Outcome of Elective Endovascular Abdominal Aortic Aneurysm Repair in Nonagenarians

Study Questions:

Do the advantages of endovascular aortic aneurysm repair (EVAR) extend to nonagenarians?

Methods:

Over a 10-year period, 24 patients ages >90 underwent EVAR at a single institution and were identified in a retrospective review of a prospectively maintained database. Preoperative aneurysm size and anatomic characteristics were determined with computed tomography (CT) angiography. Postoperatively, patients were followed at 1, 6, and 12 months and annually with CT angiography. Analysis of the data was done on an intention-to-treat basis. Complications, morbidity rates, and mortality rates over the follow-up period were calculated.

Results:

The mean patient age in the study was 91.5 ± 1.5 years (range, 90-95 years); 83.3% were male, and the mean aneurysm size was 6.8 cm (range, 5.2-8.7 cm). The mean procedural blood loss was 490 ml and 20.8% were transfused intraoperatively. Regional anesthesia was used in all cases. Five patients (20.8%) experienced endoleaks: three type I and two of indeterminate type. Mean length of stay was 6 days, and one third of patients were discharged on postoperative day 1. Major perioperative adverse events occurred in 25%, and the perioperative mortality rate was 8.3% (two patients). There were no conversions to open repair. The secondary intervention rate was 12.5%. Two patients (8.3%) died of ruptured aneurysms during follow-up. Freedom from all-cause mortality was 8.2% at 1 year and 19.3% at 5 years. Freedom from aneurysm-related mortality was 87.5% at 1 year and 73.2% at 5 years.

Conclusions:

The authors concluded that EVAR in nonagenarians is associated with acceptable outcomes and may be of benefit in very carefully selected patients >90 years of age.

Perspective:

With the aging population, we will see increasing numbers of patients in their 90s presenting with large aneurysms. The decision to repair, or not repair, aneurysms in these patients is a decision that we will have to make. In my opinion, the data presented here can be used to argue for or against EVAR in nonagenarians. A perioperative mortality of 8.3% and morbidity of 25%, in a group of patients whose overall survival rate is 19% at 5 years, is something to consider seriously when offering a 90-year-old patient EVAR. We have all seen the ‘vigorous’ 90-year-old who will likely do better than many 80-year-olds who undergo EVAR, but they are the exception rather than the rule. Even so, in my experience, these ‘vigorous’ patients can tolerate the operation you perform, but frequently cannot tolerate any associated complications.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine

Keywords: Blood Vessel Prosthesis Implantation, Follow-Up Studies, Morbidity, Vascular Surgical Procedures, Postoperative Period, Endoleak, Surgical Procedures, Elective, Aneurysm, Ruptured, Tomography, Aortic Aneurysm, Abdominal


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