endovascular Aneurysm Repair

OBJECTIVE

To evaluate outcomes of patients electively undergoing fenestrated and branched endovascular repair (F/B-EVAR) or open conversion for failed previous non-infected endovascular aneurysm repair (EVAR).

DATA SOURCES

Embase, MEDLINE, Cochrane Library.

REVIEW METHOD

The protocol was prospectively registered on PROSPERO (CRD42023404091). The review followed the PRISMA guidelines; certainty was assessed through the GRADE and quality through MINORS tools. Outcomes data were pooled separately for F/B-EVAR and open conversion. A random effects meta-analysis of proportions was conducted; heterogeneity was assessed with the I2 statistic.

RESULTS

Thirty eight studies were included, for a total of 1 645 patients of whom 1 001 (60.9%) underwent an open conversion and 644 (39.1%) a F/B-EVAR. The quality of evidence was generally limited. GRADE certainty was judged low for 30 day death (in both groups) and F/B-EVAR technical success, and very low for the other outcomes. Pooled 30 day death was 2.3% (I2 33%) in the open conversion group and 2.4% (I2 0%) in the F/B-EVAR conversion group (p = .36). Technical success for F/B-EVAR was 94.1% (I2 23%). The pooled 30 day major systemic complications rate was higher in the open conversion (21.3%; I2 74%) than in the F/B-EVAR (15.7%; I2 78%) group (p = .52). At 18 months follow up, the pooled re-intervention rate was 4.5% (I2 58%) in the open conversion and 26% (I2 0%) in the F/B-EVAR group (p < .001), and overall survival was 92.5% (I2 59%) and 81.6% (I2 68%), respectively (p = .005).

CONCLUSION

In the elective setting, and excluding infections, the early results of both open conversion and F/B-EVAR after failed EVAR appear satisfactory. Although open conversion presented with higher complication rates in the first 30 days after surgery, at follow up it seemed to be associated with fewer re-interventions and better survival compared with F/B-EVAR.

Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair

PURPOSE

The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC.

METHODS

This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes.

RESULTS

Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU.

CONCLUSIONS

In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

Comparative outcomes of physician-modified fenestrated/branched endovascular aortic aneurysm repair in the setting of prior failed endovascular aneurysm repair

OBJECTIVE

Endovascular treatment of aortic aneurysms involving renal-mesenteric arteries, especially in the setting of prior failed endovascular aneurysm repair (EVAR) typically requires fenestrated/branched endovascular aneurysm repair (F/BEVAR) with a custom-made device (CMD). CMDs are limited to select centers, and physician-modified endografts are an alternative treatment platform. Currently, there is no data on the outcomes of physician-modified F/BEVAR (PM-F/BEVAR) in the setting of failed prior EVAR. The purpose of this study was to evaluate the use of PM-F/BEVAR in patients with prior failed EVAR.

METHODS

A prospective database of consecutive patients treated at a single center with PM-F/BEVAR between March 2021 and November 2022 was retrospectively reviewed. The cohort was stratified by presence of a failed EVAR (type Ia endoleak or aneurysm development proximal to a prior EVAR) prior to PM-F/BEVAR. Demographics, operative details, and postoperative complications were compared between the groups using univariate analysis. One-year survival and freedom from reintervention were compared using the Kaplan-Meier method.

RESULTS

A total of 103 patients underwent PM-F/BEVAR during the study period; 27 (26%) were in the setting of prior EVAR. Patients with prior failed EVAR had similar age (75.2 ± 7.7 vs 71.5 ± 8.8 years; P = .058), male gender (n = 24 ; 89% vs n = 57 ; 75%; P = .130), and comorbid conditions except higher incidence of moderate-to-severe chronic obstructive pulmonary disease (n = 7 ; 26% vs n = 7 ; 9%; P = .047). Overall, aneurysm diameter was 65.5 ± 13.9 mm with aneurysms categorized as juxta-/pararenal in 43% and thoracoabdominal in 57%, with no differences between the groups. Twelve patients (14%) presented with symptomatic/ruptured aneurysms. The average number of target arteries incorporated per patient was 3.8. Four different aortic devices were modified with a greater proportion of Terumo TREO devices used in the failed EVAR group (P = .03). There was no difference in procedure time, radiation dose, or iodinated contrast use between groups. Overall technical success was 99%. Rates of 30-day mortality (n = 0 ; 0% vs n = 3 ; 4%; P = .565) and major adverse events (n = 6 ; 22% vs n = 16 ; 21%; P = 1.0) were similar between groups. For the overall cohort, rates of type 1 or 3 endoleak, branch vessel stenosis/occlusion, and reintervention were 2%, 1%, and 8%, respectively, with no difference between groups. One-year survival (failed EVAR 94% vs no EVAR 82%; P = .756) was similar between groups.

CONCLUSIONS

PM-F/BEVAR is a safe and effective treatment for patients with aneurysms involving the renal-mesenteric arteries in the setting of prior failed EVAR where additional technical challenges may be present. Additional follow-up is warranted to demonstrate long-term efficacy, but early results are encouraging and similar to those using CMDs.

Editor's Choice - The VASCUNExplanT Project: An International Study Assessing Open Surgical Conversion of Failed Non-Infected Endovascular Aortic Aneurysm Repair

OBJECTIVE

The need for open surgical conversion (OSC) after failed endovascular aortic aneurysm repair (EVAR) persists, despite expanding endovascular options for secondary intervention. The VASCUNExplanT project collected international data to identify risk factors for failed EVAR, as well as OSC outcomes. This retrospective cross sectional study analysed data after OSC for failed EVAR from the VASCUNET international collaboration.

METHODS

VASCUNET queried registries from its 28 member countries, and 17 collaborated with data from patients who underwent OSC (2005 - 2020). Any OSC for infection was excluded. Data included demographics, EVAR, and OSC procedural details, as well as post-operative mortality and complication rates.

RESULTS

There were 348 OSC patients from 17 centres, of whom 33 (9.4%) were women. There were 130 (37.4%) devices originally deployed outside of instructions for use. The most common indication for OSC was endoleak (n = 143, 41.1%); ruptures accounted for 17.2% of cases. The median time from EVAR to OSC was 48.6 months [IQR 29.7, 71.6]; median abdominal aortic aneurysm diameter at OSC was 70.5 mm [IQR 61, 82]. A total of 160 (45.6%) patients underwent one or more re-interventions prior to OSC, while 63 patients (18.1%) underwent more than one re-intervention (range 1 - 5). Overall, the 30 day mortality rate post-OSC was 11.8% (n = 41), 11.1% for men and 18.2% for women (p = .23). The 30 day mortality rate was 6.1% for elective cases, and 28.3% for ruptures (p < .0001). The predicted 90 day survival for the entire cohort was 88.3% (95% CI 84.3 - 91.3). Multivariable analysis revealed rupture (OR 4.23; 95% CI 2.05 - 8.75; p < .0001) and total graft explantation (OR 2.10; 95% CI 1.02 - 4.34; p = .04) as the only statistically significant predictive factors for 30 day death.

CONCLUSION

This multicentre analysis of patients who underwent OSC shows that, despite varying case mix and operative techniques, OSC is feasible but associated with significant morbidity and mortality rates, particularly when performed for rupture.

[Late Open Semi-conversion with Endograft Preservation for (Type II) Endoleaks with Late Aneurysm Sac Enlargement after EVAR - Indications, Method and Results in Our Own Patient Collective]

EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2-12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69 mm (58-95 mm), the operating time was 114 min (97-147 min), the blood loss was 100 ml (100-1500 ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1-5) days, the hospitalisation time was 8 (6-11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.

Engineering In Situ Weldable Vascular Devices

(1) Background: The minimally invasive implantation of medical devices is largely limited by their insertion profile, and, therefore, minimizing them constitutes a leading trend in the field. (2) Methods: This study introduces the in situ welding strategy, whereby the components of the stent grafts used to treat abdominal aortic aneurysms were decoupled, deployed sequentially, and welded together at the aneurysmal site, greatly reducing their insertion profile. Polyurethane elastomers were used to produce the graft and to coat the metallic struts of the stent to render it in vivo weldable. Results: The composition of the polyurethanes was fine-tuned, so to minimize the insertion profiles and optimize the welding properties and the clinical performance of the devices assembled. The stent and graft were deployed successively in pigs via a small 8F introducer, in situ welded, and the patency of the bi-component device was confirmed over a three-month post-implantation period. The strength of the stent/graft welded connection was fully retained, with no de-welding observed. Conclusions: The in situ welding strategy resulted in implantations that were easier to perform and markedly less injurious to tissues and organs, largely expanding the applicability of these ultra-minimally invasive procedures to especially frail segments of the population.

Use of linked registry claims data for long term surveillance of devices after endovascular abdominal aortic aneurysm repair: observational surveillance study

OBJECTIVE

To evaluate long term outcomes (reintervention and late rupture of abdominal aortic aneurysm) of aortic endografts in real world practice using linked registry claims data.

DESIGN

Observational surveillance study.

SETTING

282 centers in the Vascular Quality Initiative Registry linked to United States Medicare claims (2003-18).

PARTICIPANTS

20 489 patients treated with four device types used for endovascular abdominal aortic aneurysm repair (EVAR): 40.6% (n=8310) received the Excluder (Gore), 32.2% (n=6606) the Endurant (Medtronic), 16.0% (n=3281) the Zenith (Cook Medical), and 11.2% (n=2292) the AFX (Endologix). Given modifications to AFX in late 2014, patients who received the AFX device were categorized into two groups: the early AFX group (n=942) and late AFX group (n=1350) and compared with patients who received the other devices, using propensity matched Cox models.

MAIN OUTCOME MEASURES

Reintervention and rupture of abdominal aortic aneurysm post-EVAR; all patients (100%) had complete follow-up via the registry or claims based outcome assessment, or both.

RESULTS

Median age was 76 years (interquartile range (IQR) 70-82 years), 80.0% (16 386/20 489) of patients were men, and median follow-up was 2.3 years (IQR 0.9-4.1 years). Crude five year reintervention rates were significantly higher for patients who received the early AFX device compared with the other devices: 14.9% (95% confidence interval 13.7% to 16.2%) for Excluder, 19.5% (18.1% to 21.1%) for Endurant, 16.7% (15.0% to 18.6%) for Zenith, and early 27.0% (23.7% to 30.6%) for the early AFX. The risk of reintervention for patients who received the early AFX device was higher compared with the other devices in propensity matched Cox models (hazard ratio 1.61, 95% confidence interval 1.29 to 2.02) and analyses using a surgeon level instrumental variable of >33% AFX grafts used in their practice (1.75, 1.19 to 2.59). The linked registry claims surveillance data identified the increased risk of reintervention with the early AFX device as early as mid-2013, well before the first regulatory warnings were issued in the US in 2017.

CONCLUSIONS

The linked registry claims surveillance data identified a device specific risk in long term reintervention after EVAR of abdominal aortic aneurysm. Device manufacturers and regulators can leverage linked data sources to actively monitor long term outcomes in real world practice after cardiovascular interventions.

Psoas Muscle Area as a Prognostic Factor for Survival in Patients Undergoing EVAR Conversion

OBJECTIVE

EVAR conversion(EVAR-c) is increasingly reported and known to be technically complex and physiologically demanding. It has been proposed that pragmatic anthropomorphic measures such as psoas muscle area(PMA) may reliably quantify levels of preoperative frailty and be used to inform point of care clinical decision making and patient discussions for a variety of complex operations. To date, there is mixed data supporting use of PMA as a prognostic factor in fenestrated endovascular and open AAA repairs; however, no literature exists evaluating the impact of preoperative PMA on EVAR-c results. Therefore, the purpose of this study was to review our EVAR-c experience and evaluate the association of PMA with perioperative and long-term mortality outcomes.

METHODS

A retrospective single-center review of all AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed(n=153). Cross-sectional PMA at the mid-body of the L3 vertebrae was measured. The lowest PMA tertile was used as a threshold value to designate patients as having "low" PMA(n=51) and this cohort was subsequently compared to subjects with "normal" PMA(n=102). Cox proportional hazards modeling was used to estimate covariate association with all-cause mortality.

RESULTS

Patients with low PMA were older(77 vs. 72 years;p=.002), more likely to be female(27% vs. 5%;p<.001), and had reduced BMI(26 vs. 29kg/m²;p=.002). Time to conversion, total number of EVAR reinterventions prior to conversion and elective EVAR-c presentation incidence were similar; however, patients with low PMA had larger aneurysms(8.3 vs. 7.5cm;p=.01) and increased post-EVAR sac growth(2.3 vs. 1cm;p=.005). Unadjusted inpatient mortality was significantly greater for low PMA patients(16% vs. normal PMA, 5%, p=.02). Similarly, the total number of complications was higher among low PMA subjects(1.5±1.9 vs. normal PMA, 0.9±1.5;p=.02). Although frequency of major adverse cardiovascular events and new onset inpatient hemodialysis were similar, low PMA patients had a more than four-fold increased likelihood of having persistent requirement of hemodialysis at discharge(18% vs. 4%,p=.01). The low PMA group had decreased survival at 1 and 5 years, respectively(77±5%, 65±6% vs. normal PMA, 86±3%, 82%±5%;log-rank p=.03). Low PMA was an independent predictor of mortality with every 100mm² increase in PMA being associated with a 15% reduction in mortality(HR 0.85,95% CI, .74-.97;p=.02).

CONCLUSION

Among EVAR-c patients, subjects with low preoperative PMA had higher rates of postoperative complications and worse overall survival. PMA assessments may be a useful adjunct to supplement traditional risk-stratification strategies when patients are being considered for EVAR-c.

Contemporary incidence, outcomes, and survival associated with endovascular aortic aneurysm repair conversion to open repair among Medicare beneficiaries

OBJECTIVE

The widespread application of endovascular abdominal aortic aneurysm repair (EVAR) has ushered in an era of requisite postoperative surveillance and the potential need for reintervention. The national prevalence and results of EVAR conversion to open repair, however, remain poorly defined. The purpose of this analysis was to define the incidence of open conversion and its associated outcomes.

METHODS

The SVS Vascular Quality Initiative EVAR registry linked to Medicare claims via Vascular Implants Surveillance and Interventional Outcomes Network was queried for open conversions after initial EVAR procedures from 2003 to 2016. Cumulative conversion incidence within up to 5 years after EVAR and outcomes after open intervention were determined. Multivariable logistic regressions were used to identify independent predictors of conversion and mortality.

RESULTS

Among 15,937 EVAR patients, 309 (1.9%) underwent an open conversion: 43% (n = 132) early (<30 days) and 57% (n = 177) late (>30 days). The longitudinally observed rate of conversion was constant over time, as well as by geographic region. Independent predictors of conversion included female sex (hazard ratio [HR], 1.49; P < .001), aneurysm diameter or more than 6.0 cm at the time of index EVAR (HR, 1.74; P < .001), nonelective repair (compared with elective presentation: HR, 1.72; P < .001), and aortouni-iliac repairs (HR, 2.19; P < .001). In contrast, adjunctive operative procedures such as endo-anchors or cuff extensions (HR, 0.62; P = .06) were protective against long-term conversion. Both early (HR, 1.6; P < .001) and late (HR, 1.26; P = .07) open conversions were associated with significant 30-day (total cohort, 15%) and 1-year mortality (total cohort, 25%). Patients undergoing open conversion experienced high rates of 30-day readmission (42%) and cardiac (45%), renal (32%), and pulmonary (30%) complications.

CONCLUSIONS

This large, registry-based analysis is among the first to document the incidence and outcomes for open conversion after EVAR in a national cohort with long-term follow-up. Importantly, women, patients with large aneurysms, and complex anatomy, as well as urgent or emergent EVARs are at an increased risk for open conversion. It seems that more conversions are performed in the early postoperative period, despite perceptions that conversion is a delayed phenomenon. In all instances, conversion is associated with significant morbidity and mortality and highlights the importance of appropriate patient selection at the time of index EVAR.

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.