title: Defining high risk in endovascular aneurysm repair.
abstract: BACKGROUND
  Long-term survival benefit contrasted with rupture risk should determine which patients are suitable for abdominal aortic aneurysm (AAA) intervention. Our aim was to develop a model capable of predicting long-term survival based on preoperative characteristics.
  
  
  METHODS
  A prospective cohort study using Cox regression modeling. We aimed to associate preoperative characteristics with long-term mortality, and create a predictive nomogram, which was then externally validated on an independent cohort (697 patients) who underwent endovascular abdominal aortic aneurysm (AAA) repair.
  
  
  RESULTS
  We pooled the results of 412 patients undergoing endovascular repair of infrarenal and juxtarenal aneurysm who were high risk (average Glasgow aneurysm scores of 72.8 [SD 10.4]). Despite anatomic differences, there were no statistically significant differences in perioperative or long-term outcomes between infrarenal and juxtarenal aneurysms (log rank test, P = .5). Data from this group (64% infrarenal aneurysms and 36% juxtarenal aneurysms) were randomly and evenly split into a model development and test group. Independent predictors of mortality included in the model are age, aneurysm diameter, history of peripheral artery disease, chronic obstructive pulmonary disease (COPD), or congestive heart failure, requirement for supplemental home oxygen, and use of salicylates. Internal validation reveals good calibration and discriminative ability (c-statistic 0.68 [95% confidence interval 0.65-0.71]). External validation confirms good calibration.
  
  
  CONCLUSIONS
  In the context of acceptable perioperative results, long-term mortality risk can be predicted in endovascular AAA repair and must be balanced against risk of rupture to determine which patients should be offered treatment.
authors.affiliation: Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Tara M
authors.initials: TM
authors.lastname: Mastracci
authors.forename: Roy K
authors.initials: RK
authors.lastname: Greenberg
authors.forename: Adrian V
authors.initials: AV
authors.lastname: Hernandez
authors.forename: Catherine
authors.initials: C
authors.lastname: Morales
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000379:methods* / Q000401:mortality; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000401:mortality; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011475:Prosthesis Failure; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors; D014463:Ultrasonography