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Online ISSN 1827-1847
De Donato G., Chisci E., Trovato R., Baldi C., Giubbolini M., Cappelli A., Palasciano G., Setacci C.
Unit of Vascular and Endovascular Surgery, Department of Surgery University of Siena, Siena, Italy
Aim. The aim of this study was to study 30-day mortality rate and to assess the value of conventional open repair vs endovascular repair (EVAR) in an elderly population with abdominal aortic aneurysm (AAA) having elective, urgent or emergent repair.
Methods. During the period from January 2004 to April 2006, 241 consecutive patients were treated for AAA in our department. Among these, 184 (76.4%) were aged <80 years (mean age 66.9 years, range 55-79 years), 57 (23.6%) were aged >80 years (mean age 84.3 years, range 80-95 years). The group of older patients was retrospectively analyzed. In this group the patients presented: 1) a ruptured AAA (rAAA) in 18 cases (18/57, 31.5%): 16 required emergency AAA open repair, due to unstable hemodynamic conditions and 2 underwent emergency EVAR; 2) a symptomatic non-rAAA, with impending signs of rupture in CT images in 12 cases (12/57, 21.1%): 11 underwent urgent EVAR and 1 open repair; an asymptomatic AAA in 27 cases (27/57, 47.4%): all underwent elective repair (18 EVAR, 5 open repair). The main outcome measures were 30-day mortality and 30-day morbidity.
Results. The overall 30-day mortality of patients over 80 years of age with a rAAA and hemodynamic instability was dramatically high: 66.6% (12/18). Furthermore, we counted 1 death after emergency EVAR for rAAA, and 2 deaths in the group of asymptomatic patients (2/23, 8.6%; 1 after EVAR, 1 after open repair), while no death occurred after EVAR (0/10, 0%) in the symptomatic patients. When comparing postoperative morbidities in the octogenarians, 4 of the endovascular patients (12.5%) and 21 of the open patients (84%) had a complication (P<0.02).
Conclusions. Proper management of individual AAA in the elderly is based on balancing the perioperative risk, the risk of rupture and life expectancy. The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality for octogenarians with rAAA and hemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture, as well as for urgent cases with symptoms and sign of impending rupture.