S. Locham1, R. Lee1, B. Nejim1, H. Aridi1, M. Faateh1, H. Alshaikh1, M. Rizwan1, J. Dhaliwal1, M. Malas1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA
Introduction:
Prior RCTs have reported better perioperative outcomes following endovascular aneurysm repair (EVAR) as compared to open aneurysm repair (OAR). EVAR-1 and DREAM trial reported significantly higher mortality for OAR as compared to EVAR. However most of these studies excluded the elderly. Age is a well-known risk factor for postoperative death and the efficacy of these approaches remains controversial in the elderly population. The aim of the study is to provide recent real world outcomes using the NSQIP database (2010-2014) exclusively looking at the predictors of mortality in a large cohort of elderly population in the United States.
Methods:
Using the NSQIP targeted vascular database (2010-2014), we identified all patients over 70 years of age who underwent OAR and EVAR for non-ruptured AAA. Explanatory analyses using Pearson’s Chi-square and Student’s t-tests were performed. Univariate and multivariable logistic regression analyses were implemented to examine postoperative morbidities and mortality adjusting patient demographics and characteristics.
Results:
A total of 5,332 non-ruptured AAA repairs were performed [OAR: 809 (15%) vs. EVAR: 4,523 (85%)]. The majority of patients were male (77%) and white (81%) with mean age of 78 ± 6 years. Diabetes mellitus and obesity were more prevalent in the EVAR group (15% vs. 12%, p=0.01) and (30% vs. 25%, p=0.002), respectively. Whereas, history of chronic obstructive pulmonary disease (COPD) (22% vs. 19%, p=0.02) and smoking status (35% vs 23%, p<0.001) were more likely to be seen in patients undergoing an OAR. On average the operative time in minutes (250 vs. 151) and mean length of stay in days (11 vs. 3) was also longer for patients undergoing OAR versus EVAR (p<0.001). The mortality was higher following OAR versus EVAR (8% vs 3%, p<0.001). Compared to EVAR, OAR was associated with higher rates of cardiac (7% vs. 2%), renal (7% vs. 1%), pulmonary (20% vs. 3%) and any wound complications (4% vs. 2%) (all p<0.05). After adjusting for patients’ characteristics and comorbidities, OAR was associated with 3 times higher mortality than EVAR [OR(95%CI): 3.04(2.01-4.57), p<0.001]. The predictors of mortality in our elderly cohort were age, female gender, smoking status, functional dependency, history of COPD, steroid use, bleeding disorders, progressive renal failure, transfusion, aneurysm diameter and Type IV TAAA.
Conclusion:
Our study reflects contemporary real world outcomes following repair of non-ruptured AAA in the elderly. Endovascular approach was associated with significant reduction in the risk of postoperative cardiac, pulmonary and renal complications the elderly. Open repair was associated with 3 fold increase in mortality compared to EVAR and should be avoided in the elderly. Further prospective studies involving geriatric population is required to better understand the predictors of mortality following AAA repair.