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Severe Comorbidities And Mortality Risk Following Fenestrated Endovascular Repair Of Complex Abdominal Aortic Aneurysms
Ariela Zenilman, MD1, Kirsten Dansey, MD
2, Sara Zettervall, MD
2, Nicholas Swerdlow, MD
3, Hiroo Takayama, MD, PhD
1, Virendra I. Patel, MD. MPH
1, Thomas FX O'Donnell, MD
1.
1Columbia University Medical Center, New York, NY, USA,
2University of Washington, Seattle, WA, USA,
3Brigham and Women's Hospital, Boston, MA, USA.
OBJECTIVES: Endovascular repair has expanded the proportion of patients eligible for repair of complex abdominal aortic aneurysms, but concerns remain about appropriate patient selection given the high comorbid burden of this patient population. We therefore studied the association with certain high-risk comorbidities and short- and medium-term survival.
METHODS: We studied all elective fenestrated endovascular repairs of complex abdominal aortic aneurysms in the VQI from 2014-2022. Severe comorbidities included dialysis, home oxygen, poor functional status (lack of independence with activities of daily living), and ejection fraction (EF) <30%. Adjusted perioperative mortality, Thoracoabdominal Life Altering Events (TALE: the composite of death, permanent spinal cord ischemia, stroke and dialysis) were calculated using multilevel logistic regression, clustering by hospital and surgeon, and adjusted medium-term survival using cox regression.
RESULTS: There were 3,613 repairs during the study period. Of these, 38 (1.1%) were on dialysis, 230 (6.4%) on home oxygen, 84 (2.3%) poor functional status, and 80 (2.2%) EF<30%. Perioperative death increased stepwise with the number of comorbidities present (none: 2.7%, one: 5.0%, two: 14.3%, over two: 100%). In adjusted analyses, only EF<30% and dialysis were independently associated with perioperative death (EF<30: OR 3.7 [1.6-8.9], P=.003; dialysis: OR 3.1 [0.6-14.7], P=.09), and TALE (EF<30%: OR 2.8 [1.3-6.3], P=.01; dialysis: OR 6.2 [2.3-16.9], P<.001). However, all conditions except poor functional status were independently associated with medium-term survival (dialysis: HR 2.3 [1.2-4.5], P=.046; home oxygen: HR 1.7 [1.2-2.3], P=.003; EF<30%: HR 1.7 [1.05-2.9], P=.03). Survival decreased stepwise with the addition of each comorbidity, with one-year survival of 92%, 80%, 70% and 0% for none, one, two and over two comorbidities, respectively (Figure 1).
CONCLUSIONS: Severe comorbidities, especially low ejection fraction and dialysis, were associated with high perioperative and medium-term risk, with multiple conditions increasing risk exponentially. These data highlight the importance of careful patient selection for these complex repairs.
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