Operative treatment of abdominal aortic aneurysms in octogenarians. When is it too much too late?

Elective endovascular vs. open repair for abdominal aortic aneurysm in octogenarians

PURPOSE

The purpose of this study was to investigate the operative mortality and short-term and midterm outcomes of treatment of abdominal aortic aneurysm in Japanese patients over 80 years of age.

METHODS

Between January 2007 and December 2011, 207 patients underwent elective repair of infrarenal abdominal aortic aneurysms. Comorbidities, operative morbidity and mortality, midterm outcomes were analyzed retrospectively.

RESULTS

The average age (endovascular aneurysm repair, 84.4 ± 0.3; open, 82.8 ± 0.3, P < 0.01) and the percentage of hostile abdomen (endovascular aneurysm repair, 22.2%; open repair, 11.1%, P < 0.05) were higher in the endovascular aneurysm repair group. Percentage of outside IFU was higher in open repair (endovascular aneurysm repair, 38.5%; open repair, 63.3%, P < 0.01). The cardiac complication (endovascular aneurysm repair, 0%; open repair, 5.6%, P < 0.01) and length of postoperative hospital stay (endovascular aneurysm repair, 10.3 ± 0.8 days; open, 18.6 ± 1.6 days, P < 0.05) were significantly lower in the endovascular aneurysm repair group. There were no differences in operative mortality (endovascular aneurysm repair, 0%; open, 1.1%, P = 0.43) and the aneurysm-related death was not observed. The rate of secondary interventions (EVAR, 5.1%; open repair, 0%, P < 0.01) and midterm mortality rate were much higher in the endovascular aneurysm repair group.

CONCLUSIONS

Endovascular aneurysm repair is less invasive than open repair and useful for treating abdominal aortic aneurysm in octogenarians; however, open repair can be acceptable treatment in the inappropriate case treated by endovascular aneurysm repair.

Laparoscopic abdominal aortic aneurysm repair in octogenarians

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois?

PURPOSE

This study was performed using population-based data to determine the changing trends in the techniques for abdominal aortic aneurysm (AAA) repair in the state of Illinois during the past 9 years and to examine the extent to which endovascular aneurysm repair (EVAR) has influenced overall AAA management.

METHODS

All records of patients who underwent AAA repair (1995 to 2003 inclusive) were retrieved from the Illinois Hospital Association COMPdata database. The outcome as determined by in-hospital mortality was analyzed according to intervention type (open vs EVAR) and indication (elective repair vs ruptured AAA). Data were stratified by age, gender, and hospital type (university vs community setting) and then analyzed using both univariate (chi 2 , t tests) and multivariate (stepwise logistic regression) techniques.

RESULTS

Between 1995 and 2003, 14,517 patients underwent AAA repair (85% for elective and 15% for ruptured AAA). The average age was 71.4 +/- 7.9 years, and 76% were men. For elective cases, open repair was performed in 86% and EVAR in 14%; and for ruptured cases, open repair in 97% and EVAR in 3%. Elective EVAR was associated with lower in-hospital mortality compared with open repair regardless of age. No differences were observed with age after either type of repair for a ruptured aneurysm. Men had a lower in-hospital mortality compared with women for open repair of both elective and ruptured aneurysms. For EVAR, the mortality of an elective repair was lower in men, but there was no difference after a ruptured AAA. In men, the difference in mortality between elective open repair and EVAR was significant; the type of institution did not influence outcome. Patients >80 years of age had a higher mortality after open repair for both elective and ruptured AAA and after EVAR of a ruptured AAA. The average length of stay was 9.9 days for open elective repair, 13.1 days after open repair of a ruptured AAA, and 3.6 days for EVAR. The independent predictors of higher in-hospital mortality were female gender, age >80 years, diagnosis (ruptured vs open), and procedure (open vs EVAR). The year of the procedure and type of hospital (university vs community) were not predictive of outcome.

CONCLUSIONS

EVAR has had a significant impact on AAA management in Illinois over a relatively short time period. In this population-based review, EVAR was associated with a significantly decreased in-hospital mortality and length of stay. Octogenarians had higher mortality after both types of repair, with the exception of elective EVAR.

Endovascular Abdominal Aortic Aneurysm Repair in the Octogenarian

The aim of this study was to analyze patient outcomes following endovascular repair of infrarenal abdominal aortic aneurysms (EAR) among patients 80 years of age or older. In this study, reporting standards of the Ad Hoc Committee for Standardized Reporting Practices for Endovascular Aortic Aneurysm Repair of the Society of Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) were followed. Between August 8, 1996 and February 12, 2001 EAR was performed in 31 patients (29 male and 2 female) with an average age of 83 +/- 3 years and an average maximum aneurysm diameter of 59 +/- 7 mm. Overall technical success was 90% (28/31) with a single acute conversion and a 6% (2/32) incidence of major morbidity. There were no in-hospital deaths, but two patients (6%) died within 30 days of intervention. Four endoleaks, two type I and two type II, were observed within the first 30 days after endograft implantation and three new type II endoleaks were noted after implant periods that exceeded 1 month. Average follow-up was 16 months, with a single aneurysm-related death that occurred after late conversion to open repair, 2 years following initial endovascular treatment. Kaplan-Meier analysis revealed 3-, 12-, and 24-month estimated survivals of 93% (+/-5), 75% (+/-8), and 68% (+/-10), respectively. Clinical success rates were 90% (+/-5), 90% (+/-5), and 72% (+/-17) at 12, 24, and 36 months, respectively. We conclude that, in the octogenarian with mild to moderate medical comorbidities, endovascular aneurysm repair provides an alternative to open AAA repair with low operative morbidity and good clinical success rates. Elevated SVS/AAVS medical comorbidity scores were not associated with increased operative mortality rates, but they did show a trend toward decreased mid-term survival. Careful consideration of life expectancy and the probability of rupture, as with traditional AAA repair, should dictate necessity for intervention.

A cost analysis of surgery for ruptured abdominal aortic aneurysm

OBJECTIVE

This study compares our costs of salvaging patients with ruptured abdominal aortic aneurysms (AAA) with the costs for unruptured AAAs.

METHODS

Details of all AAAs presenting over 18 months were obtained. Costs of repair were carefully calculated for each case and were based upon ITU and ward stay and the use of theatre, radiology and pathology services. We compared the costs in unruptured AAAs with both uncomplicated ruptures and ruptures with one or more system failure.

RESULTS

The mortality rate for ruptures undergoing repair was 18% and for elective repairs was 1.6%. The median cost for uncomplicated ruptures was 6427 Pounds (range 2012-13,756 Pounds). For 12 complicated ruptures, it was 20,075 Pounds (range 13,864-166,446 Pounds), and for 63 unruptured AAAs, was 4762 Pounds (range 2925-47,499 Pounds).

CONCLUSION

Relatively low operative mortality rates for ruptured AAA repair can be achieved but this comes at substantial cost. On average, a ruptured AAA requiring system support costs four times as much as an elective repair.

Results of urgent and emergency thoracic procedures treated by endoluminal repair

INTRODUCTION

emergency surgery on the thoracic aorta is associated with a high mortality. Endovascular treatment for these patients may offer a realistic alternative to open surgery.

METHOD

between 1997 and 2002 data was collected prospectively on all patients who underwent urgent or emergency endoluminal repair for thoracic aortic pathology. All patients had ruptured or were at risk of rupture, and had been assessed as high risk for open surgery.

RESULTS

twenty-four patients required urgent/emergency stent grafts. The median age was 74 (range 17-90). Indications included: trauma (transection in 3 and traumatic dissection in 1), acute symptomatic type B dissection (4), symptomatic degenerative aneurysms (7), false aneurysms associated with infection (6), Takayasu's vasculitis causing rupture of the descending thoracic aorta (1), symptomatic aneurysm associated with chronic dissection (1) and a secondary aorto-oesophageal fistula (1). The 30-day survival was 83.3% (20/24) and the survival at 1 year was 70.8% (17/24). The median follow-up was 13.5 months (range 2-57). The complications included: transient paraplegia (1), non-disabling stroke (1), distal endoleak treated with an extension cuff (1) and a proximal endoleak (1) which required removal of the graft at open surgery.

CONCLUSION

endoluminal repair of thoracic aortic disease requiring urgent/emergency treatment has encouraging results with low morbidity and mortality rates compared with open surgery. Long-term follow-up is required to assess the durability of the grafts.

Endovascular stent grafting versus open surgical operation in patients with infrarenal aortic aneurysms: a propensity score-adjusted analysis

BACKGROUND

Although transfemoral endovascular aneurysm management (TEAM) of infrarenal abdominal aortic aneurysms (AAA) is widely performed, open graft replacement is still considered the standard of care. The aim of this study was to investigate whether clear indications for TEAM can be established in patients with significant comorbidities without investigating differences in relative procedure efficacy or durability.

METHODS AND RESULTS

A propensity score-based analysis of 454 consecutive patients treated electively for AAA from January 1995 through December 2000 was performed. Of those 454 patients, 248 received open surgery and 206 received TEAM. In-hospital mortality rates (MRs) were compared. After adjusting for propensity scores, a Cox proportional hazard model (COX) was employed to test the influence of the respective treatment on postoperative 900-day survival estimates (SEs). Several potential preoperative risk factors were used as covariates. The MR of all patients was 3.7%. Explorative analysis demonstrated that patients treated by TEAM presented with significantly more risk factors. In American Society of Anesthesiologists class IV patients, a significant difference in MR was detected (4.7% for TEAM versus 19.2% for open surgery; P<0.02). After adjusting for the propensity to receive TEAM or open surgery, a regression analysis of survival based on COX revealed predictive influences of impaired kidney (P<0.047) or pulmonary function (P<0.001), increased age (P<0.05), and selection of treatment modality (P<0.002) on SE.

CONCLUSIONS

TEAM represents a less invasive procedure for AAA therapy in patients with significant preoperative risk factors. Especially in geriatric patients with multiple morbidities, TEAM offers a method of therapy with acceptable MRs and SEs, making active treatment possible in otherwise incurable patients.

Endoluminal graft repair for abdominal aortic aneurysms in high-risk patients and octogenarians: is it better than open repair?

OBJECTIVE

To analyze the short-term and midterm results of open and endoluminal repair of abdominal aortic aneurysms (AAA) in a large single-center series and specifically in octogenarians.

METHODS

Between January 1997 and October 2000, 470 consecutive patients underwent elective repair of AAA. Conventional open repair (COR) was performed in 210 patients and endoluminal graft (ELG) repair in 260 patients. Ninety of the patients were 80 years of age or older; of these, 38 underwent COR and 52 ELG repair.

RESULTS

Patient characteristics and risk factors were similar for both the entire series and the subgroup of patients 80 years or older. The overall complication rate was reduced by 70% or more in the ELG versus the COR groups. The postoperative death rate was similar for the COR and ELG groups in the entire series and lower (but not significantly) in the ELG 80 years or older subgroup versus the COR group. The 36-month rates of freedom from endoleaks, surgical conversion, and secondary intervention were 81%, 98.2%, and 88%, respectively.

CONCLUSION

The short-term and midterm results of AAA repair by COR or ELG are similar. The death rate associated with this new technique is low and comparable, whereas the complication rate associated with COR in all patients and those 80 years or older in particular is greater and more serious than ELG repair. Long-term results will establish the role of ELG repair of AAA, especially in elderly and high-risk patients.

Impact of endovascular repair for abdominal aortic aneurysms in octogenarians

A total of 50 consecutive patients (86% male; median age, 82 years) underwent endovascular repair of abdominal aortic aneurysms (AAAs) ranging from 4.0 to 9.0 cm (median, 5.2 cm). Efficacy of aneurysm exclusion was assessed by angiography, duplex scan, and/or contrast-enhanced computed tomography (CT). Acute technical success was 82%. Access failed in one patient, and immediate conversion to open operation was required in two patients. Improper deployment of the endoluminal graft (ELG) across the renal arteries occurred in one patient. The median operation time, estimated blood loss, packed red blood cells received, contrast volume, and length of intensive care and hospital stay were 128 min, 200 mL, 0.1 unit, 297 mL, 0.9 days, and 3 days, respectively. ELG limb thrombosis was seen in one patient. There were 4 (8%) early endoleaks, and 2 endoleaks were discovered in other patients at 3 and 6 months. Local/vascular and remote/systemic postoperative complications were seen in 13 (26%) and 9 (18%) patients, respectively. At a median follow-up of 11 months (range 2 to 36 months), clinical success was 78%. The aneurysm sac diameter (n = 49) decreased from a preoperative median of 5.2 to 4.7 cm (p = 0.0001). Technical success was high, and results at 11 months were satisfactory. Long-term outcomes require further study.

The cost-effectiveness of repairing ruptured abdominal aortic aneurysms

BACKGROUND

Although advances in technology have reduced the operative risk of elective abdominal aortic aneurysm (AAA) repair, the surgical repair of ruptured AAAs is associated with a much poorer prognosis and a higher cost. Accordingly, it has been suggested that patients with predictably high rates of morbidity and mortality from ruptured AAA may not benefit from surgical intervention.

METHODS AND RESULTS

A cost-effectiveness analysis was performed with the use of a Markov decision-analytic model to compute long-term survival in quality-adjusted life years and lifetime costs for a hypothetical cohort of patients with ruptured AAAs managed with either a strategy of open surgical repair or no intervention. Probability estimates for the various outcomes were based on a review of the literature. Average costs of (1) the immediate hospitalization ($28,356) and (2) complications resulting from the procedure were based on the average use of resources as reported in the literature and from a hospital's cost accounting system. Our measure of outcome was the incremental cost-effectiveness ratio. For our base-case analysis, the repair of ruptured AAAs was cost-effective with an incremental cost-effectiveness ratio of $10,754. (Society is usually willing to pay for interventions with cost-effectiveness ratios of less than $60,000; for example, the costeffectiveness ratios for coronary artery bypass grafting and dialysis are $9500 and $54,400, respectively.) In sensitivity analyses, the cost-effectiveness of repairing ruptured AAAs was influenced only by alterations in the operative mortality. If the operative mortality exceeded 88%, repair of ruptured AAAs was no longer cost-effective. As an independent variable, increasing age had no substantial impact on the cost-effectiveness, although it is reported to be associated with increased operative mortality. It was necessary that the patient's cost of the initial hospitalization for ruptured AAA exceed $195,000 before repairing ruptured AAAs was no longer cost-effective.

CONCLUSIONS

Our analysis suggests that despite the high cost and poor outcomes, the surgical repair of ruptured AAAs is still cost-effective when compared with no intervention. The cost of repairing ruptured AAAs falls within society's acceptable limits and therefore should not be a consideration in the management of patients with AAAs.

The cost of elective and emergency repair of AAA in patients under and over the age of 80

BACKGROUND

As Australia's population ages, the number of elderly patients presenting for surgery of abdominal aortic aneurysms (AAA), both elective and ruptured, will increase. The aim of the present study was to compare the costs of treatment of patients with AAA, under and over the age of 80, in the elective and emergency settings in a hospital with a divisional structure in which the true costs can be accurately obtained.

METHODS

A total of 40 patients were selected at random from a series of 267 patients treated with open surgery for AAA between January 1987 and December 1994, 10 in each of four groups: group A, elective repair in patients aged < 80 (171/267); group B, elective AAA repair in patients aged > 80 (25/267); group C, emergency AAA repair in patients aged < 80 (50/267); and group D, emergency AAA repair in patients aged > 80 (11/267). A retrospective analysis of the hospital costs of treatment of these patients at St George Hospital was conducted. These true costs were then compared to Australian National Diagnostic Related Group (AN-DRG) costs.

RESULTS

Group A and B had no mortality. In Group C and D the mortality was 20 and 60%, respectively. The emergency treatment groups also had longer lengths of stay. A statistically significant difference in cost of AAA repair between elective and emergency groups in both age groups was seen; that is, group A cost less than group C and group B cost less than group D. Costs per survivor, however, showed a dramatic difference between the cost of group C patients ($30000) and group D patients ($60000). In comparison with AN-DRG calculated costs, the true costs of groups A and B were equivalent to AN-DRG costs. In the emergency groups, however, there were marked discrepancies between the true cost ($61000) and that calculated by the DRG ($25000) in group D, with similar differences seen in group C to a lesser extent.

CONCLUSION

Emergency repair of AAA is significantly more expensive and has a high mortality in the over-80 age group. Also, there is a substantial shortfall between the true costs of treating these patients and the funds allocated for treatment in this group.

Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians

OBJECTIVE

The purpose of this study was to demonstrate early and long-term results of surgery for thoracic aortic aneurysm in patients over 70 years of age compared with those of patients under 70 years and to clarify the clinical problems peculiar to this subset of patients.

PATIENTS AND METHODS

Of 1157 patients who underwent surgery for thoracic aortic aneurysm from 1978 to December 1997, 261 who were 70 years or older were selected for analysis. Mean age at the time of surgery was 74.4 +/- 3.5 years. Aneurysms were atherosclerotic in 177 patients and aortic dissection in 84. Acute aortic dissection was found in 25 patients and ruptured aneurysm in 44. The control group consisted of 896 patients under 70 years. Preoperative complications such as AAA, peripheral arterial disease, emphysema, and old cerebral infraction were more common in the older group. Operative procedures consisted of replacement of the ascending aorta or hemiarch in 51 patients, total arch replacement in 75, distal arch replacement in 35, descending aorta replacement in 75, replacement of the thoracoabdominal aorta in 28, and extra-anatomical repair and others in 15. The technique of extracorporeal circulation was selective cerebral perfusion in 69 patients, deep hypothermic circulatory arrest in 90, femoro-femoral bypass in 39, left heart bypass in 12, and temporary aorto-arterial bypass in 30, and others in 21.

RESULT

Early mortality was 21% (54 patients), which was greater than that of the control group (113 patients, 13%, P < 0.01). The incidence of postoperative stroke, transient brain dysfunction, and respiratory problems was higher in the study group (P < 0.01 in all). Mean duration in ICU among survivors was 9.3 +/- 20.2 days and that of the control group was 5.9 +/- 2.8 days (P < 0.01). In a recent series (from 1991 to 1997) postoperative mortality improved to 15.6% (30/192 patients) in the study group however this result was still inferior to that of the control group (8.6%, 39/452, P = 0.03) however mortality of emergency surgery during the same periods was still high (31%, 11/35 patients). Logistic regression analysis revealed that significant risk factors for postoperative hospital death were surgery before 1991, age over 70 years, preoperative cardiac problems, aneurysm rupture, postoperative stroke, low output syndrome, bleeding, and acute renal failure. Postoperative follow-up was obtained in 408 patients/year and the longest period was 10.2 years. Late deaths were documented in 31 patients. Five-year and 10-year survival were 61.2 +/- 5.7% and 31.3 +/- 16.4%, respectively. In the control group the 5-year and 10-year survival were 78.0 +/- 2.1% and 62.5 +/- 4.0%, respectively (P = 0.03). However, survival of the early survivors in the study group was similar with that of the age-matched normal population. Aortic reoperation was performed in 13 patients. Freedom from aortic reoperation was 86.7 +/- 4.2% at 5 years and 80.5 +/- 7.1% at 10 years in the study group and 83.4 +/- 1.8% at 5 years and 64.1 +/- 13.3% at 10 years in the control group (P = 0.27).

CONCLUSION

Although recent advances have been achieved, early and long-term results of surgery for thoracic aortic aneurysm in patients older than 70 years were less satisfactory compared with those of patients under 70 years of age, especially in patients who required emergency surgery. Preoperative disorder of the vital organ systems was considered to be the main causative factor for high mortality, however, pertinent surgical strategies are necessary to improve the outcome of elderly patients.

High prevalence of abdominal aortic aneurysm in a primary care screening programme

BACKGROUND

The mortality rate associated with ruptured abdominal aortic aneurysm (AAA) remains high. The objective of this study was to assess the feasibility of population screening for AAA.

METHODS

In an area with a mixed rural and industrialized population of 60000 inhabitants, all 23 general practitioners (GPs) participated. The GPs selected from their patient lists men aged 60-80 years. Men whose condition was suitable for aortic surgery were invited for screening by a single postal letter. All men responding had aortic ultrasonography in or close to the GP surgery. Diagnosis of AAA was established when the aortic diameter was 30 mm or greater. Referral for surgery was advised for an aortic diameter of 50 mm or greater.

RESULTS

Of 2914 invitations, 2419 men had ultrasonography, resulting in an attendance rate of 83.0 per cent. A total of 2416 aortic measurements were made; 196 aortic aneurysms were diagnosed (prevalence 8.1 per cent). In 40 men the aortic diameter was over 50 mm.

CONCLUSION

Ultrasonographic screening for AAA is feasible in a primary care setting.

Ruptured aortic aneurysm: the decision not to operate

Despite published criteria predicting poor survival after operation for ruptured abdominal aortic aneurysm (RAAA), little is known about the factors which influence surgeons not to operate. Questionnaires were sent to all 404 members of the Vascular Surgical Society of Great Britain and Ireland, posing questions about their practices, and factors influencing the decision not to operate (no influence; may influence; seldom operate; never operate). There were 323 responses (81%) and 97% decided not to operate on selected patients. Age over 80 years influenced 77%, and 54% seldom or never operate over age 85 years. The single most influential factor was severe neurological disease (75% seldom or never operate), while cardiac, pulmonary and renal disease influenced 22%, 28%, and 21%, respectively, to operate seldom or never (74% if two or more of these). Other factors which had some influence for most surgeons were cardiac arrest (85%), loss of consciousness (74%), prolonged hypotension (73%), and long-term nursing care (87%). By contrast, factors which influenced few surgeons were haemoglobin < 9 g/dl (30%), absence of a close relative (33%), and medicolegal considerations (22%). These data help to inform the debate about case selection for repair of RAAA.

Outcomes after abdominal aortic aneurysm repair in those > or =80 years of age: recent Veterans Affairs experience

During fiscal years 91-95, 6260 patients underwent 6269 abdominal aortic aneurysm (AAA) repairs in Veterans Affairs Medical Centers. Those > or =80 years old comprised 3.7% (n = 231) of the patients. A total of 5833 patients underwent repair of nonruptured AAA: mortality was 4.1% (228/5627) in those <80 and 8.25% (17/206) in those > or =80 years old (p < 0.009). Logistic regression analysis indicated age > or =80 was independently associated with higher mortality (odds ratio 1.834:1, 95% bounds 1.117-3.012). Octogenarian status (defined as > or =80 years of age), however, had a less important association with in-hospital death than did surgical complications of the heart or genitourinary tract, postoperative hemorrhage, septicemia, respiratory insufficiency, myocardial infarction (MI), acute renal failure, surgical complications of the central nervous system (CNS), aneurysm rupture, postoperative shock, or disseminated intravascular coagulation (DIC), in ascending order of importance. Only 5.9% (n = 25) of the 427 patients undergoing repair of ruptured AAA were > or =80 years old. In those > or =80 undergoing repair of ruptured aneurysms, mortality was 48% which did not differ from the 45% mortality in those <80 (NS). The likelihood that one would be operated for rupture was statistically greater (1.66:1) for those > or =80 years (p < 0.025). Length of stay (LOS) for those > or =80 undergoing AAA repair was longer being 22.3 +/- 14.8 days versus 18.3 +/- 13.2 days for younger patients (p < 0.001). Mortality and LOS after AAA repair were statistically greater for those > or =80 years of age. Severity of illness, however, was also greater for octogenarians. Patient Management Category (PMC) software defined illness severity was 4.06 +/- 1.22 in octogenarians versus 3.84 +/- 1.13 for those younger (p < 0.005). Though age > or =80 was independently associated with increased mortality, selected elderly patients could benefit from AAA repair.

Ruptured abdominal aortic aneurysm--can treatment costs and outcomes be predicted by using clinical or physiological parameters?

Mortality rates for patients undergoing surgery for ruptured abdominal aortic aneurysm (RAAA) remain high. The high cost of providing care for these patients mandates that proposed treatment protocols be evaluated for their cost-effectiveness. This study assessed costs related to outcome in different groups of patients with RAAA. From July 1987 to December 1993, 140 patients underwent emergency surgery for RAAA. Complete data on preoperative haemodynamic status, blood transfusion requirements, intensive care unit (ICU) stay and other hospital costs was available for 94 patients. Seventy-seven males (mean age 71.6(6)) and 17 females (mean age 77.2(6)) underwent surgery. Known risk factors including age (< or > 70 years), shock on admission (systolic blood pressure (BP) < or > 90 mm Hg), sex, and acute renal failure were analysed. For the purpose of comparison, costs (Pounds) were assessed by the ESRI (Economic and Social Research Institute of Ireland) based on 1992 prices. The overall survival rate was 48%: 53% among males and 24% among females (p < 0.05, Chi-squared test). In addition to having a significantly worse outcome than males, female patients with RAAA also had longer hospital and ICU stays and this was reflected in significantly greater expenditure. Similarly, male patients > 70 years old presenting with haemodynamic instability had significantly longer hospital and ICU stays than younger male patients. The average cost per RAAA survival (12,945 Pounds) in this series is not prohibitive, and the greater cost in high risk groups should not discourage intervention.

Endovascular AAA treatment: expensive prestige or economic alternative?

OBJECTIVES

To compare the costs of endovascular aneurysm treatment versus open surgery during the perioperative period.

METHODS

Retrospective analysis of a consecutive series of 44 patients undergoing infrarenal abdominal aneurysm repair from February 1995 to March 1996 at a university teaching hospital.

RESULTS

No endovascular procedure was converted to open repair. Operative time was shorter for endovascular treatment (207.6 min vs. 229.1 min, n.s.), as well as postoperative intensive care unit stay (ICU, 22.7 h vs. 55.0 h, p = 0.017) and the postoperative recovery period (5.6 days vs. 13.3 days, p < 0.001). Open surgery generated significantly more costs (25,374.07 ECU vs. 22,268.78 ECU, p < 0.001), despite evaluation and a more expensive endovascular procedure (10,699.48 ECU vs. 4032.01 ECU, p < 0.001). During the study, costs for open surgery exceeded the cost for endovascular treatment by 13.95%.

CONCLUSIONS

Endovascular aneurysm treatment is cost effective and less expensive than open surgery. The main reason for cost saving is faster patient recovery after surgery, associated with a shorter LOS in the patients treated with endovascular procedure.

Treatment of abdominal aortic aneurysm disease in the 9th and 10th decades of life

BACKGROUND

The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah.

METHODS

Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentation/no surgery; II, elective presentation/elective surgical repair; III, emergency presentation/surgical repair; and IV, emergency presentation/conservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death.

RESULTS

The mean age of the total group (n = 85) of patients was 84 years (range: 80-94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2-6 cm). The diameters for group I (n = 40), II (n = 22), III (n = 16) and IV (n = 7) were 4.9 cm (4.4-5.5, 95% CI), 5.7 (4.9-6.5 CI), 7.0 (6.1-7.7 CI) and 6.2 (5.2-7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P = 0.015), and group IV had a shorter survival than the total group (P = 0.001). However, the length of survival was no different for III versus IV (P = 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2), malignancy (I); III: rupture (10), malignancy (I); and (IV): rupture (6), malignancy (1).

CONCLUSIONS

Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.

Surgical treatment of abdominal aortic aneurysms of octogenarians

The purpose of this study was to determine whether elective abdominal aortic aneurysmectomy in octogenarians is justified or may even be advisable. Between January 1986 and August 1993, 30 octogenarians of mean age 83.1 (range 80-93) years underwent abdominal aortic aneurysmectomy. Patients were divided into two groups: group 1 (n = 9) underwent elective surgical repair; group 2 (n = 21) underwent emergency procedure. In 28 patients location of the abdominal aortic aneurysm was infrarenal; two patients presented with a juxtarenal aneurysm. The average aneurysm diameter was similar in both groups (group 1, 68.8 mm; group 2, 83.5 mm, P = n.s.). In group 2, two patients had free peritoneal rupture, one presented with rupture into the duodenum and one with penetration into the vena cava. Rupture was confined to the retroperitoneum in another 15 patients. Two patients had an expanding aneurysm. Hospital mortality rate was zero in group 1 and 42.8% in group 2 (P = 0.011). Most early deaths were related to cardiac disease. The overall complication rate was 22% in group 1 and 62% in group 2. Mean intensive care unit time was 1.8 (range 1-3) days in group 1 and 3.6 (range 1-8) days in group 2 (P = 0.47). The 5-year survival rate was 67% in the electively managed group and 34% in the emergency group.

Surgical treatment of abdominal aortic aneurysms in octogenarians

Due to the increase in life span and the decrease in mortality associated with aortic surgery, many geriatric patients now undergo surgery for abdominal aortic aneurysms (AAAs). Therefore, we studied our surgical results for AAAs in an elderly population to assess the value of such operations. Twenty-six patients aged 80 years or older underwent surgery during an 11-year period from 1984 to 1994 at our institutions, and their outcomes were compared with those of 212 younger patients. The ratio of ruptured to non-ruptured AAAs was significantly higher in the older patients (aged 80 years or older) than in the younger patients (aged 79 years or younger), and aneurysm size in cases of non-rupture was greater in older patients than in younger patients. For octogenarians with non-ruptured AAAs, the survival rate was 85.7% at 5 years, compared with 43.6% at 3 years for those with ruptured AAAs, and these figures were not significantly different from those in younger patients. The present findings support the value of our active surgical approach for octogenarians with AAAs. We believe that an aggressive approach for octogenarians will decrease the incidence of ruptured AAAs and contribute to better patient survival.

Ruptured abdominal aortic aneurysms: who should be offered surgery?

PURPOSE

Operation for ruptured abdominal aortic aneurysm is generally still associated with a high mortality rate. A review of our experience over a 9-year period was undertaken to identify factors present on admission associated with 30-day operative mortality.

METHODS

A retrospective analysis of 154 patients with ruptured abdominal aortic aneurysm submitted for operation in a university teaching hospital between January 1985 and December 1993 was undertaken.

RESULTS

The hospital mortality rate was 39%. Logistic regression identified a set of five independent preoperative factors associated with mortality: age (> 76 years), creatinine level (> 0.19 mmol/L), loss of consciousness after arrival, Hb (< 9 g%), and electrocardiographic ischemia. In the 52 patients with a single risk factor present, the mortality rate was 37%, with two factors (32 patients) it was 72%, with three or more factors (8 patients), it was 100%, and no patient had all five risk factors. A 16% mortality rate was found in the 62 patients with no risk factors.

CONCLUSION

These risk factors can be easily determined on admission and may be used to help improve patient selection for surgical intervention. The current operative mortality rate for ruptured abdominal aortic aneurysm remains high, and in some cases health care resources are used in a nonproductive fashion. Restricted patient selection and allocation of scarce resources will bring advantages to both the patient and the community.

Ten-year experience with abdominal aortic aneurysm repair in octogenarians: early results and late outcome

PURPOSE

This study was undertaken to determine the mortality and morbidity rates associated with abdominal aortic aneurysm (AAA) repair in octogenarians and to identify factors that may influence survival in this age group.

METHODS

One hundred fourteen patients (mean age 83 years) were admitted consecutively with 106 infrarenal and eight juxtarenal AAAs from 1984 through 1993. Ninety-four AAAs were asymptomatic, whereas 20 patients with symptoms had 11 intact and nine ruptured AAAs. The mean AAA diameter was 6.7 cm. Repair consisted of aortic bifurcation grafts in 77 patients (67%), tube grafts in 35 (31%), and extraanatomic procedures in 2 (2%). A total of 29 patients (25%) had undergone previous coronary artery bypass (24 patients) or transluminal coronary angioplasty (five patients) either incidentally or as a preliminary procedure before resection of their AAAs.

RESULTS

The 30-day mortality rate for the entire series was 14%, but it declined from 23% (11/48) during the first 5 years to 8% (5/66) during the second 5 years of the study period (p = 0.028). Fatal complications occurred in nine (9.6%) of the 94 patients with asymptomatic AAAs and in seven (35%) of the 20 patients who had symptomatic AAAs (p = 0.008). Considering only patients with asymptomatic AAAs, the early mortality rate in the second 5 years (4%) improved significantly (p = 0.038) in comparison to that (17%) for the first 5 years of the study period. The cumulative 5-year survival rate of 48% for 97 available operative survivors was not quite so good as that (59%) for the normal male population of the United States at the age of 80 years (p < 0.0001). Nevertheless, the 5-year survival rate was 80% for 27 operative survivors who received previous myocardial revascularization compared with 38% for 70 others who did not (p = 0.0077). Multiple Cox-regression analysis identified the perioperative homologous blood requirement (p = 0.03) and a history of previous myocardial revascularization (p = 0.03) as significant independent factors influencing late survival.

CONCLUSIONS

Repair of AAAs in properly selected octogenarians is safe and durable. When otherwise indicated, it should not be withheld on the basis of advanced age alone. Prior treatment of severe coronary artery disease is associated with enhanced late survival, but patient selection probably is an important consideration in this respect.