Outcomes in Patients Turned Down for Aortic Surgery: An Important Indicator of Responsible Patient Selection

Abstract

Background: Studies reporting the fate of patients deemed unsuitable for aortic aneurysm repair (‘turndowns’) are sparse. Our aim was to compare outcomes between turndowns and those managed operatively. Methods: Data were collected on all patients referred to a tertiary referral centre with an aortic aneurysm over an 18-month period beginning April 2016. Kaplan-Meier analysis was used to measure survival and multivariate analysis to determine factors that predicted turned down. Results: 568 patients were considered for intervention; complete data were available for 531(infra- renal:284, juxta-renal:106, thoracic:41, thoraco-abdominal:100). Mean age was 76.4yrs, and 80.0% were male. 345 patients (73 emergent) were managed operatively (endovascular:272, open:73). 86 [16.2%] patients were turned-down (infra-renal:40, juxta- renal:18, thoracic:5, thoraco-abdominal:23). Median follow-up was 156 (38–343) days. Renal disease, cardiac disease and history of TIA/stroke predicted turndown (P<0.05 for all). One- year all-cause mortality for elective open and endovascular procedures was 2.4% and 5.2%, respectively (infra-renal EVAR:0.4%, TEVAR:0.9%, complex endovascular repair:3.9%). One- year aneurysm related and all-cause mortality for those turned down for elective surgery was 7.1% and 21.4%, respectively, with a third of these patients dying from cancer rather than aneurysm rupture. Conclusions: The short term aneurysm-related mortality in elective turndowns is low, with a significant number of patients succumbing for other reasons. Given the plethora of treatment options available, objective selection of patients who will benefit most from intervention is increasingly important.