Aortic Aneurysm Patients Are Not Fit!

Abstract

Elective abdominal aortic aneurysm (AAA) repair is undertaken to prevent aneurysm rupture. In an individual patient we cannot predict when an aneurysm will rupture, but most vascular surgeons offer intervention when the AAA reaches 5.5 cm in maximum diameter, based on the results of the UK small aneurysm trial. Inevitably however many patients will have aneurysms repaired that would not go on to rupture, if left untreated, before they succumb to other natural causes. Perhaps the most important finding of this manuscript, reporting the mid-term follow-up of young patients undergoing AAA repair, is that life expectancy even in this group is poor. The authors report a mortality of 40% at a median follow-up of 6 years and 5 months. To put this into context, mortality in the UK small aneurysm trial was 44% at 8 years and 64% 12 years after randomization. The median age at randomization in this study was 69 years compared with the 61 years reported by Atlaf et al. One would anticipate with further follow-up a mortality of approximately 50% at 8 years in line with the EVAR 1 trial (46%) and other reports. In other words, it would appear that young aortic aneurysm patients are no fitter than their older counterparts, with the presence of an aortic aneurysm alone identifying patients at risk of premature death from associated co-morbidity. Furthermore, life expectancy for a man aged 61 years has risen in the UK from 17 to 21 years over the period of this study (1994e2010). Patients with an aortic aneurysm at this age appear to have on average half the life expectancy of the general population, dispelling the popularly held misconception that once an AAA has been repaired life expectancy reverts to that of the population as a whole. Put simply, aortic aneurysm repair does not protect a patient from death as a result of associated comorbidity such as ischaemic heart disease or malignancy. There are a number of methodological problems with this manuscript. The retrospective data collection, incomplete dataset with patients lost to follow-up and change in endovascular aneurysm repair (EVAR) practice over the 18year period mean that we should interpret the findings with some caution. It is not surprising that results for commercially available stent-grafts appear better than for the custom-made devices. In particular, the authors report lower re-intervention rates for newer generation grafts in