A large meta-analysis of elective endovascular aneurysm repair (EVAR) outcomes by age has shown that three-to-five-year survival is very low in octogenarians, prompting researchers to caution against routine intervention in these patients.
Sebastian Vaughan-Burleigh, Dominic PJ Howard and colleagues (Oxford, UK) write in the Journal of Endovascular Therapy (JEVT) that elective repair for abdominal aortic aneurysm (AAA)—a condition known to increase in prevalence with age—is commonly performed in octogenarians. However, while previous trials have confirmed elective EVAR to be an effective intervention for AAA, the authors note that the data are limited for elderly patients due to them often being excluded from randomised trials.
To evaluate the safety and outcomes of elective EVAR in elderly patients, the researchers performed a systematic review and meta-analysis of studies reporting risk of complications and death in relation to age. They included observational studies and, if outcome rates or raw data were provided, interventional arms of randomised trials.
Howard et al identified 38 eligible studies from 9,060 citations, including eight national and five international registries, 25 retrospective studies, and their own prospective cohort. The analysis included 208,997 non-octogenarians and 84,589 octogenarians in total.
The authors report in JEVT that 30-day mortality post-elective EVAR—the study’s primary outcome—was higher in octogenarians than in younger patients.
In addition, they write that linear regression demonstrated a 0.83% increase in 30-day mortality for every 10-year age increase above 60 years old.
Another key finding from the study was that mortality for octogenarians increased “significantly” during follow-up, with Howard and colleagues sharing figures of 11.35%, 22.8%, 32%, 47.53%, and 51.08% at one-through-five-year follow-up, respectively.
Finally, the authors reveal that 30-day complication rates after elective EVAR were higher in octogenarians than in younger patients.
“We have performed the largest meta-analysis of elective EVAR outcomes stratified by age to date,” Howard and colleagues state, going on to summarise that, while octogenarians experience “higher but acceptable” perioperative morbidity and mortality compared to younger patients, three-to-five-year survival is “very low” in older patients.
The authors recognise that there are certain limitations to their study, including the “increasingly infrequent” reporting of mortality data beyond 30 days, the “inconsistent” reporting of data outside mortality across studies.
Despite these limitations, Howard et al stress that many patients in the study came from registries, which they note are “generally considered most representative of underlying populations”.
Based on their findings, the authors conclude: “Our findings challenge the notion of routine intervention in elderly patients, and support very careful selection for elective EVAR.”
They continue that many octogenarians with ‘peri-threshold’ AAAs, i.e. those less than 6cm in diameter, “may derive no benefit from EVAR” due to limited three-to-five-year survival and the low risk of aneurysm rupture that is associated with conservative management. “An adjusted threshold for intervention in octogenarians may be warranted,” they assert.
