Analysis of Midterm Outcomes of Endovascular Aneurysm Repair in Octogenarians From the ENGAGE Registry

Abstract

Purpose: To assess periprocedural results and secondary endovascular procedure outcomes over 5 years in patients aged ≥80 vs <80 years undergoing endovascular aneurysm repair (EVAR). Materials and Methods: Data from the Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE) were used for the analyses. A total of 1263 consecutive patients were enrolled in the prospective, observational, single-arm registry and divided into 2 groups according to age: ≥80 years (290, 22.9%) and <80 years (973, 77.1%). Baseline patient characteristics, risk scores according to the Society for Vascular Surgery (SVS) reporting standards, American Society of Anesthesiologists (ASA) classification, quality of life assessments [EuroQol 5 (EQ5D) index], and treatment outcomes, including all-cause mortality, aneurysm-related mortality, major adverse events, secondary endovascular procedures, and endoleaks were compared between groups. Results: Octogenarians were classified into the highest category of the SVS risk stratification system; however, this did not result in a significant difference in the 30-day mortality [1.4% (4/290) vs 1.2% (12/973) for controls; p=0.85] or major adverse event rates [5.2% (15/290) vs 3.6% (35/973), p=0.23]. Multivariable analysis confirmed that age ≥80 years, pulmonary disease, large aneurysm diameter, and renal insufficiency were significantly associated with all-cause mortality, whereas diameter was the only parameter associated with increased aneurysm-related mortality. The differences in freedom from secondary endovascular procedures over 5 years between octogenarians and controls did not reach statistical significance (88.5% vs 83.2%, p=0.07). Conclusion: EVAR can be performed in individuals aged ≥80 years with no statistically significant difference in midterm aneurysm-related deaths compared with younger patients. The findings in this elderly patient cohort show that EVAR can be safely performed with acceptable morbidity rates in octogenarians.

Physiologic risk stratification is important to long-term mortality, complications, and readmission in thoracic endovascular aortic repair

“… 19 Unsurprisingly, the analysis at 5 years from the ENGAGE (Endurant stent graft natural selection global postmarket) registry among only octogenarians after EVAR found that both ASA III and ASA IV vs ASA I were associated with increased all-cause mortality. 20 Consistent with these prior findings for endovascular aneurysm repair patients, we have extended the current understanding and report that a higher ASA class is also independently associated with increased all-cause mortality and complications in the long term in patients with acute complicated type B dissection and traumatic dissection. We posit that in a more heterogeneous series, ASA class would continue to remain important.…”

Commentary: How Old Is Too Old for EVAR?

“…Pini et al 4 have shown that an American Society of Anesthesiologists (ASA) score of IV is an independent predictor of 30-day mortality in octogenarians undergoing EVAR; however, the most important finding of that study is that several factors other than ASA IV, such as peripheral artery disease, chronic obstructive pulmonary disease, and chronic renal disease, play significant roles in midterm survival. The outcomes reported by Mwipatayi and colleagues 1 are consistent with these findings, since several factors were found to predict all-cause mortality. It is also interesting to observe that quality of life has an important role in late survival.…”

“…The study from Mwipatayi et al 1 in the October 2020 issue of the JEVT is important for a variety of reasons. First of all, it reports an interesting subanalysis of the prospective, observational, single-arm ENGAGE registry, which involves almost 80 centers worldwide and represents a clear image of the real-world performance of a modern endovascular solution for most abdominal aortic aneurysms (AAA).…”

“…10 This almost 10-year difference between the 2 extremes would certainly affect the interpretation of results. Thus, the data presented by Mwipatayi and colleagues 1 should be analyzed in the context of each nation.…”

Procedural and long-term outcomes of elective endovascular abdominal aortic aneurysm repair in octogenarians

“…Actually, 80% of older patients with AAA are successfully treated with endovascular therapy 7 . Data on EVAR in octogenarian patients are contradictory, and although the success rate of the procedure is high, post-procedural and long-term complications are often higher when compared to younger patients 1,[8][9][10][11][12][13][14][15] .…”