Study Indicates That EVAR for Nonagenarians Is Safe and Effective

November 3, 2010—Endovascular aneurysm repair (EVAR) in nonagenarians can be safe and effective, according to a single-center study published by Lee J. Goldstein, MD, et al in the Journal of Vascular Surgery (2010;52:1140–1146).

As background to the study, the investigators noted that advanced age is a significant risk factor that has traditionally steered patients away from open aneurysm repair and toward expectant management. However, the reduced morbidity and mortality of aortic stent grafting has created a new opportunity for aneurysm repair in patients who were previously considered too high risk for open surgery.

In this study, the investigators reported their experience with EVAR in nonagenarians. The investigators conducted a retrospective chart review to identify all patients older than 90 years undergoing EVAR during a 9-year period at their institution, Cornell University's New York Presbyterian Hospital in New York City. Collected data included preoperative comorbidities, perioperative complications, endoleaks, reinterventions, and long-term survival.

The study was composed of 24 patients who underwent EVAR. The mean age was 91.5 years (range, 90–94) among 15 (63%) men and nine (37%) women. The mean abdominal aortic aneurysm diameter was 6.3 ± 1.1 cm. Eight patients (33%) were symptomatic (pain or tenderness). There were no ruptures. Fourteen patients (58%) had general anesthesia, whereas 10 (42%) had local or regional anesthesia.

The mean postoperative length of stay was 3.2 ± 2.4 days (2.8 ± 1.9 days for asymptomatic vs 4.1 ± 3.2 days for symptomatic; P = .29). There was one perioperative mortality (4.2%). There were two local groin seromas (8.3%) and six systemic complications (25%). One patient required reintervention due to endoleak (4.2%).

The investigators found that there were no aneurysm-related deaths beyond the 30-day postoperative period. Mean survival beyond 30 days was 29.7 ± 18 months. Cumulative estimated 12-, 24-, and 36-month survival rates were 83%, 64%, and 50%, respectively. Linear regression analysis showed an inverse relationship between the number of preoperative comorbidities and postoperative survival in this cohort (r2 = 0.701), with significantly decreased survival noted for patients presenting with > 5 comorbidities. Those still alive at follow-up had a mean survival rate of 36.1 ± 16 months.

This is the largest reported EVAR series in nonagenarians, the investigators stated. Despite their advanced age, these patients benefited from EVAR with low morbidity, low mortality, and a mean survival exceeding 2.4 years. Survival appears to be highest in those patients with ≤ 5 comorbidities. With or without symptoms, patients older than 90 years should be considered for EVAR, concluded the investigators.