Predictors of Survival in Patients Over 80 Years Old Treated with Fenestrated and Branched Endograft

Abstract

Fenestrated and branched endovascular aneurysm repair endograft (f/bEVAR) allows the endovascular repair of thoracoabdominal and juxtarenal and pararenal abdominal aortic aneurysms (T-J-P-AAAs); however, given their high cost and complexity, their use should be limited to patients with life expectancy >2years. Nevertheless, the number of patients older than 80years treated by f/bEVAR is growing, with no hard evidence of the real efficacy in this context. The aim of the present study is to analyze the survival of ≥80-year-old patients treated with f/bEVAR, and to identify possible predictors of late mortality. An analysis of clinical, anatomical, and technical characteristics of patients treated with f/bEVAR for J-, P-, and T-AAA from 2010 to 2019 in a single academic center was performed. Follow-up data were collected prospectively with clinical visit and computed tomography angiography at discharge, after 6 months, and yearly thereafter. Survival after 2years was evaluated by Kaplan-Meier analysis. Possible predictors of mortality were evaluated by univariable/multivariable analysis. In the study period, a total of 243 f/bEVARs were considered: 83 for TAAA (34%) and 160 for J/PAAA (66%). Mean age was 73±6years, with 35 (14%) patients ≥80 years old; 209 patients (86%) were male and 78 (39%) had an American Society of Anesthesiology score IV. The 30-day and 2-year survival were 96% and 80±3%, respectively. At a mean follow-up of 36±25months, independent predictors of late mortality by Cox regression analysis were chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF), and ≥80 years old (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.02-3.2, P=0.05; HR 1.7, 95% CI 1.01-3.4, P=0.04; HR 3.1, 95% CI 1.5-6.3, P=0.002, respectively). Preoperative clinical characteristics were similar in ≥80 years old versus younger patients, except for the prevalence of TAAA (14% vs. 38%, P=0.04). The technical success and 30-day mortality were similar in ≥80 vs. <80-year-old patients (93% vs. 96%, P=0.31; 7% vs. 3.5%, P=0.60, respectively). The 2-year survival estimation was significantly lower in ≥80 years old compared with younger patients (62±10% vs. 82±3%, P=0.003). The association of COPD and CRF significantly affects the 2-year survival in ≥80-year-old patients (no patients survived at 2years) and was significantly different compared with the survival in ≥80-year-old patients without these risk factors (70±11%, P=0.001). The early mortality rate and the 2-year survival after f/bEVAR justify this type of treatment in patients ≥80 years old; however, the presence of comorbidities such as COPD and CRF significantly reduces mid-term survival in this group and should be taken into consideration in the indication to f/bEVAR.