Outcomes of octogenarians receiving aortic repair

Open Repair for Nonruptured Abdominal Aortic Aneurysm in Octogenarians With Prior Abdominal Surgery

INTRODUCTION

Previous abdominal surgery (PAS) has been shown to potentially affect outcomes of open surgical repair (OSR) for abdominal aortic aneurysm (AAA). Octogenarians have been observed to face significantly higher risks following OSR for AAA, which highlights the need for a more cautious selection of their surgical candidacy. This study aimed to assess the association between PAS and the 30-d outcomes of OSR for nonemergent intact AAA among octogenarians.

METHODS

Octogenarians (aged ≥80 y) who underwent OSR for AAA were identified in American College of Surgeons National Surgical Quality Improvement Program targeted databases from 2012 to 2022. Exclusion criteria included emergency and ruptured aneurysm. Multivariable logistic regression was used to compare 30-d perioperative outcomes between octogenarians with and without PAS while adjusting for demographics, comorbidities, indications, aneurysm extents, and surgical approaches.

RESULTS

Among 4242 patients who underwent OSR for nonemergent intact AAAs, 562 patients (13.25%) were octogenarians. Among the octogenarians, 173 (30.78%) had PAS, whereas 389 (69.22%) had no history of PAS. Octogenarians with and without PAS had comparable 30-d mortality (10.4% versus 9.51%, adjusted odds ratio 1.104, 95% confidence interval 0.581-2.095, P = 0.76). However, octogenarian patients with PAS had a higher risk of lower extremity ischemia (9.83% versus 4.37%, adjusted odds ratio 2.247, 95% confidence interval 1.064-4.745, P = 0.03). All other 30-d surgical outcomes did not differ between octogenarians with and without PAS. In addition, unplanned reoperation, discharge not to home, 30-d readmission, operation time, and length of stay were not different between the groups.

CONCLUSIONS

Octogenarians with a history of PAS had largely similar 30-d mortality and morbidities, except a 2.25 times higher risk of lower extremity ischemia. Therefore, although a history of PAS should not preclude octogenarian patients from undergoing OSR for AAA, additional vigilance for postoperative lower extremity ischemia is warranted to ensure timely and appropriate secondary interventions.

The Influence of Octagenarians in Endovascular Repair for Aortoiliac Aneurysms: Long-Term Outcomes in a Prospective Cohort

BACKGROUND

This study aimed to determine the outcomes of survival, endoleaks, reinterventions, and perioperative mortality rate in patients with infrarenal aortoiliac aneurysm receiving endovascular repair in the following 2 groups of patients: octogenarians and nonoctogenarians.

METHODS

This was a prospective, consecutive cohort study of patients with infrarenal aortoiliac aneurysm who underwent endovascular treatment between January 2019 and December 2022. The following 2 groups of patients were evaluated: the octogenarian group and the nonoctogenarian group.

RESULTS

A total of 156 patients were evaluated, including the octogenarian group (30 patients, 19.2%) and the nonoctogenarian group (126 patients, 80.8%). Most of the clinical features were similar between the 2 groups, except for a higher prevalence of cardiac disease in the nonoctogenarian group than that in the octogenarian group (31.7% vs. 3.3%; P = 0.001) and a higher prevalence of chronic kidney disease in the octogenarian group than in the nonoctogenarian group (33.3% vs. 9.5%, P = 001). The perioperative mortality was 5.1%, 8 patients, higher in the octogenarian group (3 patients, 10%) than that in the nonoctogenarian group (5 patients, 4%), P = 0.036. The overall survival in a Kaplan-Meier at 1080 days was 81.6% in the octogenarian group and 77.4% in the non-octogenarian group but with no statistical significance among the groups (P = 0.36). The time freedom from reintervention at 1,080 days was statistically similar among the groups (90.6% in the octogenarian group and 72.3% in the nonoctogenarian group, P = 0.35). The Cox regression analysis for survival rates showed that chronic kidney disease [(P = 0.011; hazard ratio = 1.29) and bowel ischemia (P = 0.037, hazard ratio = 3.35) were related to poorer survival rates in both univariate and multivariate analysis.

CONCLUSION

In this study, octogenarian patients had higher rates of perioperative mortality rate when compared with nonoctogenarian patients. The main factors related to death were bowel ischemia and chronic kidney disease. Nevertheless, the time freedom from reintervention and survival rates at 1,080 days were statistically similar among the octogenarian and nonoctogenarian patients, denoting favorable outcomes in both groups of patients at midterm-long-term outcomes.

Long-Term Outcomes of Elective Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm in Japanese Elderly Patients

PURPOSE

Our primary concern was the risk of overtreating elderly patients with endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. We investigated the association between age at the time of EVAR and all-cause mortality in Japan's aging population by stratifying patients into age groups.

METHODS

Data from 175 patients who underwent elective EVAR from 2012 to 2016 were analyzed. Patients were categorized into 3 age groups: <75 years, 75-84 years, and ≥85 years, based on Japan's healthy life expectancy and average life expectancy. Survival rates and risk factors for mortality were assessed across these patient groups.

RESULTS

Among 175 patients, 3- and 5-year survival rates were significantly lower in elderly patients, with rates of 74.6% and 64.2% for those aged 75-84 years and 51.9% and 39.7% for those aged ≥85 years. Multivariate analysis identified age ≥85 years, chronic kidney disease, chronic obstructive pulmonary disease, and active cancer as independent adverse predictors of all-cause mortality, whereas obesity was identified as an independent protective predictor.

CONCLUSIONS

Adjusting guidelines to incorporate not only comorbidities but also age could optimize outcomes and healthcare resource allocation by prioritizing EVAR for patients most likely to benefit in Japan's super-aging society.

The Safety and Outcomes of Elective Endovascular Aneurysm Repair in the Elderly: A Systemic Review and Meta-Analysis

PURPOSE

Prevalence of abdominal aortic aneurysms (AAAs) increases with age. Previous trials confirm that elective endovascular aneurysm repair (EVAR) is an effective intervention for AAA. However, few elderly patients were recruited into randomized trials, whereas in contemporary clinical practice, elective repair is commonly performed on octogenarians. We evaluated the safety and outcome of elective EVAR in elderly patients to inform clinical practice and vascular service provision.

METHODS

A systematic review and meta-analysis of studies reporting risk of complications and death in patients undergoing elective EVAR was performed (PROSPERO CRD: 42022308423). Observational studies and interventional arms of randomized trials were included if the outcome rates or raw data were provided. Primary outcome was 30-day mortality. Secondary outcomes were longer-term mortality, 30-day major adverse events, and aneurysm-related mortality. Primary and secondary outcomes were compared between octogenarians and non-octogenarians. Exclusion criteria were emergency procedures, non-infrarenal aneurysms, and lack of octogenarian data.

RESULTS

A total of 41 studies were eligible from 10 099 citations, including 10 national and 5 international registries, 26 retrospective studies, and our own prospective cohort. The analysis included 208 997 non-octogenarians (mean age=70.19 [SD=0.62]) and 106 188 octogenarians (mean age=83.75 [SD=0.35]). The 30-day mortality post-elective EVAR was higher in octogenarians (1.08% in non-octogenarians, 2.31% in octogenarians, odds ratio [OR]=2.27 [2.08-2.47], p<0.0001). Linear regression demonstrated a 0.83% increase in 30-day mortality for every 10-year age increase above 60 years old. Mortality for octogenarians increased significantly during follow-up: 11.35% (OR=1.87 [1.65-2.13], p<0.001), 22.80% (OR=1.89 [1.52-2.35], p<0.001), 32.00% (OR=1.98 [1.66-2.37], p<0.001), 47.53%, and 51.08% (OR=2.40 [1.90-3.03], p<0.001) at 1-through-5-year follow-up, respectively. The 30-day major adverse events after elective EVAR were higher in octogenarians (OR=1.75-2.83, p<0.001).

CONCLUSIONS

Octogenarians experience higher but acceptable peri-operative morbidity and mortality compared with younger patients. However, 3-year to 5-year survival is very low among octogenarians. Our findings challenge the notion of routine intervention in elderly patients and support very careful selection for elective EVAR. Many octogenarians with peri-threshold (<6 cm) AAAs may derive no benefit from EVAR due to limited 3-year to 5-year overall survival and low risk of aneurysm rupture with conservative management. An adjusted threshold for intervention in octogenarians may be warranted.

CLINICAL IMPACT

Octogenarians with infra-renal AAA are increasingly managed with elective EVAR. Previous studies have demonstrated that EVAR is safer than open repair for octogenarians, with lower peri-operative mortality and major adverse events. However, randomised trials, on which much of contemporary evidence is based, recruited a relatively younger population of participants. This systematic review and meta-analysis provides a contemporary synthesis of the literature comparing outcomes in octogenarians to younger patients. The results of this analysis, together with low rupture rates amongst octogenarians in existing literature, question the benefit of routine elective intervention for peri-threshold aneurysms and an adjusted threshold for intervention in octogenarians may be warranted.