Study Evaluates Impact of Age and Urgency on TEVAR Risk in Elderly

July 26, 2016—A study of the impact of age and urgency on survival after thoracic endovascular aortic repair (TEVAR) was published by Paola De Rango, MD, et al in the Journal of Vascular Surgery (JVS; 2016;64:25–32).

The background of the study is that elderly patients are often denied treatment for descending thoracic aortic diseases (DTADs), as the benefits are uncertain, especially in acute settings. This study investigated the impact of older age and timing of TEVAR on outcomes of DTAD in patients older than 75 years.

As summarized in JVS, patients from a prospective TEVAR database were dichotomized by age (75 and 80 years). Older and younger patients were compared in three timing scenarios: elective procedures, any emergency (within 15 days from onset), and acute ruptures (any emergency subgroup). The primary outcome was perioperative mortality assessed at 30 and 90 days.

Between 2003 and 2015, 141 consecutive TEVAR procedures (71.6% men) were performed. Fifty-seven patients (40.4%) were older than 75 years, and 28 were octogenarians. Eighty-three TEVARs were electivelyperformed, and 58 were emergencies. Among overall emergencies, 42 TEVARs were for acute ruptures. 

In the elective scenario, the 30-day mortality rate was 5% versus 0% (odds ratio [OR], 1.1; 95% confidence interval [CI], 0.98–1.1; P = .23), and 90-day mortality was 7.5% versus 0% for patients older than 75 years versus those who were younger than 75 years, respectively (P = .11). Nome of the octogenarians died. 

In the emergency scenario, 30-day mortality was 41.2% versus 9.8% for patients older than 75 years versus those who were younger than 75 years (OR, 6.5; 95% CI, 1.6–26.6; P = .01), respectively, with unchanged rates at 90 days. The mortality rate was 50% for octogenarians. 

In the acute rupture scenario, 30-day mortality was 40% versus 11.1% (OR, 5.3; 95% CI, 1.1–25.99; P = .05) for patients older than 75 years versus those younger than 75 years and 46% versus 10% (OR, 7.5; 95% CI, 1.47–37.46; P = .016) for octogenarians versus younger patients. Rates remained unchanged at 90 days. Patients older than 75 years survived for a mean of 53.98 ± 7.7 months after TEVAR.

The investigators concluded that in the elderly patient population with DTAD, mortality risks from TEVAR are strongly related to timing and age. When compared to younger patients, those older than 75 years have three to five times the risk of mortality after urgent or emergent TEVAR. However, older patients should still be considered for emergent life-saving treatment, given that the majority survives, advised the investigators in JVS.