Nonagenarians should not be excluded from endovascular aortic repair (EVAR) surgeries based on age alone, but they should undergo a carefully balanced risk assessment, according to study results published in the Journal of the American College of Cardiology.
Researchers sought to report on 30-day perioperative mortality and complication rates in nonagenarian vs non-nonagenarian patient populations using updated data from the prospectively collected, nationally validated, risk-adjusted, outcomes-based National Surgical Quality Improvement Program (NSQIP) database.
Study investigators analyzed procedure-targeted EVAR NSQIP datasets from 2011 to 2017. Preoperative variables included indication for surgery, aneurysm diameter, aneurysm rupture, prior aortic surgery, access, and proximal and distal aneurysm extent. Perioperative variables included main body device; hypogastric embolization or revascularization; placement of an accessory aortic, iliac, or renal stent; and immediate conversion to open surgery. Thirty-day specific postoperative variables included ischemic colitis, lower extremity ischemia requiring intervention, and postoperative aneurysm rupture, as well as length of stay in the intensive care unit.
Primary outcomes included 30-day mortality and morbidity. Secondary outcomes included in-hospital stay and 30-day reintervention and readmission rates.
The total cohort included 12,267 patients (mean age, 73.8±8.9 years; 81.1% men) who underwent EVAR for infrarenal abdominal aortic aneurysms (AAAs); 3% of these patients were 90 years of age or older. Between 2012 and 2017, roughly 25% of all EVAR procedures were performed in patients between 80 and 89 years of age, while 3% were performed in nonagenarians. Mean AAA diameter in nonagenarian patients was 6.5±1.8 cm, which was nearly 1 cm larger than that of non-nonagenarian patients. Mean AAA diameter of intact AAAs was 6.3±1.6 cm and 5.7±1.5 cm in nonagenarians and non-nonagenarians, respectively; ruptured AAA mean diameter was 7.2±2.4 cm and 7.6±3.4 cm in these same groups, respectively.
Results of a multivariate logistic regression showed that being 90 years of age or older, male sex, functional status, preoperative ventilator dependency, bleeding disorders, preoperative dialysis dependency, and ruptured aneurysms were all independent predictors of mortality.
In patients who underwent elective repair, mean aneurysm diameter was 6.3±1.6 cm and 5.8±1.3 cm in nonagenarians and non-nonagenarians, respectively. The 30-day mortality for intact AAAs was 5.3% vs 3%, respectively, with perioperative major adverse event rates of 7% and 4.6%, respectively. No significant differences were noted in 30-day reintervention or readmission rates.
Nonagenarians who underwent elective surgeries experienced a slightly longer median length of postoperative in-hospital stay (3 days vs 2 days in non-nonagenarians), but no differences were found in short-term surgical outcomes.
For ruptured aneurysms, mean diameter was 7.2±2.4 cm and 7.2±1.6 cm in nonagenarians and non-nonagenarians, respectively. At 30 days, mortality was 38% and 28.6% in the respective groups, with perioperative major adverse event rates of 28% and 36.7%, respectively. No significant differences in 30-day reintervention or readmission rates or median length of postoperative in-hospital stay were noted.
Study limitations include the availability of only short-term 30-day outcomes within the NSQIP database, the likelihood that the nonagenarians who underwent treatment were among the fittest and healthiest because of surgeon selection criteria, and potential selection bias excluding highly comorbid patients.
“Age was identified as an independent predictor of 30-day mortality after EVAR on multivariate analysis,” the researchers wrote. “However, no differences in 30-day mortality or [major adverse event] rates were found on [propensity-score matching], suggesting that being over the age of 90 years, but with comorbidities similar to younger patients, is not associated with higher short-term mortality after EVAR.”
“Age ≥90 alone should not exclude patients from EVAR, and tailored indications and carefully balanced risk assessment are advised,” they concluded.
Prendes CF, Dayama A, Panneton JM, et al. Endovascular aortic repair in nonagenarian patients. J Am Coll Cardiol. 2021;77(15):1891-1899. doi:10.1016/j.jacc.2021.02.042