Higher Frailty Is Associated With Poor Long-term Survival In Octa- And Nonagenarians Undergoing Elective Endovascular Aneurysm Repair (EVAR)
Tatiana Chadid, MD, Laura T. Boitano, MD, MPH, Charles S. Decarlo, MD, Adam Tanious, MD, Sunita D. Srivastava, MD, Glenn M. LaMuraglia, MD, Matthew J. Eagleton, MD, Schwartz I. Samuel, MD.
Massachusetts General Hospital, Boston, MA, USA.
OBJECTIVES: Endovascular abdominal aortic aneurysm repair (EVAR) in the elderly is often questioned due to heterogeneous results and survival. Frailty, a risk factor for postoperative outcomes, offers information about vulnerable patients. This study evaluates the association of frailty and outcomes after EVAR in the very elderly.
METHODS: A retrospective analysis of institutional data evaluated elective EVAR in patients aged ≥80 years (01/2010 to 01/2019[LB1] ). Frailty was quantified using the 11-point modified frailty index (mFI) with scores ranging from 0 (low frailty) to 1 (high frailty), and patients were divided into 3 groups: low frailty (mFI score: 0-0.18), moderate frailty (mFI score: 0.18-0.27), high frailty (mFI score: 0.36-0.63). Primary endpoint was long-term 5-year survival. Other outcomes included 30-day mortality, major perioperative complications and 1-year survival. Cox regression determined predictors of 5-year survival.
RESULTS: Overall, 183 elderly patients underwent elective EVAR (78.6% male). Mean age was 84.6±3.5 years. Median mFI was 0.18 (Interquartile range [IQR]: 0-0.27). There were 57.1%, 22.5% and 20.3% of patients in the low, moderate and high frailty groups, respectively. There were 25 major perioperative complications and no difference between mFI groups (9.6% vs. 12.2% vs. 13.5%, p=0.778). Patients with highest mFI, indicating highest frailty, had the lowest survival at 1- and 5-years, with only 35% alive at 5 years compared to 88% and 62% in the low and moderate groups (p<0.001). Moderate (hazard ratio (HR): 2.9, 95% CI: 1.5-5.5; p=0.02) and high frailty (HR: 6.6, 95% CI: 3.5-12.4; p<0.001) remained associated with lower 5-year survival after risk adjustment.
CONCLUSIONS: Elderly patients with low frailty have acceptable outcomes after EVAR. However, higher frailty is associated with unacceptably low long-term survival. Careful selection of elderly patients for EVAR is essential and an assessment of frailty should be utilized to assist preoperatively with decision making.
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