- Email: [email protected]
Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians
From the Canadian Society for Vascular Surgery
Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians Oonagh Scallan, MD,a Teresa Novick, RN,a Adam H. Power, MD, MPhil,a Guy DeRose, MD,a Audra Duncan, MD,a and Luc Dubois, MD, MSc,a,b London, Ontario, Canada
ABSTRACT Objective: Patients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up. Methods: Retrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics. Results: The study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P ¼ .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P ¼ .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P ¼ .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P ¼ .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P ¼ .05) were higher in the endovascular treatment group. Conclusions: EVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients. (J Vasc Surg 2019;-:1-7.) Keywords: Abdominal aortic aneurysm; AAA; EVAR; Octogenarian
Abdominal aortic aneurysm (AAA) is an age-related disease and the tenth leading cause of death in men older than 55 years in the United States.1 First reported in 1991, endovascular aneurysm repair (EVAR) has the benefits of lower perioperative mortality and morbidity rates and shorter hospital stay compared with open repair.2-4 In a large population-based study by Schermerhorn et al,5 EVAR was shown to have a survival benefit over open repair in the perioperative period, with the survival benefit lasting up to 3 years.
From the Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre,a and the Department of Epidemiology and Biostatistics,b Western University. Author conflict of interest: none. Presented at the Fortieth Annual Meeting of the Canadian Society for Vascular Surgery, Montreal, Quebec, Canada, September 28-29, 2018. Correspondence: Luc Dubois, MD, MSc, Assistant Professor, Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, LHSC-Victoria Campus, 800 Commissioners Rd E, London, ON N6A 5W9, Canada (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.06.207
Survival into the ninth decade of life is now common in all industrialized countries.6 In Ontario, the percentage of the population older than 80 years is expected to increase from 4.2% in 2015 to 9.4% by the year 2041.7 Even without AAA, risk of death from any cause is substantial in this age group, and age is a well-known independent risk factor for death after AAA repair.8 Open repair is often not considered in octogenarians because of their advanced age as a risk factor or their comorbidities.9 After elective AAA repair, older patients have significantly higher risk compared with younger patients, especially in the postoperative period, even when matched for comorbidities.10 The risk vs benefit of elective AAA repair in the elderly continues to be a topic of debate. Prospective data are lacking on the subject of octogenarians and AAA repair as patients older than 80 years are often excluded from or poorly represented in randomized trials. A systematic review of the literature identified 39 articles concerning perioperative and late survival after AAA repair in octogenarians.11 The median 5-year survival rate from this review was 60%, although this was based on only 19 of the 39 articles because of lack of reported data. Hicks et al8 demonstrated worse outcomes for EVAR among octogenarians, even after propensity score matching on baseline, perioperative, and technical variables. A steep decline in survival was 1
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noted within the first 3 months of repair, suggesting that the difference in mortality occurs early in the postoperative course.10 A better understanding of long-term outcomes of open vs endovascular AAA repair in patients older than 80 years would help provide insight into selection and management of these patients. The purpose of this study was to review our center’s data on the outcomes of AAA repair in octogenarians with at least 5 years of follow-up.
ARTICLE HIGHLIGHTS d
d
METHODS d
A retrospective review of a prospectively collected database at our university-affiliated medical center was performed to identify all patients aged 80 years or older who underwent open repair or EVAR between 2007 and 2012. Incomplete data were obtained through chart review. All reinterventions related to the initial AAA repair were reviewed, including all aortic and access-related procedures, laparotomies for bowel obstructions and incisional hernia repairs, and femoral-femoral crossover complications (infection, thrombosis). Superficial wound infections were not included. Exclusion criteria included mycotic aneurysms, aneurysms associated with aortic dissection, and fenestrated endografts. These patients received endovascular or open repair in a nonrandomized fashion at the discretion of the attending surgeon after consideration of such issues as aneurysm anatomy and the patient’s comorbidities and preference. Open repair was performed with a midline incision and transperitoneal approach with an infrarenal clamp and a straight or bifurcated graft, depending on the extent of the aneurysm, and a woven tube or bifurcated graft for any coexisting aortoiliac occlusive disease. EVAR was performed with one of the following stent grafts by bilateral groin cutdowns: Talent (Medtronic, Minneapolis, Minn), Endurant (Medtronic), or Zenith (Cook Medical, Bloomington, Ind). Statistical analysis was performed with SPSS Statistics version 20.0 (IBM, Armonk, NY). Comparison of categorical variables was done by the c2 test and Fisher exact test, whereas continuous variables were analyzed by nonpaired t-tests. Long-term survival and freedom from reintervention were determined by life-table analysis and Kaplan-Meier curves and log-rank tests. Results are reported as medians with interquartile ranges (IQRs), and the level of statistical significance was set at P < .05. Given the retrospective nature of the study, individual patient consent for study inclusion was not obtained or required. This study received approval from the University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects.
RESULTS There were 314 consecutive patients aged 80 years or older who underwent AAA repair between January 2007 and December 2012 and were included in this
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Type of Research: Single-center retrospective cohort study Key Findings: In 314 patients aged 80 years or older who underwent endovascular aneurysm repair (EVAR) or open abdominal aortic aneurysm repair with at least 5 years of follow-up, median survival was similar in both groups (about 6 years), but there were more late reinterventions after EVAR (18%). Take Home Message: With a median survival of almost 6 years and an 18% reintervention rate, diligent long-term follow-up is crucial after EVAR even in the elderly.
study cohort. Of these 314 patients, 96 patients underwent open repair (31%) and 218 received EVAR (69%). In the EVAR group, 211 (97%) patients were elective cases, whereas seven (3%) patients were treated when they were ruptured. In the open repair group, 63 (66%) patients were treated electively and 33 (34%) were ruptured. Median age was 83 years (IQR, 5 years), with a range of 80 to 96 years; 72% of the open repair group were male compared with 83% in the EVAR group (P < .05). Median aneurysm size at the time of repair was 65 mm in the open repair group (IQR, 23 mm) and 60 mm in the EVAR group (IQR, 8 mm). The two treatment groups were otherwise similar with respect to baseline comorbidities and had similar rates of hypertension, active smoking, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease (Table I). In the patients who underwent EVAR, 76% of the patients received a bifurcated device and 24% were treated with aortouni-iliac endografts. Endografts used included 100 Cook Zenith (46%), 111 Medtronic Endurant (50%), 7 Medtronic Talent (3%), and 1 Vascutek (Inchinnan, Scotland, UK) Anaconda (0.5%). In the patients who underwent elective repair, there were nine deaths (14%) in the first 30 days in the open repair group and three (1%) in the EVAR group (P < .001; Table II). The causes of death in the open repair group were myocardial infarction in six patients, ischemic bowel in two patients, and pneumonia in one patient. Of these nine patients, four required a suprarenal clamp and five were infrarenal. Mean blood returned through cell salvage was 370 mL 6 150 mL, and mean operative duration was 200 6 85 minutes. The deaths in the EVAR group were due to renal failure, stroke, and pneumonia (Table III). Length of stay was significantly shorter after EVAR (median, 3 days; IQR, 2 days) than after open repair (median, 9 days; IQR, 12.5 days). Twelve (19%) patients who underwent open repair required reintervention within the first 30 days.
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Table I. Patient demographics and endovascular aneurysm repair (EVAR) details Open (n ¼ 96), No. (%) Mean age, years
EVAR (n ¼ 218), P value No. (%)
83.2
83.8
.08
Male
69 (72)
180 (83)
.03
Hypertension
66 (69)
178 (82)
.29
Dyslipidemia
53 (55)
139 (64)
.82
Smoker
18 (19)
28 (13)
.06
Diabetes mellitus
13 (14)
28 (13)
.57
40 (42)
99 (45)
.87
Congestive heart failure
5 (5)
15 (7)
.76
Carotid artery stenosis
2 (2)
10 (5)
.37
Chronic renal disease
4 (4)
13 (6)
.65
Coronary artery disease
Dialysis
0 (0)
2 (1)
.37
COPD
23 (24)
47 (22)
.30
7 (7)
15 (7)
.67
15 (16)
29 (13)
.38
5 (5)
19 (9)
.42
34 (35)
92 (42)
.77
7 (7)
6 (3)
.06
Peripheral vascular disease Anticoagulation Clopidogrel (Plavix) Aspirin Previous AAA repair Configuration for EVAR Bifurcated
166 (76)
Aortouni-iliac
53 (24)
Stent graft type Cook Zenith
100 (46)
Medtronic Endurant
111 (50)
Medtronic Talent
7 (3)
Vascutek Anaconda
1 (0.5)
Elective surgery Ruptured Mean AAA size, cm
623 (66)
213 (97)
33 (34)
7 (3)
<.001 <.001
71
62.4
<5.5
2 (2)
9 (4)
5.5-6
28 (29)
123 (56)
6.1-7
19 (20)
53 (24)
7.1-8
11 (12)
18 (8)
8.1-9
11 (12)
10 (5)
>9
10 (10)
3 (1)
Unknown
15 (16)
2 (1)
AAA, Abdominal aortic aneurysm; COPD, chronic obstructive pulmonary disease.
Reinterventions included 5 repairs of wound dehiscence, 3 cases of bowel ischemia, 2 cases of limb ischemia, 1 bleeding episode, and 1 sponge removal. Two (1%) patients in the EVAR group required reintervention in the
Table II. Thirty-day results for elective repair Open (n ¼ 63), No. (%)
EVAR (n ¼ 211), P No. (%) value
In-hospital mortality rate
9 (14)
3 (1)
<.001
In-hospital reintervention rate
12 (19)
2 (1)
<.001
16
4
<.001
Average length of stay, days
EVAR, Endovascular aneurysm repair.
first 30 days, one for a type IA endoleak and one for limb ischemia. The difference in the early reintervention rates between the two groups was significant (P < .001), with higher rates of early reintervention in the open repair group. Median survival and mean survival were the same for both the elective EVAR and open repair groups at 69 and 70 months, respectively. Fig 1 demonstrates a Kaplan-Meier survival analysis showing that the survival rate at 1 year was significantly higher for the elective EVAR group at 93% compared with 84% in the elective open group (P ¼ .02). There was no significant difference in survival at 5 years between elective EVAR and open repair, 57% compared with 59%. The most common causes of long-term mortality were malignant disease and cardiovascular events. There were no aneurysmrelated deaths in the open repair group. In the EVAR group, there were three aneurysm-related deaths. One patient suffered ischemic colitis after undergoing graft explantation, and two patients died of ruptured aneurysms despite previous EVAR (Table IV). Fig 2 is a Kaplan-Meier curve for the long-term reintervention rate in elective repair; this was 18% in the EVAR group compared with 4% in the open repair group (P ¼ .05). The interventions in the open repair group were related to an incisional hernia repair and one ruptured iliac artery aneurysm. In the EVAR group, all reinterventions were related to the initial aneurysm repair (Table V). Three patients underwent interventions for ischemia due to thrombosis of a limb of the endograft including one femoral-femoral bypass, one thrombectomy and iliofemoral bypass, and one thrombectomy and stenting of the iliac limb. Two patients required repair of an anastomotic aneurysm; 27 patients had reinterventions for endoleaks. Six patients underwent open explantation, five for a type IA endoleak and one for ongoing sac expansion due to type II endoleak. One patient who underwent open explantation died postoperatively of bowel ischemia. There were no other reintervention-related deaths. Ten patients had embolization for type II endoleaks. Five patients required relining because of a type IA endoleak (2), type IB endoleak (2), or type III endoleak (1). Three patients had an aortic cuff inserted and one patient had a Palmaz stent
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Table III. Thirty-day causes of death and reinterventions Open Cause of death
Table IV. Causes of long-term mortality
EVAR
6 myocardial infarction
1 renal failure
2 ischemic bowel 1 pneumonia
Open
53 unknown
1 stroke
6 cancer
17 cancer
1 pneumonia
4 myocardial infarction
15 myocardial infarction
2 respiratory failure
14 respiratory failure
2 stroke
7 stroke
1 gastrointestinal bleeding
6 renal failure
1 sepsis
1 bleeding
5 gastrointestinal bleeding
1 sponge removal
3 AAA related
5 wound dehiscence 1 type IA endoleak 3 bowel ischemia
1 limb ischemia
2 limb ischemia
EVAR, Endovascular aneurysm repair.
Cause of death
EVAR
13 unknown
Reintervention details
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2 ruptured AAA 1 ischemic colitis 2 congestive heart failure 2 multiorgan failure 1 dehydration AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair.
Fig 1. Kaplan-Meier survival curve for elective abdominal aortic aneurysm (AAA) repair, endovascular aneurysm repair (EVAR) vs open.
inserted for a type IA endoleak. In accounting for perioperative mortality associated with aneurysm reinterventions, this would increase the perioperative mortality rate to 2% from 1% in elective EVAR. Compared with 14% in the open repair group, this difference still remains significant (P < .001). Two patients died within a year of reintervention, one at 5 months of metastatic colon cancer and another at 11 months of stroke. In 30 patients, 35 procedures were performed as reinterventions, with one death; the mortality rate from elective EVAR reinterventions was 3%, also significantly lower than with open repair. In patients aged 85 years or older, there was no significant difference in outcomes when they were treated with open repair or EVAR in the setting of elective AAA repair. Mean survival for patients older than 85 years was 56.6 months in open repair and 63.4 months in
Fig 2. Freedom from reintervention for elective endovascular aneurysm repair (EVAR) group vs elective open repair group.
EVAR. In patients aged 80 to 85 years, there was also no difference in survival, with mean survival of 73.8 months in open repair and 73.4 months in EVAR. In patients who underwent repair of a ruptured aneurysm, there were 27 (82%) deaths in the open repair group and four deaths in the EVAR group (P ¼ .16; Table VI). Two (6%) patients in the open repair group required reintervention for abdominal compartment syndrome and limb thrombosis and two patients (29%) in the EVAR group required reintervention for abdominal compartment syndrome and a type IA endoleak requiring subsequent open repair.
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Table V. Causes of long-term reinterventions Open
EVAR
1 hernia repair
10 embolization
1 ruptured iliac artery aneurysm
6 open explantation 5 relining 3 aortic cuff insertion 2 iliac extension 2 repair anastomotic aneurysm 1 femoral-femoral bypass 1 thrombectomy and iliac stent 1 thrombectomy and iliofemoral bypass 1 Palmaz stent
EVAR, Endovascular aneurysm repair.
Table VI. Thirty-day results for ruptured aneurysms Open (n ¼ 33), EVAR (n ¼ 7), No. (%) No. (%)
P value
In-hospital mortality rate
27 (82)
4 (57)
.156
In-hospital reintervention rate
2 (6)
3 (43)
.01
21
26
.62
Average length of stay, days
EVAR, Endovascular aneurysm repair.
DISCUSSION This retrospective single-center study demonstrates that patients 80 years of age or older have similar longterm outcomes when undergoing elective open or endovascular AAA repair. There is a survival benefit at 1 year with elective EVAR compared with elective open repair, but there is no survival advantage beyond 1 year. With long-term data and follow-up to 5 years, outcomes were found to be similar between the two groups. Median survival was 5.75 years, which would support offering surgical repair to selected octogenarians; they should not be excluded from open or endovascular repair on the basis of age alone. The open repair group had a significantly higher proportion of ruptured aneurysms compared with the EVAR group, 34% vs 3%. Given this discrepancy, elective repair and ruptured AAA repair were analyzed separately. These data support the results of previous studies including a systematic review by Henebiens et al10 from 2008, which reported a median long-term survival rate of 60% in octogenarians undergoing open or endovascular AAA repair. This was based on 19 small, retrospective reviews and required further validation. Few studies of octogenarians undergoing AAA repair have outcomes out to 5 years, and ours was composed of patients with at least 5 years of follow-up or more.
The underlying cause of poorer outcomes in AAA repair in patients older than 80 years is unknown but is thought to be related to greater comorbidity burden.10 Elderly patients often also have more difficult anatomy to treat, with tortuous vessels and a high degree of atherosclerotic occlusive disease. Cardiac events were the predominant cause of 30-day mortality in the open repair group. Four of the nine patients who died postoperatively required suprarenal clamping, which may have contributed to the higher rate of myocardial ischemia and death. This highlights the importance of perioperative medical optimization and patient selection. The equivalence in long-term outcomes of elective open AAA repair or EVAR may also be associated with high case volumes in our center and experience in good decision-making when selecting patients for open or endovascular repair. The American College of Cardiology/American Heart Association guidelines recommend preoperative electrocardiography for all patients, and patients should be carefully selected for further evaluation with dipyridamole-thallium imaging or dipyridamole stress echocardiography on the basis of their functional capacity.11 The use of intraoperative transesophageal echocardiography may help guide fluid resuscitation efforts and identify patients with impaired left ventricular function who may require adjunctive supports, such as inotropy or close monitoring in an intensive care unit setting. In patients without risk factors or procedural risks for hemodynamic, neurologic, or pulmonary compromise, the routine intraoperative use of transesophageal echocardiography to screen cardiac abnormalities or to monitor myocardial ischemia is not recommended.12 However, vascular surgery patients often have multiple cardiac risk factors, and there are additional procedural risks with aortic cross-clamping; therefore, further research is required to evaluate the use of transesophageal echocardiography in open AAA surgery. The longterm mortality of the patients in this study was driven by their underlying comorbidities, not aortic events. With an 18% reintervention rate during 5 years after EVAR and a median survival of 69 months, this underscores the importance of long-term follow-up in these patients. This rate of reintervention is significantly higher than the results from the EVAR 1 and EVAR 2 trials, in which the secondary intervention rates were 7% to 9.4% for the Zenith and Talent grafts. In a 5-year followup study of the Zenith stent graft repair, the cumulative risk of conversion, limb occlusion, migration, or component separation was <3% at 5 years, and the cumulative risk of late endoleak was 12% to 15%, which accounted for most of the secondary interventions. Of the 32 reinterventions in this study population, 27 (84%) were for endoleak. Of those, 11 (41%) were for type II endoleak; the remainder were type IA, type IB, or type III. A laparotomy for graft explantation was required for 19% of the reinterventions. Anatomic data and instructions for use
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violations were not available in this study, but the fact that octogenarians live on average >5 years after EVAR and the relatively high reintervention rate reported here should act as a caution against using standard EVAR in octogenarians with nonideal anatomy as instructions for use violations have been shown to increase the risk of graft-related complications after EVAR.13 Reinterventions in the elective EVAR group did not significantly change the overall mortality of these patients when they were included in perioperative mortality (2% vs 1%), and it still remains significantly lower than perioperative mortality from open repair (14%). The mortality remains low despite a high proportion of the procedures being graft explantation. The decision to proceed with operative repair of an AAA typically occurs when the risk of rupture outweighs the risk of repair. The median aneurysm sizes in this study were 65 mm in the open repair group and 60 mm in the EVAR group, which is significantly larger than the typical size threshold for repair of 55 mm. This could be due to delayed diagnosis, given that aneurysm screening is not currently recommended in patients older than 75 years, or that because of their age, their quoted operative risk was higher and therefore the decision to proceed with surgery was delayed until the aneurysm reached a larger size. Previous risk scores, such as the Glasgow Aneurysm Score, Hardman index, and Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity, incorporate age into the risk calculation but are based on data from the general population, not specifically the elderly. A recent study14 reviewed Vascular Quality Initiative data from 2003 to 2016 and found the 5-year survival for patients older than 75 years undergoing elective EVAR to be excellent at 77%. A risk score was developed from these data to identify patients suitable for AAA screening and to assess expected postoperative 5-year survival. A risk score dedicated to the elderly would be useful to guide selection of patients for optimal operative intervention in regard to timing of surgery and method of repair, endovascular or open. The mortality rate of ruptured AAA repair in this population was very high in this study, with a 30-day mortality rate of 82% in open repair and 57% in EVAR, although the difference was not statistically significant. Although the data are based on a small number of patients, the high mortality rate in open repair highlights the importance of selection of patients for type of repair and for informing patients of their prognosis. Although it should not of itself preclude octogenarians from undergoing open repair of a ruptured AAA, age is an important factor in the decision-making. Our study has limitations inherent to a nonrandomized, single-center, retrospective analysis. In the open repair group, 11 patients in total were lost to follow-up, and 7 patients were lost to follow-up in the EVAR group before 1 year of follow-up. During long-term follow-up, the cause
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of death was unknown in 13 patients from the open repair group and 53 patients from the EVAR group. The reintervention rate for patients in the open repair group may be underestimated as patients may have had a nonvascular surgical procedure, such as a hernia repair, done at a peripheral center.
CONCLUSIONS This study shows that octogenarians who undergo elective EVAR or open repair have similar survival at 5 years. With a median survival of almost 6 years and an 18% reintervention rate after EVAR, diligent long-term follow-up is crucial after EVAR even in the elderly.
AUTHOR CONTRIBUTIONS Conception and design: OS, LD Analysis and interpretation: OS, TN, AP, GD, AD, LD Data collection: OS, TN Writing the article: OS, LD Critical revision of the article: OS, TN, AP, GD, AD, LD Final approval of the article: OS, TN, AP, GD, AD, LD Statistical analysis: OS, LD Obtained funding: Not applicable Overall responsibility: LD
REFERENCES 1. Bobadilla JL, Kent KC. Screening for abdominal aortic aneurysms. Adv Surg 2012;46:101-9. 2. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004;364:843-8. 3. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Matsumura JS, Kohler TR, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:1535-42. 4. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:1607-18. 5. Schermerhorn ML, Buck DB, O’Malley AJ, Curran T, McCallum JC, Darling J, et al. Long-term outcomes of abdominal aortic aneurysm in the Medicare population. N Engl J Med 2015;373:328-38. 6. World Health Organization. World report on ageing and health. Geneva: World Health Organization; 2015. 7. Bohnert N, Dion P, Chagnon J. Population projections for Canada (2013 to 2063), provinces and territories (2013 to 2038). Ottawa: Statistics Canada; 2014. 8. Hicks CW, Obeid T, Arhuidese I, Qazi U, Malas MB. Abdominal aortic aneurysm repair in octogenarians is associated with higher mortality compared with nonoctogenarians. J Vasc Surg 2016;64:956-65.e1. 9. Brady AR, Fowkes FG, Greenhalgh RM, Powell JT, Ruckley CV, Thompson SG. Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. Br J Surg 2000;87:742-9. 10. Henebiens M, Vahl A, Koelemay MJ. Elective surgery of abdominal aortic aneurysms in octogenarians: a systematic review. J Vasc Surg 2008;47:676-81.
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11. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation 2014;130:2215-45. 12. Rafiq A, Sklyar E, Bella JN. Cardiac evaluation and monitoring of patients undergoing noncardiac surgery. Health Serv Insights 2017;9. 1178632916686074. 13. Herman CR, Charbonneau P, Hongku K, Dubois L, Hossain S, Lee K, et al. Any nonadherence to instructions for use predicts graft-related adverse events in patients undergoing
elective endovascular aneurysm repair. J Vasc Surg 2018;67: 126-33. 14. O’Donnell TF, Wade JE, Liang P, Li C, Swerdlow NJ, DeMartino RR, et al. Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort. J Vasc Surg 2019;69:728-37.
Submitted Feb 4, 2019; accepted Jun 5, 2019.
Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians Oonagh Scallan, MD,a Teresa Novick, RN,a Adam H. Power, MD, MPhil,a Guy DeRose, MD,a Audra Duncan, MD,a and Luc Dubois, MD, MSc,a,b London, Ontario, Canada
ABSTRACT Objective: Patients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up. Methods: Retrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics. Results: The study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P ¼ .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P ¼ .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P ¼ .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P ¼ .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P ¼ .05) were higher in the endovascular treatment group. Conclusions: EVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients. (J Vasc Surg 2019;-:1-7.) Keywords: Abdominal aortic aneurysm; AAA; EVAR; Octogenarian
Abdominal aortic aneurysm (AAA) is an age-related disease and the tenth leading cause of death in men older than 55 years in the United States.1 First reported in 1991, endovascular aneurysm repair (EVAR) has the benefits of lower perioperative mortality and morbidity rates and shorter hospital stay compared with open repair.2-4 In a large population-based study by Schermerhorn et al,5 EVAR was shown to have a survival benefit over open repair in the perioperative period, with the survival benefit lasting up to 3 years.
From the Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre,a and the Department of Epidemiology and Biostatistics,b Western University. Author conflict of interest: none. Presented at the Fortieth Annual Meeting of the Canadian Society for Vascular Surgery, Montreal, Quebec, Canada, September 28-29, 2018. Correspondence: Luc Dubois, MD, MSc, Assistant Professor, Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, LHSC-Victoria Campus, 800 Commissioners Rd E, London, ON N6A 5W9, Canada (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.06.207
Survival into the ninth decade of life is now common in all industrialized countries.6 In Ontario, the percentage of the population older than 80 years is expected to increase from 4.2% in 2015 to 9.4% by the year 2041.7 Even without AAA, risk of death from any cause is substantial in this age group, and age is a well-known independent risk factor for death after AAA repair.8 Open repair is often not considered in octogenarians because of their advanced age as a risk factor or their comorbidities.9 After elective AAA repair, older patients have significantly higher risk compared with younger patients, especially in the postoperative period, even when matched for comorbidities.10 The risk vs benefit of elective AAA repair in the elderly continues to be a topic of debate. Prospective data are lacking on the subject of octogenarians and AAA repair as patients older than 80 years are often excluded from or poorly represented in randomized trials. A systematic review of the literature identified 39 articles concerning perioperative and late survival after AAA repair in octogenarians.11 The median 5-year survival rate from this review was 60%, although this was based on only 19 of the 39 articles because of lack of reported data. Hicks et al8 demonstrated worse outcomes for EVAR among octogenarians, even after propensity score matching on baseline, perioperative, and technical variables. A steep decline in survival was 1
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noted within the first 3 months of repair, suggesting that the difference in mortality occurs early in the postoperative course.10 A better understanding of long-term outcomes of open vs endovascular AAA repair in patients older than 80 years would help provide insight into selection and management of these patients. The purpose of this study was to review our center’s data on the outcomes of AAA repair in octogenarians with at least 5 years of follow-up.
ARTICLE HIGHLIGHTS d
d
METHODS d
A retrospective review of a prospectively collected database at our university-affiliated medical center was performed to identify all patients aged 80 years or older who underwent open repair or EVAR between 2007 and 2012. Incomplete data were obtained through chart review. All reinterventions related to the initial AAA repair were reviewed, including all aortic and access-related procedures, laparotomies for bowel obstructions and incisional hernia repairs, and femoral-femoral crossover complications (infection, thrombosis). Superficial wound infections were not included. Exclusion criteria included mycotic aneurysms, aneurysms associated with aortic dissection, and fenestrated endografts. These patients received endovascular or open repair in a nonrandomized fashion at the discretion of the attending surgeon after consideration of such issues as aneurysm anatomy and the patient’s comorbidities and preference. Open repair was performed with a midline incision and transperitoneal approach with an infrarenal clamp and a straight or bifurcated graft, depending on the extent of the aneurysm, and a woven tube or bifurcated graft for any coexisting aortoiliac occlusive disease. EVAR was performed with one of the following stent grafts by bilateral groin cutdowns: Talent (Medtronic, Minneapolis, Minn), Endurant (Medtronic), or Zenith (Cook Medical, Bloomington, Ind). Statistical analysis was performed with SPSS Statistics version 20.0 (IBM, Armonk, NY). Comparison of categorical variables was done by the c2 test and Fisher exact test, whereas continuous variables were analyzed by nonpaired t-tests. Long-term survival and freedom from reintervention were determined by life-table analysis and Kaplan-Meier curves and log-rank tests. Results are reported as medians with interquartile ranges (IQRs), and the level of statistical significance was set at P < .05. Given the retrospective nature of the study, individual patient consent for study inclusion was not obtained or required. This study received approval from the University of Western Ontario Research Ethics Board for Health Sciences Research Involving Human Subjects.
RESULTS There were 314 consecutive patients aged 80 years or older who underwent AAA repair between January 2007 and December 2012 and were included in this
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Type of Research: Single-center retrospective cohort study Key Findings: In 314 patients aged 80 years or older who underwent endovascular aneurysm repair (EVAR) or open abdominal aortic aneurysm repair with at least 5 years of follow-up, median survival was similar in both groups (about 6 years), but there were more late reinterventions after EVAR (18%). Take Home Message: With a median survival of almost 6 years and an 18% reintervention rate, diligent long-term follow-up is crucial after EVAR even in the elderly.
study cohort. Of these 314 patients, 96 patients underwent open repair (31%) and 218 received EVAR (69%). In the EVAR group, 211 (97%) patients were elective cases, whereas seven (3%) patients were treated when they were ruptured. In the open repair group, 63 (66%) patients were treated electively and 33 (34%) were ruptured. Median age was 83 years (IQR, 5 years), with a range of 80 to 96 years; 72% of the open repair group were male compared with 83% in the EVAR group (P < .05). Median aneurysm size at the time of repair was 65 mm in the open repair group (IQR, 23 mm) and 60 mm in the EVAR group (IQR, 8 mm). The two treatment groups were otherwise similar with respect to baseline comorbidities and had similar rates of hypertension, active smoking, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease (Table I). In the patients who underwent EVAR, 76% of the patients received a bifurcated device and 24% were treated with aortouni-iliac endografts. Endografts used included 100 Cook Zenith (46%), 111 Medtronic Endurant (50%), 7 Medtronic Talent (3%), and 1 Vascutek (Inchinnan, Scotland, UK) Anaconda (0.5%). In the patients who underwent elective repair, there were nine deaths (14%) in the first 30 days in the open repair group and three (1%) in the EVAR group (P < .001; Table II). The causes of death in the open repair group were myocardial infarction in six patients, ischemic bowel in two patients, and pneumonia in one patient. Of these nine patients, four required a suprarenal clamp and five were infrarenal. Mean blood returned through cell salvage was 370 mL 6 150 mL, and mean operative duration was 200 6 85 minutes. The deaths in the EVAR group were due to renal failure, stroke, and pneumonia (Table III). Length of stay was significantly shorter after EVAR (median, 3 days; IQR, 2 days) than after open repair (median, 9 days; IQR, 12.5 days). Twelve (19%) patients who underwent open repair required reintervention within the first 30 days.
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Table I. Patient demographics and endovascular aneurysm repair (EVAR) details Open (n ¼ 96), No. (%) Mean age, years
EVAR (n ¼ 218), P value No. (%)
83.2
83.8
.08
Male
69 (72)
180 (83)
.03
Hypertension
66 (69)
178 (82)
.29
Dyslipidemia
53 (55)
139 (64)
.82
Smoker
18 (19)
28 (13)
.06
Diabetes mellitus
13 (14)
28 (13)
.57
40 (42)
99 (45)
.87
Congestive heart failure
5 (5)
15 (7)
.76
Carotid artery stenosis
2 (2)
10 (5)
.37
Chronic renal disease
4 (4)
13 (6)
.65
Coronary artery disease
Dialysis
0 (0)
2 (1)
.37
COPD
23 (24)
47 (22)
.30
7 (7)
15 (7)
.67
15 (16)
29 (13)
.38
5 (5)
19 (9)
.42
34 (35)
92 (42)
.77
7 (7)
6 (3)
.06
Peripheral vascular disease Anticoagulation Clopidogrel (Plavix) Aspirin Previous AAA repair Configuration for EVAR Bifurcated
166 (76)
Aortouni-iliac
53 (24)
Stent graft type Cook Zenith
100 (46)
Medtronic Endurant
111 (50)
Medtronic Talent
7 (3)
Vascutek Anaconda
1 (0.5)
Elective surgery Ruptured Mean AAA size, cm
623 (66)
213 (97)
33 (34)
7 (3)
<.001 <.001
71
62.4
<5.5
2 (2)
9 (4)
5.5-6
28 (29)
123 (56)
6.1-7
19 (20)
53 (24)
7.1-8
11 (12)
18 (8)
8.1-9
11 (12)
10 (5)
>9
10 (10)
3 (1)
Unknown
15 (16)
2 (1)
AAA, Abdominal aortic aneurysm; COPD, chronic obstructive pulmonary disease.
Reinterventions included 5 repairs of wound dehiscence, 3 cases of bowel ischemia, 2 cases of limb ischemia, 1 bleeding episode, and 1 sponge removal. Two (1%) patients in the EVAR group required reintervention in the
Table II. Thirty-day results for elective repair Open (n ¼ 63), No. (%)
EVAR (n ¼ 211), P No. (%) value
In-hospital mortality rate
9 (14)
3 (1)
<.001
In-hospital reintervention rate
12 (19)
2 (1)
<.001
16
4
<.001
Average length of stay, days
EVAR, Endovascular aneurysm repair.
first 30 days, one for a type IA endoleak and one for limb ischemia. The difference in the early reintervention rates between the two groups was significant (P < .001), with higher rates of early reintervention in the open repair group. Median survival and mean survival were the same for both the elective EVAR and open repair groups at 69 and 70 months, respectively. Fig 1 demonstrates a Kaplan-Meier survival analysis showing that the survival rate at 1 year was significantly higher for the elective EVAR group at 93% compared with 84% in the elective open group (P ¼ .02). There was no significant difference in survival at 5 years between elective EVAR and open repair, 57% compared with 59%. The most common causes of long-term mortality were malignant disease and cardiovascular events. There were no aneurysmrelated deaths in the open repair group. In the EVAR group, there were three aneurysm-related deaths. One patient suffered ischemic colitis after undergoing graft explantation, and two patients died of ruptured aneurysms despite previous EVAR (Table IV). Fig 2 is a Kaplan-Meier curve for the long-term reintervention rate in elective repair; this was 18% in the EVAR group compared with 4% in the open repair group (P ¼ .05). The interventions in the open repair group were related to an incisional hernia repair and one ruptured iliac artery aneurysm. In the EVAR group, all reinterventions were related to the initial aneurysm repair (Table V). Three patients underwent interventions for ischemia due to thrombosis of a limb of the endograft including one femoral-femoral bypass, one thrombectomy and iliofemoral bypass, and one thrombectomy and stenting of the iliac limb. Two patients required repair of an anastomotic aneurysm; 27 patients had reinterventions for endoleaks. Six patients underwent open explantation, five for a type IA endoleak and one for ongoing sac expansion due to type II endoleak. One patient who underwent open explantation died postoperatively of bowel ischemia. There were no other reintervention-related deaths. Ten patients had embolization for type II endoleaks. Five patients required relining because of a type IA endoleak (2), type IB endoleak (2), or type III endoleak (1). Three patients had an aortic cuff inserted and one patient had a Palmaz stent
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Table III. Thirty-day causes of death and reinterventions Open Cause of death
Table IV. Causes of long-term mortality
EVAR
6 myocardial infarction
1 renal failure
2 ischemic bowel 1 pneumonia
Open
53 unknown
1 stroke
6 cancer
17 cancer
1 pneumonia
4 myocardial infarction
15 myocardial infarction
2 respiratory failure
14 respiratory failure
2 stroke
7 stroke
1 gastrointestinal bleeding
6 renal failure
1 sepsis
1 bleeding
5 gastrointestinal bleeding
1 sponge removal
3 AAA related
5 wound dehiscence 1 type IA endoleak 3 bowel ischemia
1 limb ischemia
2 limb ischemia
EVAR, Endovascular aneurysm repair.
Cause of death
EVAR
13 unknown
Reintervention details
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2 ruptured AAA 1 ischemic colitis 2 congestive heart failure 2 multiorgan failure 1 dehydration AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair.
Fig 1. Kaplan-Meier survival curve for elective abdominal aortic aneurysm (AAA) repair, endovascular aneurysm repair (EVAR) vs open.
inserted for a type IA endoleak. In accounting for perioperative mortality associated with aneurysm reinterventions, this would increase the perioperative mortality rate to 2% from 1% in elective EVAR. Compared with 14% in the open repair group, this difference still remains significant (P < .001). Two patients died within a year of reintervention, one at 5 months of metastatic colon cancer and another at 11 months of stroke. In 30 patients, 35 procedures were performed as reinterventions, with one death; the mortality rate from elective EVAR reinterventions was 3%, also significantly lower than with open repair. In patients aged 85 years or older, there was no significant difference in outcomes when they were treated with open repair or EVAR in the setting of elective AAA repair. Mean survival for patients older than 85 years was 56.6 months in open repair and 63.4 months in
Fig 2. Freedom from reintervention for elective endovascular aneurysm repair (EVAR) group vs elective open repair group.
EVAR. In patients aged 80 to 85 years, there was also no difference in survival, with mean survival of 73.8 months in open repair and 73.4 months in EVAR. In patients who underwent repair of a ruptured aneurysm, there were 27 (82%) deaths in the open repair group and four deaths in the EVAR group (P ¼ .16; Table VI). Two (6%) patients in the open repair group required reintervention for abdominal compartment syndrome and limb thrombosis and two patients (29%) in the EVAR group required reintervention for abdominal compartment syndrome and a type IA endoleak requiring subsequent open repair.
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Table V. Causes of long-term reinterventions Open
EVAR
1 hernia repair
10 embolization
1 ruptured iliac artery aneurysm
6 open explantation 5 relining 3 aortic cuff insertion 2 iliac extension 2 repair anastomotic aneurysm 1 femoral-femoral bypass 1 thrombectomy and iliac stent 1 thrombectomy and iliofemoral bypass 1 Palmaz stent
EVAR, Endovascular aneurysm repair.
Table VI. Thirty-day results for ruptured aneurysms Open (n ¼ 33), EVAR (n ¼ 7), No. (%) No. (%)
P value
In-hospital mortality rate
27 (82)
4 (57)
.156
In-hospital reintervention rate
2 (6)
3 (43)
.01
21
26
.62
Average length of stay, days
EVAR, Endovascular aneurysm repair.
DISCUSSION This retrospective single-center study demonstrates that patients 80 years of age or older have similar longterm outcomes when undergoing elective open or endovascular AAA repair. There is a survival benefit at 1 year with elective EVAR compared with elective open repair, but there is no survival advantage beyond 1 year. With long-term data and follow-up to 5 years, outcomes were found to be similar between the two groups. Median survival was 5.75 years, which would support offering surgical repair to selected octogenarians; they should not be excluded from open or endovascular repair on the basis of age alone. The open repair group had a significantly higher proportion of ruptured aneurysms compared with the EVAR group, 34% vs 3%. Given this discrepancy, elective repair and ruptured AAA repair were analyzed separately. These data support the results of previous studies including a systematic review by Henebiens et al10 from 2008, which reported a median long-term survival rate of 60% in octogenarians undergoing open or endovascular AAA repair. This was based on 19 small, retrospective reviews and required further validation. Few studies of octogenarians undergoing AAA repair have outcomes out to 5 years, and ours was composed of patients with at least 5 years of follow-up or more.
The underlying cause of poorer outcomes in AAA repair in patients older than 80 years is unknown but is thought to be related to greater comorbidity burden.10 Elderly patients often also have more difficult anatomy to treat, with tortuous vessels and a high degree of atherosclerotic occlusive disease. Cardiac events were the predominant cause of 30-day mortality in the open repair group. Four of the nine patients who died postoperatively required suprarenal clamping, which may have contributed to the higher rate of myocardial ischemia and death. This highlights the importance of perioperative medical optimization and patient selection. The equivalence in long-term outcomes of elective open AAA repair or EVAR may also be associated with high case volumes in our center and experience in good decision-making when selecting patients for open or endovascular repair. The American College of Cardiology/American Heart Association guidelines recommend preoperative electrocardiography for all patients, and patients should be carefully selected for further evaluation with dipyridamole-thallium imaging or dipyridamole stress echocardiography on the basis of their functional capacity.11 The use of intraoperative transesophageal echocardiography may help guide fluid resuscitation efforts and identify patients with impaired left ventricular function who may require adjunctive supports, such as inotropy or close monitoring in an intensive care unit setting. In patients without risk factors or procedural risks for hemodynamic, neurologic, or pulmonary compromise, the routine intraoperative use of transesophageal echocardiography to screen cardiac abnormalities or to monitor myocardial ischemia is not recommended.12 However, vascular surgery patients often have multiple cardiac risk factors, and there are additional procedural risks with aortic cross-clamping; therefore, further research is required to evaluate the use of transesophageal echocardiography in open AAA surgery. The longterm mortality of the patients in this study was driven by their underlying comorbidities, not aortic events. With an 18% reintervention rate during 5 years after EVAR and a median survival of 69 months, this underscores the importance of long-term follow-up in these patients. This rate of reintervention is significantly higher than the results from the EVAR 1 and EVAR 2 trials, in which the secondary intervention rates were 7% to 9.4% for the Zenith and Talent grafts. In a 5-year followup study of the Zenith stent graft repair, the cumulative risk of conversion, limb occlusion, migration, or component separation was <3% at 5 years, and the cumulative risk of late endoleak was 12% to 15%, which accounted for most of the secondary interventions. Of the 32 reinterventions in this study population, 27 (84%) were for endoleak. Of those, 11 (41%) were for type II endoleak; the remainder were type IA, type IB, or type III. A laparotomy for graft explantation was required for 19% of the reinterventions. Anatomic data and instructions for use
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violations were not available in this study, but the fact that octogenarians live on average >5 years after EVAR and the relatively high reintervention rate reported here should act as a caution against using standard EVAR in octogenarians with nonideal anatomy as instructions for use violations have been shown to increase the risk of graft-related complications after EVAR.13 Reinterventions in the elective EVAR group did not significantly change the overall mortality of these patients when they were included in perioperative mortality (2% vs 1%), and it still remains significantly lower than perioperative mortality from open repair (14%). The mortality remains low despite a high proportion of the procedures being graft explantation. The decision to proceed with operative repair of an AAA typically occurs when the risk of rupture outweighs the risk of repair. The median aneurysm sizes in this study were 65 mm in the open repair group and 60 mm in the EVAR group, which is significantly larger than the typical size threshold for repair of 55 mm. This could be due to delayed diagnosis, given that aneurysm screening is not currently recommended in patients older than 75 years, or that because of their age, their quoted operative risk was higher and therefore the decision to proceed with surgery was delayed until the aneurysm reached a larger size. Previous risk scores, such as the Glasgow Aneurysm Score, Hardman index, and Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity, incorporate age into the risk calculation but are based on data from the general population, not specifically the elderly. A recent study14 reviewed Vascular Quality Initiative data from 2003 to 2016 and found the 5-year survival for patients older than 75 years undergoing elective EVAR to be excellent at 77%. A risk score was developed from these data to identify patients suitable for AAA screening and to assess expected postoperative 5-year survival. A risk score dedicated to the elderly would be useful to guide selection of patients for optimal operative intervention in regard to timing of surgery and method of repair, endovascular or open. The mortality rate of ruptured AAA repair in this population was very high in this study, with a 30-day mortality rate of 82% in open repair and 57% in EVAR, although the difference was not statistically significant. Although the data are based on a small number of patients, the high mortality rate in open repair highlights the importance of selection of patients for type of repair and for informing patients of their prognosis. Although it should not of itself preclude octogenarians from undergoing open repair of a ruptured AAA, age is an important factor in the decision-making. Our study has limitations inherent to a nonrandomized, single-center, retrospective analysis. In the open repair group, 11 patients in total were lost to follow-up, and 7 patients were lost to follow-up in the EVAR group before 1 year of follow-up. During long-term follow-up, the cause
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of death was unknown in 13 patients from the open repair group and 53 patients from the EVAR group. The reintervention rate for patients in the open repair group may be underestimated as patients may have had a nonvascular surgical procedure, such as a hernia repair, done at a peripheral center.
CONCLUSIONS This study shows that octogenarians who undergo elective EVAR or open repair have similar survival at 5 years. With a median survival of almost 6 years and an 18% reintervention rate after EVAR, diligent long-term follow-up is crucial after EVAR even in the elderly.
AUTHOR CONTRIBUTIONS Conception and design: OS, LD Analysis and interpretation: OS, TN, AP, GD, AD, LD Data collection: OS, TN Writing the article: OS, LD Critical revision of the article: OS, TN, AP, GD, AD, LD Final approval of the article: OS, TN, AP, GD, AD, LD Statistical analysis: OS, LD Obtained funding: Not applicable Overall responsibility: LD
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11. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation 2014;130:2215-45. 12. Rafiq A, Sklyar E, Bella JN. Cardiac evaluation and monitoring of patients undergoing noncardiac surgery. Health Serv Insights 2017;9. 1178632916686074. 13. Herman CR, Charbonneau P, Hongku K, Dubois L, Hossain S, Lee K, et al. Any nonadherence to instructions for use predicts graft-related adverse events in patients undergoing
elective endovascular aneurysm repair. J Vasc Surg 2018;67: 126-33. 14. O’Donnell TF, Wade JE, Liang P, Li C, Swerdlow NJ, DeMartino RR, et al. Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort. J Vasc Surg 2019;69:728-37.
Submitted Feb 4, 2019; accepted Jun 5, 2019.