Jim Jeffrey, Sanchez Luis A, Sicard Gregorio A, Curci John A, Choi Eric T, Geraghty Patrick J, Flye M Wayne, Rubin Brian G
Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
Ann Vasc Surg. 2010 May;24(4):441-6. doi: 10.1016/j.avsg.2009.10.009. Epub 2009 Dec 29.
We report the outcomes of a single-center experience with endovascular aneurysm repair (EVAR) in nonagenarians.
Via a retrospective medical records review, we identified all patients > or = 90 years old who underwent EVAR at a single university teaching hospital during a 5-year period (January 2004 to December 2008). Patients were evaluated for surgical risk factor profile, preoperative imaging, technical success, postoperative complications, length of hospital stay, and need for secondary intervention. In addition, mortality rates were evaluated at 30 days, 365 days, and 2 years.
There were 18 nonagenarians (12 male, 67%) with a mean age of 91.2 years (range 90-95). Each patient averaged 3.5 risk factors, and the mean preoperative maximal aneurysm size was 68.3mm (range 50-105). Sixteen (89%) patients were treated on an elective basis, and two patients were emergently treated for aneurysm rupture, with one undergoing aortouni-iliac stenting with femoral-femoral bypass. All other patients in the study had bifurcated stent grafts. There was 100% technical success with no need for open conversion. The mean length of hospital stay was 4.3 days with a mean intensive care unit stay of 0.6 days. Systemic complications occurred in three patients (17%) including one death within 30 days. Secondary interventions were required in two patients (11%). One had endovascular treatment of a type I endoleak at 4 months, and a second patient underwent femoral-femoral bypass at 25 months for severe flow-limiting limb angulation. Mortality rates were 5.6% at 30 days, 41.2% at 365 days, and 58.3% at 2 years. Mean survival of the 11 patients who expired beyond the first 30 days was 17.5 months (range 4-50). Of these, mean survival of the nine patients treated electively was 20.2 months (range 7-50). Mean survival of the six patients still alive is 25.6 months (range 8-65).
EVAR is safe in nonagenarians despite their advanced age and significant surgical risk factor profile. The procedure can be performed with excellent technical success and a low rate of perioperative complications. However, mortality rates after 30 days are significant. The substantial long-term mortality raises the question of possible treatment futility in this unique population. While age should not be a contraindication for EVAR, recommendations for the procedure should be based on individual patient selection.
我们报告了一家单中心对非agenarians进行血管内动脉瘤修复术（EVAR）的经验结果。
通过回顾性病历审查，我们确定了在一所大学教学医院5年期间（2004年1月至2008年12月）接受EVAR的所有年龄≥90岁的患者。对患者进行手术风险因素评估、术前影像学检查、技术成功率、术后并发症、住院时间以及二次干预需求评估。此外，评估30天、365天和2年时的死亡率。
有18例非agenarians（12例男性，67%），平均年龄91.2岁（范围90 - 95岁）。每位患者平均有3.5个风险因素，术前最大动脉瘤平均大小为68.3mm（范围50 - 105）。16例（89%）患者为择期治疗，2例患者因动脉瘤破裂接受急诊治疗，其中1例接受主动脉单髂动脉支架置入术并股股旁路移植术。研究中的所有其他患者均使用分叉型支架移植物。技术成功率达100%，无需转为开放手术。平均住院时间为4.3天，平均重症监护病房停留时间为0.6天。3例患者（17%）发生全身并发症，包括1例在30天内死亡。2例患者（11%）需要二次干预。1例在4个月时对I型内漏进行了血管内治疗，另1例患者在25个月时因严重的血流受限肢体成角接受了股股旁路移植术。30天死亡率为5.6%，365天死亡率为41.2%，两年死亡率为58.3%。在最初30天后死亡的11例患者的平均生存期为17.5个月（范围4 - 50）。其中，9例择期治疗患者的平均生存期为20.2个月（范围7 - 50）。6例仍存活患者的平均生存期为25.6个月（范围8 - 65）。
尽管非agenarians年龄较大且手术风险因素显著，但EVAR对他们是安全的。该手术技术成功率高，围手术期并发症发生率低。然而，30天后的死亡率较高。较高的长期死亡率引发了在这一特殊人群中可能存在治疗无效的问题。虽然年龄不应成为EVAR的禁忌证，但该手术的建议应基于个体患者的选择。
