Division of Vascular and Endovascular Surgery, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
Department of Statistical Science, Southern Methodist University, Dallas, TX, USA.
J Endovasc Ther. 2022 Jun;29(3):381-388. doi: 10.1177/15266028211049342. Epub 2021 Oct 8.
Treatment decisions for the elderly with abdominal aortic aneurysms (AAAs) are challenging. With advancing age, the risk of endovascular aneurysm repair (EVAR) increases while life expectancy decreases, which may nullify the benefit of EVAR. The purpose of this study was to quantify the impact of EVAR on 1-year mortality in patients of advanced age.
The 2003-2020 Vascular Quality Initiative Database was utilized to identify patients who underwent EVAR for AAAs. Patients were included if they were 80 years of age or older. Exclusions included non-elective surgery or missing aortic diameter data. Predicted 1-year mortality of untreated AAAs was calculated based on a validated comorbidity score that predicts 1-year mortality (Gagne Index, excluding the component associated with AAAs) plus the 1-year aneurysm-related mortality without repair. The primary outcome for the study was 1-year mortality.
A total of 11 829 patients met study criteria. The median age was 84 years [81, 86] with 9014 (76.2%) being male. Maximal AAA diameters were apportioned as follows: 39.6% were <5.5 cm, 28.6% were 5.5-5.9 cm, 21.3% were 6.0-6.9 cm, and 10.6% were ≥7.0 cm. The predicted 1-year mortality rate without EVAR was 11.9%, which was significantly higher than the actual 1-year mortality rate with EVAR (8.2%; p<0.001). The overall rate of perioperative MACE was 4.4% (n = 516). Patients with an aneurysm diameter <5.5cm had worse actual 1-year mortality rates with EVAR compared to predicted 1-year mortality rates without EVAR. In contrast, those with larger aneurysms (≥5.5cm) had better actual 1-year mortality rates with EVAR. The benefit from EVAR for those with Gagne Indices 2-5 was largely restricted to those with AAAs ≥ 7.0cm; whereas those with Gagne Indices 0-1 experience a survival benefit for AAAs larger than 5.5 cm.
The current data suggest that EVAR decreases 1-year mortality rates for patients of advanced age compared to non-operative management in the elderly. However, the survival benefit is largely limited to those with Gagne Indices 0-1 with AAAs ≥ 5.5 cm and Gagne Indices 2-5 with AAAs ≥ 7.0 cm. Those of advanced age may benefit from EVAR, but realizing this benefit requires careful patient selection.
对于老年腹主动脉瘤（AAA）患者的治疗决策颇具挑战性。随着年龄的增长，血管内修复术（EVAR）的风险增加，而预期寿命却降低，这可能使 EVAR 的获益化为泡影。本研究旨在定量评估 EVAR 对高龄患者 1 年死亡率的影响。
本研究利用 2003 年至 2020 年血管质量倡议数据库，确定了接受 EVAR 治疗的 AAA 患者。纳入标准为年龄 80 岁或以上。排除标准为非择期手术或缺失主动脉直径数据。根据预测 1 年死亡率的合并症评分（不包括与 AAA 相关的成分）加上未经修复的 1 年与动脉瘤相关的死亡率，计算未治疗 AAA 的预测 1 年死亡率。本研究的主要结局为 1 年死亡率。
共有 11829 例患者符合研究标准。中位年龄为 84 岁[81，86]，9014 例（76.2%）为男性。AAA 最大直径分配如下：39.6%直径<5.5cm，28.6%直径为 5.5-5.9cm，21.3%直径为 6.0-6.9cm，10.6%直径≥7.0cm。未行 EVAR 的预测 1 年死亡率为 11.9%，显著高于 EVAR 的实际 1 年死亡率（8.2%；p<0.001）。围手术期主要不良心脑血管事件（MACE）发生率为 4.4%（n=516）。与未经 EVAR 治疗的预测 1 年死亡率相比，直径<5.5cm 的患者行 EVAR 后实际 1 年死亡率较差。相比之下，直径较大的动脉瘤（≥5.5cm）行 EVAR 后实际 1 年死亡率更好。Gagne 指数为 2-5 的患者，行 EVAR 的获益主要限于 AAA≥7.0cm；而 Gagne 指数为 0-1 的患者，AAA 直径大于 5.5cm 行 EVAR 则有生存获益。
目前的数据表明，与老年患者的非手术治疗相比，EVAR 降低了高龄患者的 1 年死亡率。然而，生存获益主要局限于 Gagne 指数为 0-1 且 AAA 直径≥5.5cm 以及 Gagne 指数为 2-5 且 AAA 直径≥7.0cm 的患者。高龄患者可能从 EVAR 中获益，但实现这一获益需要仔细的患者选择。
