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Endovascular Aortic Repair in Nonagenarian Patients
Quick Takes
- Nonagenarians had an unadjusted 30-day mortality of 9.9% versus 2.2% for younger patients.
- Nonagenarians had larger aneurysms and more frequent repair after aneurysm rupture.
- Endovascular aneurysm repair in nonagenarians was associated with increased 30-day mortality on multivariable analysis, but age-associated risks were no longer significant after propensity score matching.
Study Questions:
Are 30-day outcomes of endovascular aortic repair (EVAR) different between nonagenarians (i.e., patients ≥90 years old) and non-nonagenarians?
Methods:
This study evaluated outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients treated with EVAR for intact or ruptured abdominal aortic aneurysms (AAAs) from 2011-2017 were retrospectively identified. Aneurysm diameters, prevalence of rupture at time of repair, comorbidity, and 30-day outcomes were compared between nonagenarians versus the rest of the cohort using multivariable logistic regression and propensity score matching.
Results:
A total of 12,267 patients (365 of whom were nonagenarians) treated with EVAR were analyzed. Nonagenarians had larger mean aneurysm diameters at time of repair (6.5 ± 1.8 cm vs. 5.8 ± 1.7 cm; p < 0.001) and more often underwent repair for ruptured AAA (15.7% vs. 6.5%; p < 0.001). Unadjusted 30-day mortality was 9.9% among nonagenarians versus 2.2% in non-nonagenarians (p < 0.001). Age was associated with mortality in a multivariable model (odds ratio [OR], 3.36), along with male sex (OR, 1.78), functional status (OR, 4.22), preoperative ventilator dependency (OR, 3.80), history of bleeding disorder (OR, 1.52), dialysis (OR, 2.56), and ruptured AAA (OR, 17.2). After propensity matching, however, nonagenarians and non-nonagenarians had similar rates of 30-day mortality and adverse events.
Conclusions:
Age ≥90 years should not be a stand-alone exclusion criterion for EVAR, and nonagenarians with similar comorbidities to younger patients have similar perioperative mortality.
Perspective:
A 10% perioperative mortality rate (as observed among nonagenarians in the current study) should prompt trepidation when considering an elective procedure. As stated in the background section of this paper’s abstract, the increasing proportion of nonagenarians being treated for AAA in the “endovascular era” is controversial. Although the current analysis suggests that fit nonagenarians may have similar perioperative risks as younger patients with comparable comorbidity, the more important question that remains unanswered is whether they enjoy a similar long-term survival benefit. Although the authors reference a life expectancy of 5 years for 90-year-olds living in the United States, these population-based survival estimates from the Geriatrics literature are not burdened by the front-end 10% mortality risk observed in this cohort. This is a steep disadvantage that may be challenging to overcome after EVAR for patients with a relatively limited survival horizon.
Larger AAA diameters among nonagenarians in this analysis (which included both elective and emergency EVARs) suggests that elective repairs were indeed considered more carefully among patients >90 years. The greater frequency of EVAR for ruptured AAA observed in this subgroup further suggests that some nonagenarians who initially opt for observation or defer repair reconsider after aneurysm rupture. This is certainly understandable from the patient’s perspective, since rupture comes with a 100% mortality risk in a matter of minutes to hours that usually overwhelms concerns for operative complications. Unfortunately, AAA rupture also has major negative effects on EVAR survival and other perioperative outcomes versus elective repair. These tradeoffs are important to discuss with older patients with large diameter AAA and their families, regardless of whether elective repair is undertaken or not. For those patients choosing observation, documenting their wishes regarding repair versus palliative care if rupture occurs is valuable for making a decision that is time sensitive and filled with ethical implications for doctors and family members either way.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Aortic Surgery, Interventions and Vascular Medicine
Keywords: Aortic Aneurysm, Abdominal, Aortic Rupture, Blood Vessel Prosthesis Implantation, Cardiac Surgical Procedures, Comorbidity, Endovascular Procedures, Geriatrics, Aged, 80 and over, Hemorrhage, Life Expectancy, Palliative Care, Postoperative Complications, Quality Improvement, Renal Dialysis, Vascular Diseases, Ventilators, Mechanical
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