Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea

ABDOMINAL AORTIC ANEURYSM IN PATIENTS OVER 80 YEARS. COMPARATIVE ANALYSIS OF SOME ASPECTS ACCORDING TO THE DATA OF RYAZAN (RUSSIA) AND DUSHANBE (TAJIKISTAN)

Highlights

No studies have been published comparing the treatment of abdominal aortic aneurysms in residents of the Central Asian region and Russia ≥80 years of age. Differences in the number of emergency and planned operations in the studied countries have been revealed. Thus, despite the predominance of planned operations in the total structure, the frequency of emergency operations related to AAA rupture is extremely high, which is associated with a large aneurysm diameter. In Tajikistan there is no difference in mortality between patients of different age groups, while in the Russian Federation this indicator is higher among persons up to and including 79 years of age. The number of comorbidities is high in both countries.

 

Abstract

Aim. To analyse the demography, the structure of comorbidity and mortality in the treatment of patients with AAA with an age priority of study up to 79 and over 80 years old in Russia and Tajikistan.

Methods. A retrospective, comparative study of patients with infrarenal AAA who underwent endovascular repair of abdominal aortic aneurysm (EAAA) or open AAA reconstruction during the period from 2011 to 2015 at the clinic of Russian State Medical University named after N.N. acad. I.P. Pavlov in Ryazan, Russia and in the RSCCS, Dushanbe, Tajikistan (2011–2017). The study included 226 patients, 60 from Dushanbe (Tajikistan) and 166 from Ryazan (Russia). The study examined age, gender, comorbidities: diabetes, coronary heart disease (CHD), hypertension, COPD, smoking, as well as abdominal aortic diameter and 30-day mortality.

Results. There are significantly more male patients with AAA in both countries. The number of comorbidities (CHD, hypertension, COPD, diabetes) per patient reaches 2.30 in Russia and 2.35 in Tajikistan. The number of patients older than 80 years in Russia was 11.4% and in Tajikistan 23.7% of the total number of patients operated on for AAA. In all countries, patients with AAA, inclusive, up to 79 years of age are statistically significantly more than patients 80 years of age or older. There are statistically significantly more patients under 79 in Russia. The age of patients after 80 is statistically significantly higher among patients from Russia. The number of emergency operations in all countries is significantly lower than elective operations, but still emergency operations were performed in almost one third of cases. In the group of patients up to 79 years old, the smallest number of emergency operations due to aneurysm ruptures was found in Russia. In the group of patients aged 80 years old and over, the smallest number of elective surgeries was found in Russia. The AAA diameter in patients from the two countries did not differ statistically significantly and amounted to 60.0 [48.0; 75.0] and 57.0 [54.0; 61.5] mm. in RF and RT, respectively (p > 0.05). In the age category up to 79 years old, there were statistically significantly fewer men in Tajikistan than in Russia. However, in the category after 80 years old there are statistically significantly fewer men in Russia than in Tajikistan. In Tajikistan, there was no difference in mortality between ages, however, in the Russian Federation it is higher in patients up to 79 years of age inclusive.

Conclusion. As the results of the study showed, the average age of all patients with AAA was elderly, and the number of patients older than 80 years was 11.4% and 23.4% in Russia and Tajikistan, respectively. The group of patients over 80 years of age, according to the criterion of average age, was older among patients from Russia. It is important that the number of emergency operations in all countries is significantly lower than planned, but emergency operations were performed in almost one third of cases. In addition, the number of high-risk comorbidities is high in both countries.

Impact of Serum Albumin Levels and Body Mass Index on Outcomes of Open Abdominal Aortic Aneurysm Repair in Korean Population

BACKGROUND

Although obese patients seem to be susceptible to chronic diseases, obesity paradox has been observed in the field of vascular surgery, in which many previous studies have reported that overweight patients have good postoperative outcomes and underweight patients have poor postoperative outcomes. The purpose of our study is to evaluate the impact of body mass index (BMI) and serum albumin levels, which are evaluated as indicators of nutritional status, on outcomes of open abdominal aortic aneurysm (AAA) repair.

METHODS

We reviewed the vascular surgery database of a single tertiary referral center for all patients who underwent open AAA repair due to degenerative etiology from 1996 to 2021. To analyze the effect of BMI, patients were classified into 4 groups according to the Asian-Pacific classification of BMI: underweight (UW) (<18.5 kg/m2), normal weight (NW) (18.5-22.9 kg/m2), overweight (OW) (23-24.9 kg/m2), and obese (OB) (≥25 kg/m2). The χ2, Fisher's exact, and Kruskal-Wallis tests were used to compare demographics, comorbidities, radiologic findings, surgical details, and 1-year mortality rates between the 4 groups. We also compared the preoperative serum albumin levels of each group to assess nutritional status indirectly. Cox's proportional hazards model was performed to determine factors associated with mortality. A Kaplan-Meier survival analysis was performed, and the differences were analyzed by a log-rank test. We did not perform an analysis for 30-day mortality because cases of 30-day mortality in UW patients were rare due to the unbalanced distribution of the number of patients in the 4 groups.

RESULTS

Among a total of 678 patients, 22 were classified as UW (3.2%), 200 as NW (29.5%), 183 as OW (27.1%), and 273 as OB (40.1%). The median age was 70 (64-75) years and 577 of 678 (85.1%) patients were male gender. Higher serum albumin level was associated with decreased 1-year mortality (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.15-0.63; P = 0.001). UW patients had a higher 1-year mortality rate than NW patients (HR, 3.67; 95% CI, 1.02-13.18; P = 0.046). OB patients had a lower overall mortality rate than NW patients (HR, 0.73; 95% CI, 0.53-1; P = 0.05).

CONCLUSIONS

Low BMI (<18.5 kg/m2) and low serum albumin level were associated with poor 1-year survival after elective open AAA repair. These patients also need more careful preoperative intervention, like weight gain or nutritional support, for better outcomes. The obesity paradox existed in our study; high BMI (≥25 kg/m2) was associated with better overall survival after elective open AAA repair.

Outcomes of octogenarians receiving aortic repair

OBJECTIVE

Abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm in men and 5 cm in women. Because AAA is more common among the elderly, we sought to evaluate contemporary practices of elective AAA repair and 2-year postoperative outcomes in octogenarians.

METHODS

We identified octogenarians undergoing elective AAA repair in the Vascular Quality Initiative from 2012 to 2019. We included patients undergoing endovascular (EVAR) and open (OAR) aortic repair. Demographics and comorbid conditions were compared between patient groups. Frailty was calculated using previously published methods. Patients with frailty scores above the 75th percentile of the operative cohort were considered high frailty. The primary outcome was 1- and 2-year mortality. Secondary outcomes included postoperative complications. Standard statistical methods were utilized. Cox proportional hazard models were used to identify factors that affect mortality.

RESULTS

The frequency of AAA repair in octogenarians has remained stable. Of all aortic operations, 21.4% were performed on octogenarians; 9735 (23.3% of 41,712) EVAR and 755 (10.3% of 7325) OARs. Among octogenarian patients, 42.0% of EVARs were under size thresholds: 48.3% males ≤5.5 cm diameter and 21.5% females ≤5.0 cm diameter compared with 18.8% OARs: 23.4% males and 10.7% females. Additionally, 25.6% had high frailty scores. Among octogenarians, 1- and 2-year mortality was 9.3% ± 0.3% and 14.8% ± 0.4% for EVAR and 15.2% ± 1.3% and 18.9% ± 1.5% for OAR patients, respectively (P < .01). In-hospital mortality rate was higher after OAR (0.87% EVAR vs 7.55% OAR; P < .01) and differed with frailty (EVAR, low frailty 0.2% vs high frailty 1.7%; OAR, low frailty 2.3% vs high frailty 15.6%). For EVAR, patient factors associated with mortality included heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.06-1.25; P = .001) and dialysis (HR, 1.71; 95% CI, 1.13-2.59; P = .012). For OAR, coronary artery disease (HR, 1.55; 95% CI, 0.98-2.44; P = .062) was associated with mortality. Statin use was protective of mortality for all patients (EVAR: HR, 0.68; 95% CI, 0.60-0.78; P < .01): OAR: HR, 0.58; 95% CI, 0.37-0.92; P = .020). Among octogenarians, high frailty was independently associated with 2-year mortality (EVAR: HR, 3.36; 95% CI, 2.62-4.31; P < .01 and OAR: HR, 2.35; 95% CI, 1.09-5.10; P = .030).

CONCLUSIONS

Nationally, a large portion of elective AAA repair in octogenarians is performed below recommended size thresholds, one-quarter of whom are frail with poor long-term 2-year mortality rates. High 2-year mortality following AAA repair in this age group exceeds the published risk of rupture for 5- to 5.5-cm AAA, suggesting that increase in the size threshold of elective repair among octogenarians should be explored.