Van Damme H, Sakalihasan N, Vazquez C, Desiron Q, Limet R
Department of Cardiovascular, CHU Liège, Belgium.
Acta Chir Belg. 1998 Mar-Apr;98(2):76-84.
The decision on whether to operate or not abdominal aortic aneurysms (AAA) in elderly depends on the relative risk of the operation versus the natural course of the unoperated AAA. From January 1984 to December 996, 138 patients, aged 80 years and older, were referred to our department for an aneurysm of 40 mm or more (transverse diameter) of the infrarenal abdominal aorta (95 asymptomatic, 15 painful, and 28 ruptured AAA). For 58 patients with asymptomatic AAA, operation was denied at referral because of transverse diameter less than 50 mm (n = 21), patient refusal (n = 10) or unacceptable operative risk or poor general condition (n = 27). Thirty-four of these observed AAA were ultimately operated after a mean delay of 41 months because of aneurysm enlargement (n = 15), aneurysm tenderness (n = 6) or rupture (n = 13). Overall, 52 patients had immediate (n = 37) or delayed (n = 15) elective repair of their AAA, with an in-hospital mortality of 5.7%. Urgent operation was done for 21 patients with a painful AAA. Six patients died at hospital (28% mortality rate). Emergent surgery was applied to 41 patients with ruptured AAA (including 13 AAA who ruptured during surveillance). The operative mortality in this subgroup attained 68%. Follow-up for the 77 survivors and the 24 non-operative patients averaged 43 months. The 5-year survival (operative mortality included) is 47% for electively operated patients, 30% for urgently and 20% for emergently operated patients. For comparison, the 5-year survival of an age and sex matched Belgian population is 63%. For the 24 medically followed AAA, the 5-year survival was 33%. In six cases, the cause of death was rupture of the AAA. Of the 58 patients for whom operation was initially not considered, 19 (33%) presented AAA rupture (13 operated in emergency and 6 who never came to surgery). The operative outcome of AAA repair in octogenarians is less favourable than in the younger age group (3.6% mortality after elective repair, 44% after operation for AAA rupture, according to our institution data). The authors conclude that AAA surgery should not be denied to octogenarians on the basis of advanced age alone. They recommend a straightforward surgery for otherwise healthy octogenarians with AAA of 50 mm diameter, surveillance up to 60 mm for high-risk patients and no surgery for unfit, bedridden or demented patients.
对于老年腹主动脉瘤（AAA）患者是否进行手术的决策，取决于手术的相对风险与未手术AAA的自然病程。1984年1月至1996年12月，138例年龄在80岁及以上的患者因肾下腹主动脉瘤（横径40mm或更大）被转诊至我科（95例无症状，15例疼痛，28例破裂性AAA）。对于58例无症状AAA患者，转诊时因横径小于50mm（n = 21）、患者拒绝（n = 10）或手术风险不可接受或一般状况差（n = 27）而未进行手术。这些观察到的AAA中有34例最终在平均延迟41个月后因动脉瘤增大（n = 15）、动脉瘤压痛（n = 6）或破裂（n = 13）而接受手术。总体而言，52例患者进行了AAA的即刻（n = 37）或延迟（n = 15）择期修复，住院死亡率为5.7%。对21例疼痛性AAA患者进行了急诊手术。6例患者在医院死亡（死亡率28%）。对41例破裂性AAA患者进行了急诊手术（包括13例在监测期间破裂的AAA）。该亚组的手术死亡率达到68%。对77例幸存者和24例未手术患者的随访平均为43个月。择期手术患者的5年生存率（包括手术死亡率）为47%，急诊手术患者为30%，紧急手术患者为20%。作为对比，年龄和性别匹配的比利时人群的5年生存率为63%。对于24例接受医学随访的AAA患者，5年生存率为33%。6例患者的死亡原因是AAA破裂。在最初未考虑手术治疗的58例患者中，19例（33%）出现AAA破裂（13例进行了急诊手术，6例未进行手术）。八旬老人AAA修复的手术结果不如年轻患者（根据我们机构的数据，择期修复后死亡率为3.6%，AAA破裂手术后死亡率为44%）。作者得出结论，不应仅凭高龄就拒绝为八旬老人进行AAA手术。他们建议，对于其他方面健康、直径50mm的AAA八旬老人应直接进行手术，对高危患者监测至60mm，对不适合手术、卧床或痴呆患者不进行手术。
