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Home > Vascular Annual Meeting > beck_predicting_one_year_mortality

Predicting One Year Mortality After Elective AAA Repair: When NOT to Operate

Adam W. Beck¹, Phillip P. Goodney¹, Brian W. Nolan¹, Donald S. Likosky¹, Jens Jorgensen², Jack L. Cronenwett¹, for The Vascular Study Group of Northern New England (VSGNNE).
¹Dartmouth-Hitchcock Medical Center, Lebanon, N.H.;²Maine Medical Center, Portland, Maine.

OBJECTIVES: Benefit of prophylactic AAA repair requires sufficient survival to overcome operative risk. We postulated that death within one year of open or endovascular (EVAR) infrarenal AAA repair would define ineffective treatment and developed a prediction model to aid clinical decision making.

METHODS: We used a prospective registry of 1429 consecutive patients undergoing elective AAA repair from 2003-2007 by 49 surgeons from 11 hospitals. Multivariate logistic regression was utilized to identify risk factors for one year mortality, including medical co-morbidities, aortic clamp site, peri-operative risk factor modification (e.g., beta-blockade) and aneurysm size. Deaths were determined from the Social Security Death Index.

RESULTS: Thirty-day and one-year mortality after open repair (n=790) was 2.5% and 7.3% and after EVAR (n=639) was 0.5% and 6.5%, respectively. Factors found to be associated mortality within one-year after open repair were: age over 70 (p=0.02; OR 2.4, 95% CI 1.1-5.0), history of COPD (p=0.001; OR 3.3, 95%CI 1.7-6.5), chronic renal insufficiency (Cr>1.8) (p=0.003; OR 2.3, 95%CI 1.6-8.5) and suprarenal aortic clamp site (p=0.001; OR 3.8, 95%CI 1.8-8.2). Depending on the number and combination of risk factors present, patients undergoing open AAA repair have predicted one year mortality from 1% (0 risk factors) to 58% (4 risk factors, Figure 1). Correlation between observed and expected deaths was excellent for this model (r=0.97, inset Figure 1). For EVAR, the only identified risk factor for death within one year was a history of CHF (p=0.002; OR 3.3, 95%CI 1.5-7.0). A model using CHF had only fair predictive value (r2=0.62).

CONCLUSIONS: Predictors of one year mortality can identify patients less likely to benefit from elective AAA repair. These factors differ for open repair vs. EVAR and should be considered in individual patient decision making. A combination of age, COPD, renal insufficiency and need for suprarenal clamping provide accurate prediction of one year mortality after elective open AAA repair.
AUTHOR DISCLOSURES: A.W. Beck, None; P.P. Goodney, None; B.W. Nolan, None; D.S. Likosky, None; J. Jorgensen, None; J.L. Cronenwett, None.