Endovascular Aortic Repair Improves One-Year Survival in Octogenarians
Mitri K. Khoury, Christopher A. Heid, Jacqueline Babb, Bala Ramanan, Shirling Tsai, Melissa L. Kirkwood, Carlos H. Timaran, John Gregory Modrall
University of Texas, Southwestern, Dallas, TX
Introduction: Treatment decisions for octogenarians with abdominal aortic aneurysms (AAAs) are challenging. With advancing age, the risk of endovascular aortic repair (EVAR) increases while life expectancy decreases, which may nullify the benefit of EVAR. It is currently unknown whether offering repair to those of advanced aged improves overall mortality. The purpose of this study was to quantify the impact of EVAR on one-year mortality in octogenarians.
Methods: The 2003-2020 Vascular Quality Initiative Database was utilized to identify patients that underwent EVAR for AAAs. Patients were included if they were greater than 79 years of age. Exclusions included non-elective surgery or missing aortic diameter data. Predicted one-year mortality of untreated AAAs was calculated by adding the one-year mortality based on a validated comorbidity score that predicts one-year mortality (Gagne Index) plus the one-year aneurysm-related mortality without repair (one-year aortic rupture risk based on aneurysm diameter x 0.85). The primary outcome for the study was one-year mortality. Secondary outcomes included perioperative major adverse cardiac events (MACE; clinically significant arrhythmia, congestive heart failure, and myocardial infarction).
Results: A total of 11,829 patients met study criteria. The median age was 84 years [IQR 81-86 years] with 9,014 (76.2%) being male. There was a total of 4681 (39.6%) patients operated on for an aortic diameter <5.5cm, 3381 (28.6%) 5.5-5.9cm, 2514 (21.3%) 6.0-6.9cm, and 1253 (10.6%) >7.0cm. The predicted one-year mortality rate without EVAR was 13.1%, which was significantly higher than the actual one-year mortality rate with EVAR (10.6%) (p<.001). Patients with a Gagne Index 0-4 had significantly lower actual one-year mortality rates with EVAR compared to the predicted one-year mortality rates without repair (Table 1). There were no differences in actual versus predicted mortality rates in patients with a Gagne Index 5-8 (Table 1). Patients with an aneurysm diameter <5.5cm had no differences in predicted one-year mortality rate without EVAR compared to the actual one-year mortality rate with repair; however, differences were seen for those with larger aneurysms (Table 2). Variables associated with mortality over time were: age (HR 1.03, 95% CI 1.01-1.05), body mass index (HR .97, 95% CI .95-.98), coronary artery disease (HR 1.25, 95% CI 1.09-1.43), aspirin use (HR .73, 95% CI .63-.83), statin use (HR .73, 95% CI .63-.83), abdominal aortic aneurysm diameter (HR1.02, 95% CI 1.02-1.03), independent functional status (HR 2.04, 95% CI 1.56-2.66), and increasing Gagne Index (HR 1.34, 95% CI 1.29-1.40). The overall rate for perioperative MACE was 0.1% (n=8).
Conclusion: EVAR decreases one-year mortality rates for octogenarians compared to non-operative management. No significant benefit of EVAR was observed for patients with a Gagne Index >5 and AAA size <5.5cm, so preference should be given to octogenarians with lower Gagne Indexes and larger AAAs.
Table 1.
| Gagne Index | N | Predicted | Actual | P-Value |
| 0 | 2161 | 10.2% | 6.0% | <.001 |
| 1 | 3258 | 12.5% | 8.4% | <.001 |
| 2 | 1987 | 15.3% | 11.1% | <.001 |
| 3 | 937 | 19.7% | 16.2% | .019 |
| 4 | 575 | 23.5% | 21.0% | .006 |
| 5 | 204 | 28.5% | 21.6% | .137 |
| 6 | 68 | 32.8% | 29.4% | .853 |
| 7 | 15 | 38.9% | 53.3% | .715 |
| 8 | 7 | 48.2% | 28.6% | 1.0 |
Table 2.
| Diameter | N | Predicted | Actual | P-Value |
| <5.5cm | 3529 | 7.7% | 8.5% | .256 |
| 5.5-5.9cm | 2615 | 15.0% | 9.4% | <.001 |
| 6.0-6.9cm | 1964 | 16.2% | 12.0% | <.001 |
| >7.0cm | 1013 | 35.3% | 18.8% | <.001 |
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