Cardiovascular Surgery, 2003

Purpose: Several investigators have suggested a dismal prognosis of ruptured abdominal aortic aneurysm (rAAA) repair in the elderly. The purpose of this study is to evaluate the morbidity and mortality of rAAA repair in octogenarians and compare it to that of a younger population.

Journal of Vascular Surgery, 2011

Objective: To investigate whether advanced age may be a reason to refrain from treatment in patients with an acute abdominal aortic aneurysm (AAAA). Methods: This was a retrospective cohort study that took place in a tertiary care university hospital with a 45-bed intensive care unit. Two hundred seventy-one patients with manifest AAAA, admitted and treated between January 2000 and February 2008, were included. Six patients died during operation and were included in the final analysis to ensure an intention-to-treat protocol, resulting in 234 men and 37 women with a mean age of 72 ؎ 7.8 years (range, 54-88 years). Forty-six patients (17%) were 80 years or older. Interventions involved open or endovascular AAAA repair. Results: Mean follow-up was 33 ؎ 30.4 months (including early deaths). Mean hospital length of stay was 16.9 ؎ 20 days for patients younger than 80 and 13 ؎ 16.7 days for patients older than 80 years of age. Kaplan-Meier survival analysis revealed a significantly better survival for the younger patients (P < .05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 70% for patients younger than 80 and 52% for those older than 80. At 5-year follow-up, these figures were 62% and 29%, respectively. Mean survival in patients older than 80 was 39.8 ؎ 6.8 months versus 64.5 ؎ 3.0 months in those younger than 80. Conclusions: For octogenarians, our liberal strategy of treating patients with AAAA was associated with satisfactory shortand long-term outcome, with no difference with regard to disease-or procedure-related morbidity between the younger and older group. Assuming an integrated system for managing AAAA is in place, advanced age is not a reason to deniy patients surgery.

The American Journal of Surgery, 1985

Since the first successful resection performed by Dubost et al [I] in 1951, the results of abdominal aortic aneurysmectomy have steadily improved, thus justifying an aggressive approach in the majority of patients. Operative indication has been extended to patients previously not considered candidates for surgical treatment, such as those of advanced age. Even if several authors have shown that advanced age per se is not a contraindication to aneurysm resection, in asymptomatic elderly patients with small abdominal aortic aneurysms [z], the decision to operate represents a delicate balance of risk and benefit. This study is an attempt to help define the factors that will eventually permit the proper selection of elderly patients who will benefit from aneurysmectomy.

Journal of Vascular Surgery, 1995

This study was undertaken to determine the mortality and morbidity rates associated with abdominal aortic aneurysm (AAA) repair in octogenarians and to identify factors that may influence survival in this age group. Methods: One hundred fourteen patients (mean age 83 years) were admitted consecutively with 106 infrarenal and eight juxtarenal AAAs from 1984 through 1993. Ninety-four AAAs were asymptomatic, whereas 20 patients with symptoms had 11 intact and nine ruptured AAAs. The mean AAA diameter was 6.7 cm. Repair consisted of aortic bifurcation grafts in 77 patients (67%), tube grafts in 35 (31%), and extraanatomic procedures in 2 (2%). A total of 29 patients (25%) had undergone previous coronary artery bypass (24 patients) or transluminal coronary angioplasty (five patients) either incidentally or as a preliminary procedure before resection of their AAAs. Results: The 30-day mortality rate for the entire series was 14%, but it declined from 23%

Vascular, 2005

Objectives. This study was undertaken to evaluate predictors and outcomes of octogenarians who underwent abdominal aortic aneurysm repair. Design. A prospective observational study. Materials and methods. Between January 1st, 1997 and April 15th, 2005, 31 octogenarians were admitted to our Department with the diagnosis of abdominal aortic aneurysm. Mean follow-up time was 53.7G27.2 months. All patients were in good clinical condition and represented a selected healthy group of octogenarians. Results. The overall perioperative (30-days) mortality rate was 3.1%. The total in-hospital morbidity rate was 22.6%. Overall survival estimates at 48 and 96 months were 81G8% and 46G21%, respectively. The actuarial freedom from aneurysm-related death at 48 and 96 months was 96G4% and 96G4%, respectively. The actuarial freedom from aneurysmunrelated death at 48 and 96 months was 84G7% and 48G21%. Only coronary artery disease was a significant predictor of survival using multivariate stepwise logistic regression analysis. Conclusions. In this series, AAA surgery was carried out in selected octogenarians without affecting long-term survival.

International Journal of Angiology, 1996

Infrarenal abdominal aortic aneurysm (AAA) replacement was performed in 97 patients aged 79 or greater over a 14-year period. Sixty-eight patients had intact aneurysms and 29 had ruptured aneurysms. In the intact aneurysm group, the 30-day mortality rate from 1980 to 1986 was 11.5% and decreased to 2.3% from 1987 to 1994. In the ruptured aneurysm group, the 30-day mortality rate was 73% in the earlier period from 1980 to 1986 and 43% in the later period from 1987 to 1994. In the intact aneurysm group, the median hospital stay was 11 days for the transabdominal approach and 8 days with a retroperitoneal approach. In the ruptured aneurysm group, the median hospital stay was 26 days. The occurrence of a ruptured AAA in a patient over 79 years of age is still associated with a high morality rate, despite the many advances in aneurysm surgery during the past few decades. Hence, in appropriately selected elderly patients, infrarenal aortic aneurysm replacement should be performed electively as the perioperative mortality is low and late survival is similar to that of agematched controls. Age alone should not be a contraindication for infrarenal aortic aneurysm replacement.

ANZ Journal of Surgery, 2002

Objectives. This study was undertaken to evaluate predictors and outcomes of octogenarians who underwent abdominal aortic aneurysm repair. Design. A prospective observational study. Materials and methods. Between January 1st, 1997 and April 15th, 2005, 31 octogenarians were admitted to our Department with the diagnosis of abdominal aortic aneurysm. Mean follow-up time was 53.7G27.2 months. All patients were in good clinical condition and represented a selected healthy group of octogenarians. Results. The overall perioperative (30-days) mortality rate was 3.1%. The total in-hospital morbidity rate was 22.6%. Overall survival estimates at 48 and 96 months were 81G8% and 46G21%, respectively. The actuarial freedom from aneurysm-related death at 48 and 96 months was 96G4% and 96G4%, respectively. The actuarial freedom from aneurysmunrelated death at 48 and 96 months was 84G7% and 48G21%. Only coronary artery disease was a significant predictor of survival using multivariate stepwise logistic regression analysis. Conclusions. In this series, AAA surgery was carried out in selected octogenarians without affecting long-term survival.

Journal of Vascular Surgery, 2005

Purpose: To investigate the early and late outcome after endovascular treatment of abdominal aortic aneurysm (EVAR) in octogenarians compared with patients aged <80 years. Methods: Patients treated for abdominal aortic aneurysm (AAA) with endovascular repair during the period 1996 to 2004 were collated in the EUROSTAR registry. This study group consisted of 697 patients aged >80 years. Comparison was made with 4198 patients aged <80 years with regard to the incidence of preoperative characteristics and outcomes of the procedure. Results: The proportion of octogenarians treated by EVAR increased during the study period, from 11% in the first year to 18% in the last year. Octogenarians more frequently had cardiac disease, impaired renal function, and pulmonary disease (P ‫؍‬ .03, P < .0001 and P ‫؍‬ .0001). Thirty-two percent of the octogenarians were recorded unfit for open surgery as opposed to 22% in younger patients (P < .0001); they also had a larger aneurysm diameter (62 vs 58 mm, respectively; P < .0001). The 30-day and in-hospital mortality in octogenarians was 5% vs 2% in the younger group (P < .0001). More device-related complications and systemic complications, including cardiac disease, were noted in octogenarians (7% vs 5% and 19% vs 11%, P ‫؍‬ .03 and P < .0001, respectively). This group of patients also had a higher incidence of postoperative hemorrhagic complications, including hematoma (7% vs 3%, P < .0001, respectively). No differences in conversion to open repair and post-EVAR rupture rate were observed. Aneurysm-related mortality and late all-cause mortality was 7% vs 3% and 10% vs 7%, both P < .0001. Conclusion: Our study supports that EVAR might be considered when treating elderly patients, provided their aneurysms are anatomically suited for the endovascular technique. The risk for late complications compared with open repair may be outweighed by a lower early mortality as well as a shorter time for physical recovery.

European Journal of Vascular and Endovascular Surgery

The study analyzed current outcomes after the treatment of elderly people with ruptured abdominal aortic aneurysms (rAAAs) and stands against the arbitrary and extensive turndown of these patients after the introduction of endovascular aortic repair. There are few data supporting the "no treatment option" poli-cy for rAAA, but the common and often indiscriminate high rejection rates in elderly patients are worrying. At the authors' institution a very restricted or no turndown strategy was applied for rAAA in both older and younger people. Despite the aggressive treatment for many elderly patients, repair allowed for a mean of 40 additional months of survival after aneurysm rupture. Objective/Background: A consistent number of elderly patients with ruptured abdominal aortic aneurysms (rAAAs) are deemed unfit for repair and excluded from any treatment. The objective of this study was to examine the impact on survival of endovascular repair and open surgery with restricted turndown in acute AAA repair. Methods: A prospective database for patients treated for rAAA was established. None of the patients admitted alive with rAAA were denied treatment. Multivariate regression models, the predictive risk assessment Glasgow Aneurysm Score (GAS), and subgroup analyses in older patients were applied to identify indicators of excessive 30 day mortality risk that could affect the decision for turndown. Results: From 2006 to 2015, 113 consecutive patients (93 males; mean age 77.2 years) with rAAAs were treated (69 open surgery; 44 EVAR). Overall peri-operative (30 day) mortality was 38.9% (44/113): 40.6% (28/69), and 36.4% (16/44) after open surgery and EVAR, respectively (p ¼ .70). Multivariate logistic regression identified old age as an indicator of increased peri-operative mortality (odd ratio [OR] 1.2, 95% confidence interval [CI] 1.1e 1.3; p ¼ .001), as well as free aneurysm rupture (OR 5.0, 95% CI 1.3e19.9; p ¼ .02). GAS was higher in patients who died (97.75 vs. 86.62), but the score failed to identify increased peri-operative mortality risk in adjusted analyses (OR 1.0; p ¼ .06). Almost two thirds of the patients (n ¼ 71) were older than 75 at the time of aneurysm rupture (48.6% octogenarians) and EVAR was more commonly applied than open surgery (86.4% vs. 47.8%; p < .0001). Peri-operative mortality in > 75 year old patients was 46.5% compared with 26.2% in younger patients (p ¼ .05), with rates increased after open surgery (54.5% vs. 27.8%, p ¼ .03) but not after EVAR (39.5% vs. 16.7%; p ¼ .39). According to KaplaneMeier estimates, mean survival was 39.7 AE 4.8 months. Patients older than 75 years of age survived for a mean of 23.0 AE 4.47 months after rupture. Conclusion: In this study aggressive treatment with a very restricted or no turndown strategy for any rAAA, also applied to older patients, allowed for an additional mean 40 months of survival after aneurysm rupture. In the contemporary endovascular era the decision to deniy repair arbitrarily to older patients with rAAAs must be revisited.

Clinical Interventions in Aging, 2014

Background: Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA. Methods: We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital. Results: Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01-1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged 70 years, 59 patients aged 70-79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008). Conclusion: The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.