Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA.
Division of Vascular Surgery, Boston University, Boston, MA.
J Vasc Surg. 2024 Jan;79(1):34-43.e3. doi: 10.1016/j.jvs.2023.09.005. Epub 2023 Sep 14.
Abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm in men and 5 cm in women. Because AAA is more common among the elderly, we sought to evaluate contemporary practices of elective AAA repair and 2-year postoperative outcomes in octogenarians.
We identified octogenarians undergoing elective AAA repair in the Vascular Quality Initiative from 2012 to 2019. We included patients undergoing endovascular (EVAR) and open (OAR) aortic repair. Demographics and comorbid conditions were compared between patient groups. Frailty was calculated using previously published methods. Patients with frailty scores above the 75th percentile of the operative cohort were considered high frailty. The primary outcome was 1- and 2-year mortality. Secondary outcomes included postoperative complications. Standard statistical methods were utilized. Cox proportional hazard models were used to identify factors that affect mortality.
The frequency of AAA repair in octogenarians has remained stable. Of all aortic operations, 21.4% were performed on octogenarians; 9735 (23.3% of 41,712) EVAR and 755 (10.3% of 7325) OARs. Among octogenarian patients, 42.0% of EVARs were under size thresholds: 48.3% males ≤5.5 cm diameter and 21.5% females ≤5.0 cm diameter compared with 18.8% OARs: 23.4% males and 10.7% females. Additionally, 25.6% had high frailty scores. Among octogenarians, 1- and 2-year mortality was 9.3% ± 0.3% and 14.8% ± 0.4% for EVAR and 15.2% ± 1.3% and 18.9% ± 1.5% for OAR patients, respectively (P < .01). In-hospital mortality rate was higher after OAR (0.87% EVAR vs 7.55% OAR; P < .01) and differed with frailty (EVAR, low frailty 0.2% vs high frailty 1.7%; OAR, low frailty 2.3% vs high frailty 15.6%). For EVAR, patient factors associated with mortality included heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.06-1.25; P = .001) and dialysis (HR, 1.71; 95% CI, 1.13-2.59; P = .012). For OAR, coronary artery disease (HR, 1.55; 95% CI, 0.98-2.44; P = .062) was associated with mortality. Statin use was protective of mortality for all patients (EVAR: HR, 0.68; 95% CI, 0.60-0.78; P < .01): OAR: HR, 0.58; 95% CI, 0.37-0.92; P = .020). Among octogenarians, high frailty was independently associated with 2-year mortality (EVAR: HR, 3.36; 95% CI, 2.62-4.31; P < .01 and OAR: HR, 2.35; 95% CI, 1.09-5.10; P = .030).
Nationally, a large portion of elective AAA repair in octogenarians is performed below recommended size thresholds, one-quarter of whom are frail with poor long-term 2-year mortality rates. High 2-year mortality following AAA repair in this age group exceeds the published risk of rupture for 5- to 5.5-cm AAA, suggesting that increase in the size threshold of elective repair among octogenarians should be explored.
对于男性腹主动脉瘤（AAA）大于 5.5cm 和女性 AAA 大于 5cm 的患者，建议进行 AAA 修复。由于 AAA 在老年人中更为常见，我们旨在评估 80 岁以上患者接受择期 AAA 修复的当代实践以及术后 2 年的结果。
我们在 2012 年至 2019 年的血管质量倡议中确定了接受择期 AAA 修复的 80 岁以上患者。我们纳入了接受血管内修复（EVAR）和开放修复（OAR）的患者。比较了两组患者的人口统计学和合并症情况。使用先前发表的方法计算虚弱程度。虚弱评分高于手术队列第 75 百分位的患者被认为是高虚弱患者。主要结局是 1 年和 2 年死亡率。次要结局包括术后并发症。采用标准统计方法。使用 Cox 比例风险模型来确定影响死亡率的因素。
80 岁以上患者接受 AAA 修复的频率保持稳定。在所有主动脉手术中，21.4%在 80 岁以上患者中进行；9735 例（41712 例的 23.3%）EVAR 和 755 例（7325 例的 10.3%）OAR。在 80 岁以上的患者中，42.0%的 EVAR 低于尺寸阈值：男性 48.3%直径小于 5.5cm，女性 21.5%直径小于 5.0cm，而 OAR 患者中，男性 23.4%，女性 10.7%。此外，25.6%的患者有高虚弱评分。在 80 岁以上的患者中，EVAR 组的 1 年和 2 年死亡率分别为 9.3%±0.3%和 14.8%±0.4%，OAR 组分别为 15.2%±1.3%和 18.9%±1.5%（P<0.01）。OAR 术后院内死亡率更高（EVAR 为 0.87%，OAR 为 7.55%；P<0.01），且与虚弱程度相关（EVAR：低虚弱为 0.2%，高虚弱为 1.7%；OAR：低虚弱为 2.3%，高虚弱为 15.6%）。对于 EVAR，与死亡率相关的患者因素包括心力衰竭（HR，1.15；95%CI，1.06-1.25；P=0.001）和透析（HR，1.71；95%CI，1.13-2.59；P=0.012）。对于 OAR，冠心病（HR，1.55；95%CI，0.98-2.44；P=0.062）与死亡率相关。他汀类药物的使用对所有患者的死亡率都有保护作用（EVAR：HR，0.68；95%CI，0.60-0.78；P<0.01）：OAR：HR，0.58；95%CI，0.37-0.92；P=0.020）。在 80 岁以上的患者中，高虚弱与 2 年死亡率独立相关（EVAR：HR，3.36；95%CI，2.62-4.31；P<0.01 和 OAR：HR，2.35；95%CI，1.09-5.10；P=0.030）。
在全国范围内，对 80 岁以上患者进行的择期 AAA 修复中，很大一部分手术低于建议的尺寸阈值，其中四分之一的患者虚弱且长期 2 年死亡率较差。该年龄段 AAA 修复后 2 年死亡率较高，超过了 5-5.5cm AAA 破裂的公布风险，这表明应探讨增加择期修复的尺寸阈值。
