Complex EVAR Is Associated With Higher Perioperative Mortality but Not Late-Mortality Compared to Infrarenal EVAR Amongst Octogenarians

Abstract

An increasing number of elderly patients are being offered endovascular repair of juxtarenal aneurysms. We sought to evaluate outcomes after complex endovascular aneurysm repair (EVAR) compared to infrarenal EVAR in a cohort of octogenarians. A single-center retrospective review was conducted with a database of consecutive patients treated with elective EVAR for abdominal aortic aneurysms (AAAs) between 2009 and 2015. Only patients aged ≥80 years were included. The complex EVAR group was treated with snorkel (Sn-EVAR) or fenestrated (F-EVAR) techniques, whereas infrarenal EVAR consisted of aneurysm repair without renovisceral involvement. Relevant demographic, anatomic/device variables, and clinical outcomes were collected. A total of 105 patients (69 infrarenal, 36 complex) were treated within the study period with a mean follow-up of 22 months. A total of 79 branch grafts were placed (61 renal, 11 celiac, 7 superior mesenteric artery) in the complex group, with a target vessel patency of 98.2% at latest follow-up. Patients with complex EVAR were more likely to be male (83.3% vs 61.1%; P = .019) and have a higher prevalence of renal insufficiency (72.2% vs 44.5%; P = .008). Thirty-day mortality was significantly more common in patients treated with complex EVAR (11.1% vs 0%; P = .012). There were no significant differences in major adverse events (P = .795) or late reintervention (P = .232) between groups. Interestingly, sac growth >10 mm was noted to be more frequent with infrarenal EVAR (17.6% vs 2.9%; P = .039). However, both type Ia (5.7% infrarenal; 5.0% complex) and type II endoleaks (32.3% infrarenal; 25.7% complex) were found to be equally common in both groups. Complex EVAR was not associated with increased all-cause mortality at the latest follow-up (P = .256; Fig). Multivariate Cox modeling demonstrated that AAAs >75 mm in diameter (hazard ratio, 5.1; 95% confidence interval, 1.8-13.9), and renal insufficiency (hazard ratio, 4.45; 95% confidence interval, 1.27-15.6) were the only independent risk factors of late death. Complex EVAR is associated with higher perioperative mortality compared to infrarenal EVAR amongst octogenarians. However, late outcomes are not significantly different. Larger aneurysms and chronic kidney disease portends greater risk of late death after EVAR, regardless of AAA complexity. These patient-related factors should be considered when offering endovascular therapy to older patients.