Endo AAA Repair: Are There OctogenarianBenefits?

BY PATRICE WENDLING

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CHICAGO -- Endovascular repair offered no long-term survival advantage over open abdominal aortic aneurysm repair in a 10-year review of results in 150 octogenarians who underwent the procedures electively.

However, endovascular repair (EVAR) was associated with the ancillary benefits of significantly less blood loss (325 mL vs. 2,800 mL), shorter hospital stays (median 3 days vs. 9 days), and more patients discharged to home (86% vs. 58%). These results were reported at the Midwestern Vascular Surgical Society annual meeting by Dr. David Paolini and his colleagues at the Jobst Vascular Center, Toledo (Ohio) Hospital.

"We conclude that age should not influence recommendations for or against either treatment type," he said.

This same research group presented a study of patients of all ages at last year's Midwestern Vascular meeting.

These earlier results showed no difference between the two modalities in 1-year mortality, a midterm advantage at 3 years favoring the open group, and an insignificant difference in mortality between groups at 5 years.

The survival curve was no different in those aged 70 years and older, among whom the majority (85%) of mortality occurred, Dr. Paolini said.

Similar survival curves have been reported among all patients by other research groups, notably the Lifeline Registry of EVAR Publications Committee (J. Vasc. Surg. 2005;42:1-10).

But results are conflicting in the few small studies that directly compared the two modalities in patients who were octogenarians, Dr. Paolini said.

The current study evaluated elective abdominal aortic aneurysm (AAA) repairs conducted in 150 octogenarians during the period from June 1996 to August 2006. Of these procedures, 81 were EVAR and 69 were open repairs.

In both of the groups, 70% of the patients were male and the average age was 83 years.

Significantly more patients in the open group had chronic obstructive pulmonary disease at baseline than in the EVAR group (38% vs. 15%); in addition, aneurysm size was significantly larger in the open group (6.2 cm vs. 5.8 cm).

Operative mortality did not differ significantly between the EVAR and open groups (4 patients vs. 6 patients), Dr. Paolini said.

Overall mortality in the study was 33% (27 of 81) versus 49% (34 of 69), which Dr. Paolini characterized as not significant, although it may have appeared so. The lack of significance may be due to the wide differences in average follow-up, which varied from 2.1 years in the EVAR group to 3.6 years in the open group, Dr. Paolini explained.

A Kaplan-Meier log-rank analysis also showed that there was no significant difference in survival between EVAR and open surgery (P = .13).

The median survival time found for EVAR was 350 weeks (range 145-404), compared with 317 weeks (233-342) for the open repair group.

Similar to their previous results, there seemed to be a survival advantage at 3 years favoring the open group (13 patients vs. 15 patients); however, this difference was not found to be statistically significant, Dr. Paolini said.

When compared with results in the literature, the data confirm that octogenarians have higher mortality with both open and endovascular repairs than do patients less than 80 years of age.

Further breakdown of these age groups revealed that the patients who were in their seventh decade fared better than those who were in their eighth decade, who in turn did significantly better than those patients who were treated in their ninth decade, Dr. Paolini reported.

When asked to comment on this story, Dr. Wesley S. Moore, professor and chief emeritus, division of vascular surgery, UCLA Medical Center, stated: "This is a case of deciding whether or not the glass is half full or half empty.

"What the authors have shown is that octogenarians do equally well regarding long-term survival with either open repair or EVAR.

"Since EVAR is associated with short hospital stay, with minimal incisions, less pain and suffering, minimal blood loss, and a rapid return to normal activity while yielding the same benefit as a big operation, which would you choose?

"Put me down for EVAR,"Dr. Moore concluded.

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