title: Designation as "unfit for open repair" is associated with poor outcomes after endovascular aortic aneurysm repair.
abstract: BACKGROUND
  Endovascular aortic aneurysm repair (EVAR) is often offered to patients with abdominal aortic aneurysms (AAAs) considered preoperatively to be unfit for open AAA repair (oAAA). This study describes the short- and long-term outcomes of patients undergoing EVAR with AAAs <6.5 cm who are considered unfit for oAAA.
  
  
  RESULTS
  We analyzed elective EVARs for AAAs <6.5 cm diameter in the Vascular Study Group of New England (2003-2011). Patients were designated as fit or unfit for oAAA by the treating surgeon. End points included in-hospital major adverse events and long-term mortality. We identified patient characteristics associated with being unfit for open repair and predictors of survival using multivariable analyses. Of 1653 EVARs, 309 (18.7%) patients were deemed unfit for oAAA. These patients were more likely to have advanced age, cardiac disease, chronic obstructive pulmonary disease, and larger aneurysms at the time of repair (54 versus 56 mm, P=0.001). Patients unfit for oAAA had higher rates of cardiac (7.8% versus 3.1%, P<0.01) and pulmonary (3.6 versus 1.6, P<0.01) complications and worse survival rates at 5 years (61% versus 80%; log rank P<0.01) compared with those deemed fit for oAAA. Finally, patients designated as unfit for oAAA had worse survival, even adjusting for patient characteristics and aneurysm size (hazard ratio, 1.6; 95% confidence interval, 1.2-2.2; P<0.01).
  
  
  CONCLUSIONS
  In patients with AAAs <6.5 cm, designation by the operating surgeon as unfit for oAAA provides insight into both short- and long-term efficacy of EVAR. Patients unable to tolerate oAAA may not benefit from EVAR unless their risk of AAA rupture is very high.
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Randall R
authors.initials: RR
authors.lastname: De Martino
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Brooke
authors.forename: William
authors.initials: W
authors.lastname: Robinson
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Indes
authors.forename: Jessica B
authors.initials: JB
authors.lastname: Wallaert
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D009511:New England; D011183:Postoperative Complications / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
keywords: aneurysm; complications; mortality
references.citation: Lancet. 2005 Jun 25-Jul 1;365(9478):2179-86
references.pmid: 15978925
references.citation: J Vasc Surg. 2011 Aug;54(2):287-94
references.pmid: 21367562
references.citation: J Clin Epidemiol. 2004 Dec;57(12):1223-31
references.pmid: 15617947
references.citation: Br J Surg. 2008 Jun;95(6):677-84
references.pmid: 18446774
references.citation: N Engl J Med. 2004 Oct 14;351(16):1607-18
references.pmid: 15483279
references.citation: J Vasc Surg. 2012 May;55(5):1529-37
references.pmid: 22542349
references.citation: J Vasc Surg. 2007 Dec;46(6):1093-1101; discussion 1101-2
references.pmid: 17950568
references.citation: Circulation. 2011 Dec 13;124(24):2661-9
references.pmid: 22104552
references.citation: JAMA. 2002 Jun 12;287(22):2968-72
references.pmid: 12052126
references.citation: Eur J Vasc Endovasc Surg. 2004 Apr;27(4):372-81
references.pmid: 15015186
references.citation: JAMA. 2009 Oct 14;302(14):1535-42
references.pmid: 19826022
references.citation: Lancet. 2005 Jun 25-Jul 1;365(9478):2187-92
references.pmid: 15978926
references.citation: Ann Vasc Surg. 2011 Jul;25(5):590-7
references.pmid: 21724099
references.citation: J Vasc Surg. 2005 Oct;42(4):650-3
references.pmid: 16242549
references.citation: J Vasc Surg. 2006 Aug;44(2):229-36
references.pmid: 16690242