Optimal selection of patients for elective abdominal aortic aneurysm repair based on life expectancy

Abstract

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 ≥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 m2 (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 m2, are unlikely to achieve sufficient long-term survival to benefit from surgery, unless their AAA rupture risk is very high. (J Vasc Surg 2013;58:589–95.)

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

“…161, 162 The difficulty is in defining carefully this group of patients. In EVAR-2, the participating clinicians appeared to have had good judgement in selecting patients for this trial: by 4 years < 40% of patients remained alive and by 8 years this had reduced to < 20%.…”

Impact of sarcopenia on long-term mortality following endovascular aneurysm repair

“…[4][5][6] However, in 2013, the Vascular Surgical Group of New England (VSGNE) did identify four major and four minor risk factors for assessing long-term survival (5 years) following AAA repair. 7 Their major risk criteria included: unstable angina or recent myocardial infarction, age >80 years, oxygen-dependent COPD, and estimated glomerular filtration rate <30 ml/min/1.73 m 2 . The minor risk criteria included: age 75-79 years, prior myocardial infarction, stable angina, and not taking aspirin or statins.…”

External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair

“…3 The validation cohort consisted of 1038 patients undergoing elective AAA repair during the same time interval. Compared with the derivation cohort, a higher proportion of patients in the validation group underwent OAR (n = 430 [41%]) vs EVAR (n = 608 [59%]; P < .001 for comparison of procedures between derivation and validation).…”

“…2 A previously developed risk prediction model for survival after AAA repair has been created using data from the Vascular Study Group of New England (VSGNE). 3 The purpose of our current study was to externally validate this risk prediction model in an independent group of patients.…”