NEW YORK (Reuters Health) – Reasonably healthy patients older than 80 with an abdominal aortic aneurysm (AAA) that meets criteria for repair should have endovascular surgery, according to a study from Emory University in Atlanta. And they should have it electively whenever possible.
In an email to Reuters Health, senior author Dr. John J. Ricotta II said that in patients over 80, the 30-day mortality rate after elective endovascular repair (EVAR) is 2%, and in patients over 90 it’s 3.8%. When these elderly patients present with a ruptured aneurysm, however, the postoperative mortality rate jumps 10-fold for both octogenarians and nonagenarians.
Dr. K. Craig Kent, who chairs the surgery department at the University of Wisconsin, said, “This is a good study. The points the authors make are not incredibly novel but are important to individuals who manage aneurysms.”
The study, published online in the Journal of the American College of Surgeons, reviewed 2005-2010 data on AAA patients from the National Surgical Quality Improvement Project, which collects risk-adjusted data from over 400 hospitals in the U.S.
The 20,095 patients who had aortic aneurysm surgery were stratified by age into four categories: younger than 65; 65 to 79; 80 to 89; and 90 or older.
Nonagenarians had emergency surgery significantly more often than the other groups (p=0.001). Their 30-day mortality rate after elective cases – 13.2% — was significantly higher, compared to 3.1% in the youngest patients, 4.9% in the 65- to 79-year-olds, and 7.2% in the octogenarians (p = 0.01).
For emergency cases, 30-day mortality was 53.3% in the nonagenarians, 43.8% in octogenarians, 31.8% in the 65-to-79 age range, and 19.1% for patients under age 65 (p<0.001).
For all groups, mortality rates were significantly lower with EVAR.
On multivariate analysis, the odds ratios for postoperative death were 3.28 for patients aged 90 or older, 2.65 for octogenarians, and 1.85 for the 65-to-79 group, compared to patients younger than 65.
Complication risks were similar in all groups for elective surgery but were significantly higher in emergency cases in each of the three older subsets.
With data from over 20,000 patients, Dr. Ricotta feels the strength of his study is in the numbers. The results, he said, show that patients who are older than 80 have an elective mortality after EVAR of 2% compared to 7.4% for open, and for patients over 90 years of age, the mortality for EVAR is 3.8% vs 18.8% for open.
“In the emergent setting, when these elderly patients present after their aneurysm has already ruptured, the mortality rate for EVAR skyrockets 10-fold to 22% for both octogenarians and nonagenarians,” he added.
According to Dr. Ricotta, current guidelines say the threshold for AAA repair is a largest diameter of 5.5 cm for men and 5.0 cm for women, or aneurysm growth of more than 0.5 cm over six months.
But, he added, “One must assess the risk-benefit ratio.” For example, he explains, a 5.5-cm AAA has an annual rupture risk of 3% to 5% — and for a 65 year old patient in this study, the mortality rate after endovascular repair was 1.2%. “Therefore, the benefit of surgery outweighs the risk of no surgery and potential aneurysm rupture (so) it makes sense to repair the aneurysm,” he said.
However, he continued, in a 90-year old with a 5.5-cm AAA, the risk of mortality is 3.8% with EVAR, “and therefore it makes more sense to observe the aneurysm. If it grows to a point where the risk of AAA rupture exceeds the risk of surgery then repair it at that time.”
“In other words,” he adds, “these thresholds need to be individualized for each patient.”
Dr. Kent too urges that patients be chosen carefully. “The more I see and the more senior I become, the less aggressive I have become about AAAs in (the) elderly,” he said. “It’s all about selection. To use extremes, an 80-year-old with severe COPD on home oxygen with a 5.5-cm AAA might have a repair. If he dies of pulmonary failure six months later, it’s a waste of health care resources. But If I saw a 90-year-old spunky fellow with a remote history of MI but a good cardiac ejection fraction with a 6.5 cm AAA and anatomy suitable for an EVAR, I would fix this person in a minute, probably to his benefit.”
Dr. Ricotta also noted that EVAR can often be performed under local anesthesia, obviating the risk of general anesthesia for the elderly.
Both surgeons agree on the take-home message: primary care physicians and vascular surgeons should weigh the risks and benefits for elderly patients, and those with good predicted longevity and large aneurysms should undergo elective surgery if an endovascular repair is feasible.
J Am Coll Surg 2012.