Octogenarians Undergoing Open Repair Have Higher Mortality Compared with Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving the Visceral Vessels.
Prior studies have shown that octogenarians have a higher risk of mortality than nonoctogenarians undergoing open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Fenestrated endovascular aneurysm repair (F-EVAR) was approved by the Food and Drug Administration (FDA) in 2012 and has been used as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared with traditional OAR. The aim of the study is to compare 30-day outcomes of F-EVAR versus OAR in octogenarians undergoing repair of AAA involving the visceral vessels in the United States.
All patients with postoperative diagnosis of nonruptured AAA repair were identified in the National Surgical Quality Improvement Program database (2006-2015). Univariate and multivariate analyses were implemented to examine 30-day morbidity and mortality adjusting for patient demographics and comorbidities.
A total of 548 octogenarians underwent repair of nonruptured AAA involving the visceral vessels, of which 242 (44%) were F-EVARs, and 306 (56%) were OARs. Octogenarians undergoing F-EVAR were on average 1-year older (median age [interquartile range]: 83 [82, 86] versus 82 [81, 85], P = 0.004) and more likely to be male (82% vs. 64%, P < 0.001) compared with OAR. Prevalence of diabetes (13% vs. 6%, P = 0.005) and progressive renal failure (57% vs. 47%, P = 0.03) was also higher in patients undergoing F-EVAR compared with OAR. Thirty-day postoperative mortality was higher after OAR (8.5% vs. 4.1%, P = 0.04). Secondary outcomes including cardiopulmonary (27.1% vs. 5.8%, P < 0.001) and renal injury (10.8% vs. 2.1%, P < 0.001) were also significantly higher in OAR compared with F-EVAR. After adjusting for patients' demographics and comorbidities, OAR had almost 4-fold increased risk of 30-day postoperative mortality compared with F-EVAR (odds ratio [95% confidence interval]: 3.90 [1.48-10.31], P = 0.006).
In this large national cohort of octogenarians undergoing repair for complex AAA's, we showed that F-EVAR is associated with significantly lower postoperative morbidity and mortality than open repair. One of the main limitations of the study is the lack of anatomical data. However, despite that, our findings support the shifting paradigm toward minimally invasive approach in this frail population for treatment of complex AAA's. Further studies are needed to evaluate the long-term benefit of any repair in octogenarians.
Locham S
，Faateh M
，Dakour-Aridi H
，Nejim B
，Malas M
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Outcomes and Durability of Endovascular Aneurysm Repair in Octogenarians.
Endovascular aneurysm repair (EVAR) accounts for the majority of all abdominal aortic aneurysm (AAA) repairs in the United States. EVAR utilization in the aging population is increasing due to the minimally invasive nature of the procedure, the low associated perioperative morbidity, and early survival benefit over open repair. The objective of this study is to compare the outcomes of octogenarians after elective EVAR to their younger counterparts, a question that can be answered by a long-term, institutional data set.
This was a retrospective series of 255 patients, who underwent elective EVAR within our institution from 2008 to 2015. A comparative analysis of patients aged 80 years and older and less than 80 years was performed. Outcomes measured included perioperative death and myocardial infarction (MI), length of stay, and readmission within 30 days. Aneurysm reintervention, long-term surveillance imaging, and aneurysm-related deaths were also evaluated. In addition, subset analyses of octogenarians were compared for survival at 24 months.
Overall, 255 patients were included in our analysis. Fifty-nine patients were octogenarians, and 196 patients were nonoctogenarians. The mean age difference between the two groups was significant (84.5 years [SD, ±3.44] vs. 69.6 years [SD, ±6.13] in the ≥80 and <80 groups, respectively; P < 0.0001). There was no significant difference in the mean aneurysm size (6.03 cm [SD, ±1.12] vs. 5.535 cm [SD, ±0.9]; P < 0.06) between the ≥80 and < 80 groups. Octogenarians had higher rates of perioperative MI (5% vs. 1%, P < 0.04), thirty-day mortality (7% vs. 0%, P < 0.003), a higher number of perioperative complications (0.64 incidence per patient [SD, ±1.11] vs. 0.31 [SD, ±0.69], P < 0.005), and a longer mean hospital stay (5.34 [SD, ±5.75] days vs. 3.16 [SD, ±3.23] days, P < 0.0003), and they were also less likely to be discharged home after surgery (75% vs. 91%, P < 0.002). In the evaluated long-term outcomes, the two groups were similar with regard to aneurysm reintervention (10% vs. 9%, P < 0.06) and the stability of aneurysm sac size on imaging at last follow-up (71% vs. 80%, P < 0.27). The overall aortic related cause of death was different between the groups (8% vs. 1%, P < 0.003); however, the long-term aortic related mortality was not different between the two groups (2% vs. 1%, P < 0.4). Finally, a subset analysis of the octogenarian group was performed comparing patients based on survival status at 24 months. Higher preoperative creatinine (1.73 mg/dL [SD, ±1.54] vs. 1.15 mg/dL [SD, ±0.46]) and lower preoperative hematocrit (33.9% [SD, ±3.43] vs. 37.2% [SD, ±4.9]) along with number of perioperative complications (1.2 incidence per patient [SD, ±1.74] vs. 0.45 [SD, ±0.73]) were associated with death at 24 months after the index operation.
Elective endovascular repair of AAA in octogenarians carries a higher risk of perioperative mortality but acceptable long-term outcomes. Appropriateness of elective EVAR in octogenarians should be answered based on this potential short-lived survival benefit, taking into account that advanced age should not be the sole basis of exclusion for otherwise suitable candidates for elective EVAR.
Lagergren E
，Chihade D
，Zhan H
，Perez S
，Brewster L
，Arya S
，Jordan WD Jr
，Duwayri Y
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Complex endovascular aneurysm repair is associated with higher perioperative mortality but not late mortality compared with infrarenal endovascular aneurysm repair among octogenarians.
As our collective experience with complex endovascular aneurysm repair (EVAR) has grown, an increasing number of older patients are being offered endovascular repair of juxtarenal aneurysms. Outcomes after complex EVAR in this older subpopulation are not well-described. We sought to specifically evaluate clinical outcomes after complex EVAR compared with infrarenal EVAR in a cohort of octogenarians.
A single-center retrospective review was conducted using a database of consecutive patients treated with elective EVAR for abdominal aortic aneurysms (AAAs) between 2009 and 2015. Only patients 80 years of age or older were included. Patients in the complex EVAR group were treated with either snorkel/chimney or fenestrated techniques, whereas infrarenal EVAR consisted of aneurysm repair without renal or visceral involvement. Relevant demographic, anatomic, and device variables, and clinical outcomes were collected.
There were 103 patients (68 infrarenal, 35 complex) treated within the study period with a mean follow-up of 21 months. A total of 75 branch grafts were placed (59 renal, 11 celiac, 5 superior mesenteric artery) in the complex group, with a target vessel patency of 98.2% at latest follow-up. Patients undergoing complex EVAR were more likely to be male (82.8% vs 60.2%; P = .02) and have a higher prevalence of renal insufficiency (71.4% vs 44.2%; P = .008). The 30-day mortality was significantly greater in patients treated with complex EVAR (8.6% vs 0%; P = .03). There were no differences in major adverse events (P = .795) or late reintervention (P = .232) between groups. Interestingly, sac growth of more than 10 mm was noted to be more frequent with infrarenal EVAR (17.6% vs 2.8%; P = .039). However, both type IA (5.7% infrarenal; 4.9% complex) and type II endoleaks (32.3% infrarenal; 25.7% complex) were found to be equally common in both groups. Complex EVAR was not associated with increased all-cause mortality at latest follow-up (P = .322). Multivariable Cox modeling demonstrated that AAAs greater than 75 mm in diameter (hazard ratio; 4.9; 95% confidence interval, 4.6-48.2) and renal insufficiency (hazard ratio, 3.71; 95% confidence interval, 1.17-11.6) were the only independent risk factors of late death.
Complex EVAR is associated with greater perioperative mortality compared with infrarenal EVAR among octogenarians. However, late outcomes, including the need for reintervention and all-cause mortality, are not significantly different. Larger aneurysms and chronic kidney disease portends greater risk of late death after EVAR, regardless of AAA complexity. These patient-related factors should be considered when offering endovascular treatment to older patients.
Tran K
，Lee AM
，McFarland GE
，Sgroi MD
，Lee JT
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