EVAR in Nonagenarians Shows Acceptable Perioperative Mortality

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Endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) in patients aged 90 years or older is associated with acceptable procedural success and perioperative morbidity and mortality, according to a study published online March 3, 2011, ahead of print in the Journal of Vascular Surgery. The results suggest that the procedure may be beneficial in carefully selected nonagenarians, the authors say.

In the subset analysis, Peter L. Faries, MD, of the Mount Sinai School of Medicine (New York, NY), and colleagues analyzed outcomes from 24 patients aged 90 years or older included in a database of 322 patients aged 80 years or older who underwent elective EVAR at their institution between January 1997 and November 2007.

The study subjects’ mean age was 91 ± 1.5 years (range 90-95 years), and 83.3% were men. The mean maximum AAA diameter was 6.8 cm (range 5.2-8.7 cm).

In the 24 nonagenarians, the technical success rate of EVAR was 91.6%. Of the 2 failures, 1 involved a type I endoleak and the other a perforation by a bifurcated device. There were no intraoperative deaths. The mean estimated blood loss was 491 mL, with 5 patients requiring intraoperative transfusion. The average postoperative stay was 6 ± 9 days, although one-third of patients were discharged on the first day after the procedure.

Only 2 Perioperative Deaths

Six major complications occurred during the 30-day postoperative period, including lower limb ischemia, respiratory failure, vascular injury, TIA, and groin hematoma. In addition, 2 patients died—at 15 and 24 days after EVAR—yielding an 8.3% mortality rate.

At 1 year, 91.0% of the patients remained free from secondary reintervention. Five patients experienced endoleaks: 3 type I (2 requiring reintervention) and 2 of indeterminate type. There were no instances of conversion to open repair.

Freedom from AAA-related mortality was 87.5% at 1 year and 73.2% at 5 years. Overall, there were 5 AAA-related deaths, including 2 aneurysm ruptures that occurred at 507 and 1,254 days postprocedure. After 5.2 years only 3 of the nonagenarian patients remained alive.

“EVAR prevented death from AAA rupture in most individuals with low rates of reintervention,” the researchers write. “The medium-term results suggest that EVAR may be of limited benefit in very carefully selected patients who are aged ≥ 90 years.”

Life Expectancy a Key Factor in EVAR Decision

The researchers point out that as life expectancy continues to increase, people over 85 years represent the fastest-growing segment of the US population.

“As a result, physicians are facing the conundrum of whether to treat someone of that age, and the difficulty of measuring what the predictive life expectancy is vs. the benefit of the procedure,” Barry T. Katzen, MD, of Baptist Cardiac and Vascular Institute (Miami, FL), told TCTMD in a telephone interview. “It is possible that these results may change clinical practice, because it does seem to show that the procedure can be done safely on the front end in this group of patients.”

But physicians must still wrestle with the ethics of performing the procedure on a case by case basis, Dr. Katzen added.

“What we have to do is drill down with any individual patient,” Dr. Katzen explained. “If the patient has a [limited] life expectancy because of [metastatic] cancer, the answer is probably no, we should not do the procedure. But if the patient is physically active and maintaining an independent living, I would think the answer would be yes.

“There will always be patients that fall in between,” Dr. Katzen acknowledged. “However, in general, if we can treat these patients [with] a high level of success, and the patient has life-threatening disease, we have an obligation to protect them from that.”

Pooling Experience with Nonagenarians

The researchers state that because the study was part of a retrospective review, selection bias may have occurred. Specifically, patients deemed unfit for EVAR were not included in the study, meaning that the 24 patients examined represent a small minority of this patient population.

Dr. Katzen agreed; however, he pointed out that the average aneurysm diameter of the patients examined was 6.8 cm. “If you look at most EVAR trials, the average is closer to 5 cm, so clearly they were not just treating nonagenarians but nonagenarians with high-risk aneurysms that had grown pretty large.”

Dr. Katzen encouraged other clinicians to report their experiences treating this age group before any larger clinical trials are developed. “The fact that the authors focused on this topic is a great thing, and it will allow all of us to focus our efforts on understanding what our collective results have been to date,” he concluded.

Study Details

Hypertension (58.3%) and arrhythmia (37.5%) were the most common comorbidities.

Regional anesthesia was used in all cases. A majority of patients received a bifurcated device (87.5%) although 12.5% were treated with an aortouniiliac device: 58.3% received Talent grafts (Medtronic, Minneapolis, MN), 33.3% received Gore (WL Gore and Associates, Flagstaff, AZ), and 8.3% received AneuRx (Medtronic).

 

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Source:
Prenner SB, Turnbull IC, Serrao GW, et al. Outcome of elective endovascular abdominal aortic aneurysm repair in nonagenarians. J Vasc Surg. 2011;Epub ahead of print.

 

 

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