Elective EVAR in nonagenarians is safe in carefully selected patients.
BACKGROUND
Nonagenarians are typically considered poor operative candidates for major aortic intervention because of shorter life expectancy, multiple comorbidities, and increased perioperative morbidity and mortality. Endovascular abdominal aortic aneurysm repair (EVAR) has clearly been associated with a lower perioperative morbidity and mortality in most anatomically suitable patients. There have been many reports of the technical success of EVAR in octogenarians, but few documenting EVAR in nonagenarians. In this study, we sought to review our experience with elective EVAR in nonagenarians to determine outcomes, complications, and long-term survival after repair.


METHODS
We retrospectively reviewed our prospectively maintained aneurysm database from 2000 to 2010 at an academic referral center. Fifteen patients ≥90 years old underwent elective EVAR. No symptomatic or ruptured abdominal aortic aneurysm patients >90 years old were treated. Comorbidities, preoperative and postoperative functional status, aneurysm size, and technical success rate were all recorded in accordance with Society for Vascular Surgery reporting guidelines. Follow-up was performed within 30 days, 6 months, and annually thereafter unless more frequent follow-up was indicated.


RESULTS
Of the 749 EVAR procedures performed in the decade-long experience, 15 nonagenarians underwent repair (14 male, 93%; mean age, 90.3 ± 0.6 years). Mean aneurysm diameter was 6.4 ± 1.45 cm with a median diameter of 5.8 cm (range 4.5-8.8 cm). All patients were offered repair because of having good to excellent preoperative functional status with an average number of comorbidities per patient of 2.7. Immediate technical success rate was 100%. Median intensive care unit stay was 1 day (range 1-17 days). Mean length of stay was 4.6 ± 5.3 days with a median of 3.5 days. Thirty-day mortality was 0%. Mean follow-up was 35 months. Mean survival was 56 months. Overall survival estimated annually extending out to 5 years was 91.7%, 83.3%, 71.4%, 57.1%, and 38.1%, respectively. Thirty-day rate of any complication was 40%, with a 20% readmission rate, with many of the issues being related to wound complications. On follow-up imaging there were noted to be 4 (27%) type I, 9 (60%) type II, and no type III or type IV endoleaks identified. Overall reintervention rate was 27%. No ruptures were noted in the postoperative period or long-term follow-up, and there were no conversions to open surgery.


CONCLUSIONS
We found a median survival of 56.2 months in this carefully selected cohort of EVAR in nonagenarians. As techniques and technology improve and evolve, and particularly as devices become lower profile, there is the potential to apply EVAR to the increasingly older population. If perioperative morbidity can be minimized and the patient has good functional status, EVAR can be a safe procedure and provide rupture-free survival.
Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA.
George K
GK
Lee
Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA.
Brant W
BW
Ullery
Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA. Electronic address: jtlee@stanford.edu.
Jason T
JT
Lee
D000046:Academic Medical Centers; D000367:Age Factors; 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; D002140:California; D016208:Databases, Factual; D018572:Disease-Free Survival; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D019233:Retreatment; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome