Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, GA 30322, USA.
J Am Coll Surg. 2012 Nov;215(5):690-701. doi: 10.1016/j.jamcollsurg.2012.06.411. Epub 2012 Aug 3.
In the endovascular era, elderly patients are offered repair of their aortoiliac aneurysms (AAA) more frequently than in the past. Our objective is to compare age groups and draw inferences for AAA repair outcomes.
We identified 20,095 patients who underwent AAA repair between 2005 and 2010 using the American College of Surgeons NSQIP national database. Preoperative characteristics and outcomes were compared among age groups (group A: 0 to 64 years; B: 65 to 79 years; C: 80 to 89 years; and D: 90 years and older).
The age distribution of the cohort was A: 17.1%, B: 57.2%, C: 24%, and D: 1.7%. Nonagenarians presented significantly more often as emergencies in comparison with groups A to C (A: 13.8%, B: 10.8%, C: 12.9%, D: 22.1%; p < 0.001). Endovascular aneurysm repair was performed more frequently in older patients (A: 55.2%, B: 63.7%, C: 74.6%, D: 77.9%; p < 0.001). Risk of any complication was significantly different among groups, becoming more prevalent with advanced age (A: 22.8%, B: 23.4%, C: 24.7%, D: 27.8%; p = 0.041). Nonsurgical complications (A: 14.7%, B: 16.4%, C: 18%, D: 19.8%; p < 0.001) and cardiovascular complications (A: 3.9%, B: 4.5%, C: 5.5%, D: 5.2%; p = 0.003) were also higher with advanced age. Overall mortality was 3.1%, 4.9%,7.2%, and 13.2% for groups A to D, respectively (p < 0.001). Mortality after elective AAA repair was significantly higher for open surgery compared with endovascular aneurysm repair in all age groups (open surgery vs endovascular aneurysm repair, A:1.9% vs 0.5%; p = 0.001; B: 3.9% vs 1.2%; p < 0.001; C: 7.4% vs 2%; p < 0.001; D: 18.8% vs 3.8%; p = 0.004). After adjusting for confounders in the entire cohort, advanced age persisted as an independent factor for postoperative mortality with a higher risk of death of 1.8 (95% CI, 1.3-2.5), 2.7 (95% CI, 1.9-3.8), and 3.3 (95% CI, 1.8-6.1) times for groups B, C, and D, respectively (group A reference).
Advanced age is independently associated with higher risk of death after AAA repair and indication for surgery should be adjusted for different age groups accordingly. Endovascular aneurysm repair should be preferred for octogenarians and nonagenarians with indication to undergo repair of their AAA.
在血管内治疗时代，与过去相比，老年患者接受腹主动脉瘤（AAA）修复的频率更高。我们的目的是比较不同年龄组并得出 AAA 修复结果的推论。
我们使用美国外科医师学院 NSQIP 国家数据库确定了 2005 年至 2010 年间接受 AAA 修复的 20095 名患者。比较了年龄组（A 组：0 至 64 岁；B 组：65 至 79 岁；C 组：80 至 89 岁；D 组：90 岁及以上）之间的术前特征和结果。
队列的年龄分布为 A：17.1%，B：57.2%，C：24%，D：1.7%。与 A 至 C 组相比，90 岁以上的非高龄患者更常以急诊就诊（A：13.8%，B：10.8%，C：12.9%，D：22.1%；p <0.001）。在较年长的患者中，血管内动脉瘤修复的比例明显更高（A：55.2%，B：63.7%，C：74.6%，D：77.9%；p <0.001）。所有并发症的风险在各组之间均有显著差异，随着年龄的增长而更为普遍（A：22.8%，B：23.4%，C：24.7%，D：27.8%；p = 0.041）。非手术并发症（A：14.7%，B：16.4%，C：18%，D：19.8%；p <0.001）和心血管并发症（A：3.9%，B：4.5%，C：5.5%，D：5.2%；p = 0.003）随着年龄的增长而增加。A 至 D 组的总死亡率分别为 3.1%、4.9%、7.2%和 13.2%（p <0.001）。在所有年龄组中，择期 AAA 修复后开放手术的死亡率明显高于血管内动脉瘤修复（开放手术与血管内动脉瘤修复相比，A：1.9% vs 0.5%；p = 0.001；B：3.9% vs 1.2%；p <0.001；C：7.4% vs 2%；p <0.001；D：18.8% vs 3.8%；p = 0.004）。在整个队列中调整混杂因素后，高龄仍然是术后死亡率的独立危险因素，B、C 和 D 组的死亡风险分别增加 1.8 倍（95%CI，1.3-2.5）、2.7 倍（95%CI，1.9-3.8）和 3.3 倍（95%CI，1.8-6.1）（B 组参考）。
高龄与 AAA 修复后死亡风险增加独立相关，应根据不同年龄组调整手术指征。对于有 AAA 修复指征的 80 岁及以上高龄患者，应优先考虑血管内动脉瘤修复。
