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Delay in Surgery is Associated with Worse Peri-Operative Outcomes in Patients with Asymptomatic Abdominal Aortic Aneurysms
Isibor J. Arhuidese, MB.BS MPH, Christopher J. Abularrage, MD, Umair Qazi, MD MPH, Julie A. Freischlag, MD, Mahmoud B. Malas, MD MHS.
Johns Hopkins University, Baltimore, MD, USA.
Objectives: Elective repair of Abdominal Aortic Aneurysms (AAA) is associated with significant perioperative mortality. When repair is delayed, patients with asymptomatic large AAA face the risk of death from rupture. We evaluate the impact of operative delay on perioperative mortality, which is largely un-documented, for patients who meet the criteria for repair.
Methods: We queried the American college of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for all patients 50 years and older who underwent endovascular or open repair for asymptomatic AAA between 2005 and 2011. Multivariable logistic regression was used to evaluate the effect of increasing age on 30-day post-operative mortality. This association was analyzed with age as a categorical variable, in a spline model and as a continuous variable. Delay in repair was inferred from increments in age.
Results: There was an 87% increase in the odds of death in patients aged between 65 and 79 years compared to patients less than 65 years (OR: 1.87 95%CI 1.24 – 2.81; P=0.002). The odds of death in patients aged 80 to 89 years was 3.5 times the odds of death in patients less than 65 years of age (OR: 3.5 95%CI 2.27 – 5.37; P<0.001). The odds of death in patients aged 90 years or more was 6.5 times the odds of death in patients less than 65 (OR: 6.5 95%CI 3.28 – 12.89; P<0.001). Spline models showed that the increase in perioperative mortality with age was linear. There was a relative increase of 7% (OR: 1.07, 95%CI 1.05 – 1.08; P<0.001) in the odds of death after repair of AAA with each year of operative delay independent of type of treatment. There was a relative increase of 5% for EVAR (OR: 1.05, 95%CI 1.03 – 1.07; P<0.001) and 8% for open repair (OR: 1.08, 95%CI 1.06 – 1.11; P<0.001) with each year increase in age.
Conclusions: To our knowledge, this is the first study that shows a linear relationship between age and perioperative mortality. Our results confirm that perioperative mortality worsens with increasing age and the advantage conferred by EVAR is higher at older ages. There is an increase in the risk of perioperative mortality associated with delay in repair of AAA for patients who meet the criteria for repair.
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