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Operative Management of Ruptured Abdominal Aortic Aneurysms in the Elderly
Micah E. Girotti, MD, Anna Eliassen, MD, Katherine A. Gallagher, MD, John E. Rectenwald, MD, Jonathan L. Eliason, MD, Dawn M. Coleman, MD.
University of Michigan, Ann Arbor, MI, USA.
OBJECTIVES:
Although elective open and endovascular aortic aneurysm repair (EVAR) in the elderly is documented as safe, justification for interventions on ruptured aneurysms remains unclear given the increase in perioperative mortality in patients >80 years old. This study evaluates the safety and efficacy of open surgery and EVAR for ruptured abdominal aortic aneurysm (rAAA) in the elderly at an institutional and national level.
Methods:
A retrospective review of a single center experience with rAAA was performed. The patient population was stratified as elderly (age ≥ 80) and non-elderly (NE); analysis was performed based on type of repair (open vs. EVAR). Primary outcomes included complications and 30-day mortality. Univariate regression was used to analyze the effect of independent variables on the primary outcomes. A Kaplan-Meier (KM) analysis for survival was performed. Additionally, national trends in post-operative complication and mortality were similarly assessed using 2008-2009 NSQIP data.
Results:
69 patients were managed between 2003 and 2013. Eighteen (26%) were elderly. The elderly and NE cohorts were similar in demographics, comorbidities, and aneurysm size. In the elderly cohort 8 patients underwent EVAR and 10 underwent open repair. 30-day mortality rates were 12.5% and 80% respectively (P=0.03). In the NE cohort 21 patients underwent EVAR and 30 patients underwent open repair. 30-day mortality rates were 19% and 30% respectively (P=0.52). Despite elderly patients being significantly more anemic, hypothermic and hypotensive, outcomes for the two groups were similar. Sub-set analysis of open repair and EVAR in the elderly revealed significantly lower rates of complications (100% v. 42.9%, P=0.02) and a trend toward shorter length of stay in the EVAR cohort. Final sub-set analysis of all EVAR patients revealed no differences in outcomes between elderly and NE patients. Analysis of NSQIP data revealed similar results with no statistically significant difference in major morbidity or mortality following EVAR. National sampled 30-day mortality rates were 34.2% for octogenarians undergoing EVAR for rAAA in comparison to 25.8% for younger patients (P=0.17).
CONCLUSIONS:
National and institutional data suggest that elderly patients fare as well as younger patients following EVAR for rAAA. Given high rates of morbidity and mortality, decisions to offer open repair to elderly patients should be made thoughtfully and with clearly defined expectations.
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