Octogenarians with AAA Face Higher Mortality, Slower Recovery After Elective EVAR

Download this article's Factoid (PDF & PPT for Gold Subscribers) 

Recovery of quality of life (QoL) after elective endovascular aortic aneurysm repair (EVAR) takes longer for those aged 80 years or older compared with younger patients, reports a registry study published online March 21, 2014, ahead of print in the Journal of Vascular Surgery. Moreover, octogenarians have an elevated risk of adverse events and all-cause death at 1 year.

Robert A. Pol, MD, PhD, of University Medical Center Groningen (Groningen, the Netherlands), and colleagues examined outcomes of 1,263 patients with infrarenal abdominal aortic aneurysm (AAA) who received the Endurant endograft (Medtronic, Santa Rosa, CA) from March 2009 to April 2011 and were enrolled in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE).

Patients were stratified by age at the time of the procedure, with 22.9% ≥ 80 years and 77.1% younger than 80.

Outcomes Similar Initially, Diverge Over Time

Technical success was nearly 99% in both age groups. Anatomic and procedural characteristics differed, however. For example, compared with younger patients, octogenarians had larger aneurysm size (61.9 mm ± 11.3 mm vs 59.8 mm ± 11.7 mm; P = 0.007) and greater infrarenal neck angulation (33.2° ± 24.0° vs 29.5° ± 23.6°; P = 0.021). Older patients also had procedures that lasted a mean of 9.4 minutes longer (P = 0.002) and stayed in the hospital for a mean of 1.4 more days (P < 0.001). Initial outcomes tended to be similar between the 2 groups.

At 1 year, all-cause mortality was higher for older patients as were the rates of major adverse events (bowel ischemia, MI, paraplegia, renal failure, respiratory failure, or stroke) and aneurysm rupture (table 1).

Table 1. Outcomes at 1 Year After Elective EVAR by Age

In particular, the 1-year rate of MI was doubled in the octogenarian cohort compared with the younger patients (0.4% vs 0.2%). In addition, twice as many secondary endovascular procedures were necessary to correct type I/III endoleaks in this group (2.4% vs 1.1%); after 1 year, this resulted in a difference in the aneurysm rupture rate favoring the younger group (0.7% vs 0.0%; P = 0.01). Conversion to open surgery and performance of overall secondary endovascular procedures did not differ by age.

QoL as assessed by the composite EuroQoL 5-Dimensions Questionnaire was similar for both age groups in most dimensions except for mobility (P = 0.03) and self-care (P < 0.001). At 1 year, octogenarians reported more problems in mobility (P < 0.001), self-care (P < 0.001), usual activity (P < 0.001), and perception of pain and discomfort (P = 0.001). There was some improvement within the older cohort compared with baseline for mobility, pain/discomfort, and anxiety/depression; however, unlike younger patients, octogenarians still had not completely recovered their pretreatment level of QoL by 1 year (P = 0.014).

Age Still No Barrier to EVAR

In an email with TCTMD, Dr. Pol said that based on 30-day results of the ENGAGE registry, the researchers had not expected recovery of QoL to take so long in octogenarians.

One explanation for the differences in recovery between older and younger patients may be that the elderly were treated when their disease was at a more advanced stage, he suggested. “Advanced stage abdominal aneurysms have been proven less suitable for EVAR with increased rates of aneurysm-related death, all-cause mortality, and rupture. This is indeed evident from the 1-year data,” Dr. Pol said, attributing the “persistent reduction in QoL… to [patient] expectations of the surgery.”

Yet he asserted that the longer than expected recovery time should “absolutely not” deter use of EVAR in patients aged 80 years and older. Despite the current findings, “EVAR should still be considered the gold standard in octogenarians as it offers an important benefit… in elderly patients with significantly less major systemic morbidity than open repair,” Dr. Pol concluded.

However, he said, some steps can be taken to optimize outcomes for older patients.

“Providing more awareness [before the procedure] is probably more important than previously thought and may even contribute to a faster recovery,” Dr. Pol advised, adding. “Proper provision of information goes beyond procedure-related mortality and morbidity [and] should also provide the patient with more awareness [of] preservation and loss in QoL after surgery. Although this is true for all age groups, for elderly frail patients it is of great importance.”

Baseline Characteristics Suggest Possible Overtreatment

Frank A. Lederle, MD, of the Veterans Affairs Medical Center (Minneapolis, MN), told TCTMD in a telephone interview that the paper focuses too much on the strength of the statistical methodology, specifically P values, and not enough on clinical significance and other crucial information.

“Does age make everything worse? Well, of course it does,” he said. But the most important outcome—the effect of age on aneurysm-related mortality—is unreported, Dr. Lederle stressed. “So it’s very difficult to interpret.”

More troubling, however, is the fact that the aneurysm diameters of many patients in the registry were too small to merit treatment, he emphasized. “The story here is that they probably did 300 repairs of aneurysms smaller than 5.5 cm, many of these in people over 80,” Dr. Lederle noted, reporting that 4 randomized trials--UKSAT, ADAM, PIVOTAL, and CAESAR—have shown no benefit from operating on such aneurysms even “in the best candidates,” much less the elderly.

Until there are randomized trial data to support performing elective EVAR for small AAAs in octogenarians, to do so is inappropriate, he commented.

“It’s concerning that people are doing these elective repairs in patients for whom there almost certainly is no benefit,” Dr. Lederle concluded. He explained that older patients with smaller aneurysm diameters are unlikely to survive long enough for their AAAs to rupture.

 

---

Source:
Pol RA, Zeebregts CJ, van Sterkenburg SMM, et al. Outcome and quality of life after endovascular abdominal aortic aneurysm repair in octogenarians. J Vasc Surg. 2014;Epub ahead of print.

 

 

Related Stories:

• Designation as ‘Unfit for Open Repair’ Predicts Worse EVAR Outcomes
• Women, Men Fare Equally Well After Endovascular AAA Repair
• Ambulatory EVAR an Option for One-Third of AAA Patients