Optimal selection of patients for elective abdominal aortic aneurysm repair based on life expectancy
Department of Surgery, Division of Vascular and Endovascular Surgery
Medical Subject Headings
Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; Chi-Square Distribution; *Decision Support Techniques; Elective Surgical Procedures; *Endovascular Procedures; Female; Humans; *Life Expectancy; Male; Middle Aged; Multivariate Analysis; New England; *Patient Selection; Proportional Hazards Models; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; *Vascular Surgical Procedures
Surgery | Surgical Procedures, Operative
OBJECTIVE: Elective abdominal aortic aneurysm (AAA) repair is beneficial when rupture is likely during a patient's expected lifetime. The purpose of this study was to identify predictors of long-term mortality after elective AAA repair for moderately sized AAAs ( < 6.5-cm diameter) to identify patients unlikely to benefit from surgery.
METHODS: We analyzed 2367 elective infrarenal AAA ( < 6.5 cm) repairs across 21 centers in New England from 2003 to 2011. Our main outcome measure was 5-year life-table survival. Cox proportional hazards analysis was used to describe associations between patient characteristics and 5-year survival.
RESULTS: During the study period, 1653 endovascular AAA repairs and 714 open AAA repairs were performed. Overall, 5-year survival rates were similar by procedure type (75% endovascular repair, 80% open repair; P = .14). Advanced age greater than or equal to 75 years (hazard ratio [HR], 2.0; P < .01) and age > 80 years (HR, 2.6; P < .01), coronary artery disease (HR, 1.4; P < .04), unstable angina or recent myocardial infarction (HR, 4.6; P < .01), oxygen-dependent chronic obstructive pulmonary disease (HR, 2.7; P < .01), and estimated glomerular filtration rate < 30 mL/min/1.73 m(2) (HR, 2.8; P < .01) were associated with poor survival. Aspirin (HR, 0.8; P < .03) and statin (HR, 0.7; P < .01) use were associated with improved survival. We used these risk factors to develop risk strata for low-risk, medium-risk, and high-risk groups with survival, respectively, of 85%, 69%, and 43% at 5 years (P < .001).
CONCLUSIONS: More than 75% of patients with moderately sized AAAs who underwent elective repair in our region survived 5 years, but 4% were at high risk for 5-year mortality. Patients with multiple risk factors, especially age > 80 years, unstable angina, oxygen-dependent chronic obstructive pulmonary disease, and estimated glomerular filtration rate < 30 mL/min/1.73 m(2), are unlikely to achieve sufficient long-term survival to benefit from surgery, unless their AAA rupture risk is very high.
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Citation: J Vasc Surg. 2013 Sep;58(3):589-95. doi: 10.1016/j.jvs.2013.03.010. Epub 2013 May 1. Link to article on publisher's site
De Martino, Randall R.; Goodney, Philip P.; Nolan, Brian W.; Robinson, William P. III; Farber, Alik; Patel, Virendra I.; Stone, David H.; and Cronewett, Jack L., "Optimal selection of patients for elective abdominal aortic aneurysm repair based on life expectancy" (2013). University of Massachusetts Medical School Faculty Publications. 568.