Morbidity and Mortality Following EVAR and Open AAA Repair in Ruptured Abdominal Aortic Aneurysms in Octogenarians

Life expectancy of the North American population over 80 years of age is on the rise. Octogenarian abdominal aortic aneurysm (AAA) repair constitutes more than 20% of the intact AAA repairs performed in several countries. However, to date, no study has investigated the prevalence and outcomes associated with ruptured AAA (rAAA) repair in octogenarians. Our goal was to use the Vascular Quality Initiative (VQI) database to quantify differences in survival and morbidity outcomes following rAAA in octogenarians. A multicenter, retrospective cohort study was conducted using the VQI database. All patients who underwent endovascular aneurysm repair (EVAR) or open rAAA repair between January 1, 2003, and November 30, 2021, were included. Propensity-score matching was used to balance the two groups for known confounding factors. Cox proportional hazard models on the matched data were used for calculation of mortality. Binomial regression for calculation of length of stay (LOS) and Poisson regression for calculation of mortality risk. A total of 1451 octogenarians underwent rAAA repair. The majority underwent EVAR (63.1%) and were male (69.9%) and Caucasian (89.4%). Table I depicts baseline clinical characteristics. The average maximum diameter of rAAA at time of presentation was 74.6 ± 20.7 mm, and the mean time to repair was 21.8 ± 45.9 hours. The overall in-hospital, 30-day, and 1-year mortality was 38.7%, 47.9%, and 60.2%, respectively. The relative risk (RR) for in-hospital, 30-day, and 1-year mortality of open rAAA repair compared with EVAR was 1.4 (95% confidence interval [CI], 1.21-1.60), 1.18 (95% CI, 1.05-1.32), and 1.09 (95% CI, 1.00-1.19), respectively. Fig 1 demonstrates the survival probability between the two groups. The hazard ratio (HR) for open rAAA repair compared with EVAR was 1.33 (95% CI, 1.14-1.55). Open rAAA compared with EVAR demonstrated a significantly longer intensive care unit and hospital LOS (RR, 1.66; 95% CI, 1.41-1.95 and RR, 1.16; 95% CI, 0.83-1.63). Overall repair of rAAA in octogenarians was associated with a 61% in-hospital survival. Patients who underwent EVAR had a 33% lower likelihood of death compared with those who underwent open rAAA repair.Table IBasic clinical characteristicsTotal rAAAEndovascular rAAAOpen rAAAn = 1451n = 916n = 535Demographics Age, years848484 Sex, male1015 (69.9)645 (70.1)370 (69.1) BMI, kg/m226.7 ± 6.226.9 ± 6.526.2 ± 5.6 RaceWhite1297 (89.4)807 (87.9)492 (92)Black/African American63 (4.34)55 (6)8 (1.5)Asian19 (1.31)16 (1.75)3 (0.56)American Indian or Alaskan Native3 (0.21)2 (0.22)1 (0.19)Native Hawaiian1 (0.07)–1 (0.19)Unknown/other64 (4.41)36 (3.93)28 (5.23)Hispanic or Latino32 (2.2)23 (2.5)9 (1.68)Medical history HTN1224 (84.35)766 (83.6)458 (85.6) DM253 (17.4)166 (18.1)87 (16.3) SmokingNever462 (31.8)314 (34.3)148 (27.7)Prior642 (44.2)410 (44.7)232 (43.4)Active296 (20.4)163 (17.8)133 (24.86) Family history of AAA55 (3.8)30 (3.3)25 (4.7) CAD symptoms388 (26.7)242 (26.4)146 (27.3) COPD448 (16.8)257 (28.1)191 (35.7) Prior aneurysm repair77 (5.3)55 (6.0)22 (4.1) ASA608 (41.9)379 (41.4)229 (42.8) Plavix123 (8.5)93 (10.1)30 (5.6) Statin694 (47.8)452 (49.3)242 (45.2) Chronic beta blocker588 (40.5)385 (42.0)203 (37.9) ACE in use424 (29.2)295 (32.2)129 (24.1)Preoperative Maximum AAA diameter74.65 ± 20.772.7 ± 20.9178.1 ± 20.3 Time of symptoms to repair, hours21.76 ± 45.8722.53 ± 50.4120.45 ± 43.03 Preoperative creatinine128.8 ± 63.5130.1 ± 59.4126.6 ± 65.8 Preoperative Hgb109.7 ± 22.7109.96 ± 22.22109.19 ± 22.97 Preoperative EF<30%23 (1.6)17 (1.8)6 (1.12)30%-50%101 (6.9)52 (5.68)49(9.16)>50%389 (26.8)128 (13.97)261 (48.78)Not done or unknown925 (63.7)708 (77.29)217 (40.56) Lowest pre-intubation sBP89.19 ± 31.6791.84 ± 30.1584.7 ± 32.24 Mental status, normal1044 (71.9)664 (72.5)380 (71.03)Operative EBL1992.7 ± 3279.3649.6 ± 4006.84310.7 ± 1665.70 Autotransfusion––1528.0 ± 1702.1 Intraoperative pRBC4.8 ± 5.53.35 ± 5.97.2 ± 4.7 Crystalloid3363 ± 2829.12373 ± 3387.15075.6 ± 1825 Total procedure time, minutes168.1 ± 98.8146.1 ± 112.21205.6 ± 82.4AAA, Abdominal aortic aneurysm; ACE, angiotensin-converting enzyme; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; EBL, estimated blood loss; EF, ejection fraction; Hgb, hemoglobin; HTN, hypertension; pRBC, packed red blood cells; rAAA, ruptured abdominal aortic aneurysm; sBP, systolic blood pressure.Data are presented as number (%), median, or mean ± standard deviation. Open table in a new tab