Abstract
Background
With an aging population, the number of patients over 80 undergoing abdominal aortic aneurysm (AAA) repair is increasing. This study examines factors associated with mortality in these patients.
Methods
A retrospective cohort study involving 66 patients aged >80 who underwent AAA repair between January 2010 and December 2022 was conducted. Baseline characteristics, treatment methods (open surgical repair [OSR] or endovascular aneurysm repair [EVAR]), post-treatment mortality, complications, and reinterventions were analyzed.
Results
The mean age of patients was 82.74±2.64 years, with men comprising 74.2%. The OSR group had significantly younger patients than the EVAR group (81.92 years vs. 83.28 years, p=0.04). Rupture prevalence was significantly higher in the OSR group (27% vs. 7.5%, p=0.03). No significant difference was found in 30-day mortality rates between the OSR and EVAR groups (11.5% vs. 10%, p=0.85). Univariate logistic regression identified emergency surgery (odds ratio [OR], 6.18; p=0.04), post-treatment pneumonia (OR, 7.47; 95% confidence interval [CI], 1.00–55.70; p=0.05), and vasopressor use (OR, 44.57; p<0.01) as significant factors associated with 30-day mortality. Cox proportional hazard regression revealed age (hazard ratio [HR], 1.19; p=0.02), preoperative bedridden state (HR, 22.24; p<0.01), sacrifice of both internal iliac arteries (HR, 5.26; p=0.04), and postoperative vasopressor use (HR, 30.04; p<0.01) as significant predictors of overall mortality.
Conclusion
In patients aged >80 years, aneurysm rupture and emergency operation significantly increased 30-day mortality following AAA repair. Preoperative bedridden status, management of internal iliac arteries, and postoperative vasopressor use were significant predictors of overall mortality. When determining surgical indications and predicting outcomes, careful attention should be given to factors influencing mortality throughout the entire surgical process.
Keywords: Abdominal aortic aneurysm, Endovascular aneurysm repair, Octogenarians, Operative surgical procedures
Introduction
The prevalence of abdominal aortic aneurysm (AAA) in the Asian population is 1.3% [1]. Data from Norway, published in 2001, revealed that 1% of men aged 55–64 years had an AAA >4 cm, with this prevalence increasing by 2%–4% per decade of advancing age [2].
The standard treatments for AAA are open surgical repair (OSR) and endovascular aneurysm repair (EVAR), both of which have excellent outcomes when performed electively [3]. Previous studies reported elective open repair mortality rates of 5%–8%; however, more recent studies indicate a decrease to as low as 3% [4-7].
EVAR is recommended as a primary treatment due to its lower perioperative mortality than OSR [8-12]. Nonetheless, the long-term durability and survival advantages of EVAR remain uncertain [13]. A review of 15-year outcomes from the EVAR-1 trial reported that after 8 years, EVAR had higher all-cause mortality (adjusted hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.0–1.56; p=0.048) and aneurysm-related mortality rates (adjusted HR, 5.82; 95% CI, 1.64–20.65; p<0.01) than OSR [14].
Age has consistently been identified as an independent risk factor for mortality after AAA repair [15-19]. Howard et al. [20] reported that two-thirds of ruptured AAA events occurred in individuals aged ≥75 years. Earlier studies demonstrated a higher perioperative mortality risk following elective AAA repair in older patients compared to younger patients [19]. Globally, populations are aging, and by 2040, the number of individuals aged >80 is projected to be 5 times the current figure [21]. With this demographic shift, the number of AAA repairs in patients aged >80 years is rising [22-24]. Patients in their 80s with AAA may be reluctant to pursue aggressive treatment due to concerns regarding comorbidities, baseline activity levels, or advanced age [25]. However, a meta-analysis involving patients with ruptured AAA indicated that 30-day and 1-year mortality rates among those aged >80 years were similar to those in younger populations [26].
The present study aimed to re-examine factors previously reported to be associated with mortality in patients aged ≥80 years undergoing AAA repair. Mortality rates were analyzed both short-term (within 30 days) and overall. In the mortality analyses, treatment modality, internal iliac artery (IIA) management, emergency operation status, and preoperative bedridden state were specifically evaluated.
Methods
Ethics statement
This retrospective cohort study was approved by the Institutional Review Board (IRB) of Pusan National University Hospital (IRB no., 2406-009-140), which waived the requirement for informed consent. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Description of participants
Patient data were collected from the electronic medical records of the participating hospital. Among 1,251 patients diagnosed with AAA between January 2010 and December 2022, 538 required interventions. The treatment methods used were OSR and EVAR. Of the 381 patients who underwent treatment, 66 were aged >80 years. No patients included in this study were lost to follow-up, and there were no cases of missing imaging data.
AAA repairs were performed by 4 vascular surgeons (with 27, 15, 12, and 9 years of experience), 1 cardiologist (with 20 years of experience), and 1 interventionist (with 25 years of experience). Patient demographics (age, sex, and body mass index) and comorbidities (smoking, hypertension, diabetes mellitus, coronary artery disease, cerebrovascular accident, chronic obstructive pulmonary disease, chronic kidney disease, malignancy, and peripheral artery disease) were investigated. Preoperative status was assessed using the patients’ bedridden state and hemoglobin levels. Anatomical data were collected from preoperative imaging records, including neck length, angle of the aneurysmal neck, presence of iliac artery aneurysm, maximum AAA diameter, and iliac artery size. Emergency surgery indications included ruptured AAA with retroperitoneal hematoma observed on computed tomography and impending ruptured AAA indicated by clinical symptoms (abdominal pain and altered contrast enhancement of thrombus).
Procedure
In the OSR group, operative time, clamping sites, IIA management, and transfusion during surgery were documented. For the EVAR group, the anesthesia method, IIA management, and procedural duration were assessed.
Proximal anastomosis was conducted using end-to-end anastomosis techniques. Distal anastomosis was performed on the common iliac artery, external iliac artery, common femoral artery, or IIA, depending on the patient’s peripheral arterial condition. Management of the IIA was categorized based on whether both sides were preserved, one side was sacrificed, or both sides were sacrificed. The types of grafts used were: 15 collagen-coated polyester grafts (Hemagard; MAQUET), 3 collagen-impregnated polyester grafts (Hemashield; MAQUET), 5 Dacron bifurcated grafts (Intergard; MAQUET), 2 Dacron bifurcated grafts (InterVascular S.A.), and 1 Dacron bifurcated graft (Gelsoft; Vascutek). A systemic intravenous heparin injection (1,000 IU/kg) was routinely administered before aortic cross-clamping.
In the EVAR group, either local or general anesthesia was administered. The Perclose ProGlide (Abbott Medical) was used to control bleeding at the puncture site. A systemic intravenous heparin injection (1,000 IU/kg) was also routinely administered.
If IIA embolization was required, either coil embolization or an Amplatzer plug (Abbott Medical) was used. If bilateral IIA occlusion was needed, the embolization was performed in stages, separated by intervals of 2–4 weeks. However, unilateral embolization was performed concomitantly with the main procedure. The stent-grafts used included 7 Cook Zenith devices (Cook), 22 Endurant stent-grafts (Medtronic Vascular Inc.), 5 Low Porosity Excluder grafts (W. L. Gore & Associates Inc.), 2 SEAL stent-grafts (S&G Biotech), and 3 AFX2 endografts (Endologix).
Outcomes
Short-term outcomes evaluated included length of stay in the intensive care unit (ICU) and hospital, postoperative vasopressor use, duration of mechanical ventilation, reintubation, and 30-day mortality rate. Vasopressors administered included norepinephrine and vasopressin.
Long-term outcomes assessed included reinterventions, redo operations, and overall mortality rate. Reinterventions encompassed stent-graft extension, branch vessel embolization for endoleak management, and aneurysm sac thrombin injection. Redo operations involved thrombectomy and graft removal due to infection.
Complications
Short-term complications included pneumonia, myocardial ischemia, cerebrovascular accidents, kidney injury, wound complications, graft infection, and ischemic complications such as hip claudication, ischemic colitis, and graft thrombosis. Long-term complications included endoleaks, graft thrombosis, and delayed graft infections.
Statistical analysis
Normally distributed data were expressed as mean±standard deviation, whereas non-normally distributed data were expressed as median (interquartile range). Categorical variables were expressed as numbers (percentages). Patients were divided into OSR and EVAR groups, and independent t-tests were used to analyze differences between variables. Univariate logistic regression analysis was performed to identify factors influencing the 30-day mortality rate. Cox proportional hazards regression analysis was conducted to identify variables influencing mortality throughout the follow-up period. Statistical significance was set at p<0.05. All statistical analyses were performed using MedCalc Statistical Software ver. 22.106 (MedCalc Software Ltd.).
Results
Table 1 presents the baseline characteristics of the patients. The mean age was 82.74±2.64 years, with 74.2% being male. The most prevalent comorbidity was hypertension (65.2%), followed by cerebrovascular accident (16.7%). Patients in the OSR group were significantly younger than those in the EVAR group (81.92±1.87 years vs. 83.28±2.94 years, p=0.04). The mean aneurysm diameter was 63.42± 14.61 mm, significantly larger in the OSR group (67.00± 17.32 mm vs. 61.33±12.77 mm, p=0.01). The mean preoperative hemoglobin level was 11.82±2.32 g/dL, significantly higher in the EVAR group compared to the OSR group (12.34±2.24 g/dL vs. 11.02±2.26 g/dL, p=0.02). At diagnosis, rupture prevalence was higher in the OSR group (27.0% vs. 7.5%, p=0.03).
Table 1.
Baseline characteristics
| Characteristic | OSR (n=26) | EVAR (n=40) | Overall (n=66) | p-value |
|---|---|---|---|---|
| Age (yr) | 81.92±1.87 | 83.28±2.94 | 82.74±2.64 | 0.04 |
| Male | 18 (69.2) | 31 (77.5) | 49 (74.2) | 0.46 |
| Body mass index (kg/m2) | 22.84±3.12 | 23.24±2.83 | 23.09±2.93 | 0.58 |
| Baseline hemoglobin (g/dL) | 11.02±2.26 | 12.34±2.24 | 11.82±2.32 | 0.02 |
| Rupture | 7 (27.0) | 3 (7.5) | 10 (15.2) | 0.03 |
| AAA diameter (mm) | 67±17.32 | 61.33±12.77 | 63.42±14.61 | 0.01 |
| Comorbidities | ||||
| Smoking | 3 (11.5) | 2 (3.3) | 5 (7.6) | 0.33 |
| CAOD | 4 (15.4) | 5 (12.5) | 9 (13.6) | 0.74 |
| Cerebrovascular accident | 5 (19.2) | 6 (15.0) | 11 (16.7) | 0.66 |
| Hypertension | 19 (73.0) | 24 (60.0) | 43 (65.2) | 0.28 |
| Diabetes mellitus | 4 (15.4) | 6 (15.0) | 10 (15.2) | 0.90 |
| COPD | 2 (7.7) | 2 (5.0) | 4 (6.1) | 0.66 |
| Chronic kidney disease | 4 (15.4) | 2 (5.0) | 6 (9.1) | 0.16 |
| Peripheral artery disease | 0 (0) | 3 (7.5) | 3 (4.5) | 1.00 |
| Prior AAA repair | 1 (3.8) | 0 (0) | 1 (1.5) | 1.00 |
| Bedridden state | 1 (3.8) | 1 (2.5) | 2 (3.0) | 0.76 |
| Preop antiplatelet drug | 12 (46.0) | 21 (53.0) | 33 (50.0) | 0.62 |
| Preop statin | 11 (42.3) | 16 (40.0) | 27 (40.9) | 0.86 |
| Preop B-blocker | 3 (32.6) | 5 (33.4) | 8 (12.1) | 0.91 |
Values are presented as mean±standard deviation or number (%).
OSR, open surgical repair; EVAR, endovascular aneurysm repair; AAA, abdominal aortic aneurysm; CAOD, coronary arterial occlusive disease; COPD, chronic obstructive pulmonary disease; Preop, preoperative.
Differences in procedural factors between the OSR and EVAR groups are summarized in Table 2. Procedural time was significantly longer in the OSR group compared to the EVAR group (300.00±90.09 minutes vs. 140.18±74.48 minutes, p<0.01). Anatomical characteristics of the AAA revealed that the OSR group generally had a shorter neck length, larger neck angle, and larger common iliac artery diameter. In the EVAR group, the proportion of cases outside the instructions for use (IFU) was 30%.
Table 2.
Procedure-related factors
| Variable | OSR (n=26) | EVAR (n=40) | Overall (n=66) | p-value |
|---|---|---|---|---|
| Anesthesia | ||||
| General | 26 | 8 | 34 (51.52) | |
| Local | 0 | 32 | 32 (48.48) | |
| Total procedure times (min) | 300±90.09 | 140.18±74.48 | <0.01 | |
| Anatomy | ||||
| Neck length (mm) | 31.84±15.10 | 40.04±15.42 | 36.89±15.70 | 0.04 |
| Angle of neck (mm) | 62.15±24.75 | 46.82±20.08 | 52.72±23.06 | <0.01 |
| CIA size (mm) | 22.12±6.46 | 19.47±10.63 | 20.49±9.29 | 0.01 |
| Iliac artery aneurysm | 16 (61.54) | 11 (27.50) | 27 (40.91) | <0.01 |
| Iliac artery handling | ||||
| Both reserve | 16 (61.54) | 31 (77.50) | 47 (72.30) | |
| 1 sacrificed | 9 (34.62) | 7 (17.50) | 16 (24.60) | |
| Both sacrificed | 1 (3.85) | 1 (2.50) | 2 (3.10) | 0.28 |
Values are presented as number, mean±standard deviation, or number (%).
OSR, open surgical repair; EVAR, endovascular aneurysm repair; CIA, common iliac artery.
The prevalence of a common IIA diameter >2 cm was 40.91% overall, with significantly more cases in the OSR group than in the EVAR group (61.54% vs. 27.5%, p<0.01). Both IIAs were preserved in 72.3% of patients, with a higher preservation rate in the EVAR group compared to the OSR group (77.50% vs. 61.54%). The sacrifice of both IIAs occurred more frequently in the OSR group (3.85% vs. 2.50%).
Patient outcomes are shown in Table 3. The mean hospital stay for all patients was 16.97±19.94 days, and the overall 30-day mortality rate was 10.6%. Intraoperative transfusion in the EVAR group occurred exclusively in cases involving rupture. Postoperative vasopressor use was significantly higher in the OSR group than in the EVAR group (38.46% vs. 7.5%, p<0.01). Patients were discharged from the ICU when their vital signs had stabilized sufficiently to discontinue vasopressor therapy. ICU stay duration was longer in the OSR group compared to the EVAR group (2 days vs. 1 day, p<0.01).
Table 3.
Outcomes
| Variable | OSR (n=26) | EVAR (n=40) | Overall (n=66) | p-value |
|---|---|---|---|---|
| 30-day mortality | 3 (11.50) | 4 (10.00) | 7 (10.60) | 0.85 |
| 1-year all cause mortality | 4 (15.40) | 4 (10.00) | 8 (12.12) | 0.28 |
| Hospital days (day) | 29.00±27.51 | 9.15±4.29 | 16.97±19.94 | <0.01 |
| ICU stay days (days) | 2.33±1.93 | 1.40±0.96 | 1.72±1.43 | 0.01 |
| RBC transfusion (units) | 7.19±7.15 | 0.03±0.16 | 0.41±0.50 | <0.01 |
| Vasopressor use | 10 (38.46) | 3 (7.50) | 13 (19.70) | <0.01 |
| Reintervention | 0 (0) | 4 (10.00) | 6 (9.09) | 0.75 |
Values are presented as number (%) or mean±standard deviation.
OSR, open surgical repair; EVAR, endovascular aneurysm repair; ICU, intensive care unit; RBC, red blood cell.
The 5-year reintervention-free rate in the EVAR group was 83.1%. Among the 40 EVAR patients, 4 required reintervention: additional stenting in the right common iliac artery (n=1), inferior mesenteric artery embolization for type II endoleak (n=1), iliolumbar artery embolization for type II endoleak (n=1), and femoro-femoral bypass surgery due to iliac limb occlusion (n=1).
Table 4 stratifies patients by rupture status. Because the OSR group included many ruptured cases, outcomes were analyzed by rupture status. Patients with rupture experienced longer ventilation duration, higher transfusion of red blood cell (RBC) units, prolonged ICU and hospital stays, and higher 30-day mortality rates compared to those without rupture.
Table 4.
Outcomes of non-rupture versus rupture
| Variable | Non-rupture (n=56) | Rupture (n=10) | p-value |
|---|---|---|---|
| Ventilator duration (day) | 0.45±2.43 | 6.70±11.27 | <0.01 |
| Intensive care unit stay (day) | 1.95±3.18 | 9.70±10.94 | <0.01 |
| Hospital stay (day) | 13.71±11.36 | 35.20±40.61 | <0.01 |
| 30-day mortality (%) | 7 | 30 | 0.03 |
Values are presented as mean±standard deviation or %.
Postoperative complications are detailed in Table 5. The most common complication was pneumonia (7.58%). Ischemic complications occurred in 4.55% of patients; 1 patient experienced buttock claudication, which resolved within 6 months. Ventilation duration and reintubation rates were significantly higher in the OSR group than in the EVAR group, although the proportion of ruptured AAAs did not differ significantly between groups.
Table 5.
Complication
| Variable | Overall | OSR(n=26) | EVAR (n=40) | p-value |
|---|---|---|---|---|
| Ischemic complications | ||||
| Buttock claudication | 1 (1.52) | 1 (3.85) | 0 (0) | |
| Ischemic colitis | 2 (3.03) | 2 (7.69) | 0 (0) | |
| Skin necrosis | 0 (0) | 0 (0) | 0 (0) | 0.09 |
| Ventilator days (day) | - | 3.35±8.04 | 0.13±0.52 | 0.01 |
| Reintubation | 3 (4.55) | 3 (11.54) | 0 (0) | 0.03 |
| Pneumonia | 5 (7.58) | 4 (15.38) | 1 (2.5) | 0.05 |
| Wound infection | 1 (1.52) | 1 (3.85) | 0 (0) | 0.21 |
| Hemodialysis | 1 (1.52) | 1 (3.85) | 0 (0) | 0.21 |
| Cerebrovascular accident | 1 (1.52) | 1 (3.85) | 0 (0) | 0.21 |
Values are presented as number (%) or mean±standard deviation.
OSR, open surgical repair; EVAR, endovascular aneurysm repair.
Table 6 shows the results of univariate logistic regression analysis for 30-day mortality. Emergency surgery was associated with a 6.18-fold increase in mortality (odds ratio [OR], 6.18; 95% CI, 1.09–34.98; p=0.04). Ruptured AAAs were associated with a 5.57-fold increase in mortality (OR, 5.57; 95% CI, 1.03–30.26; p<0.01). Age differences between 83 and 85 years were not significant. Transfusion of 1 pack of RBCs increased the 30-day mortality rate by 1.16-fold (OR, 1.16; 95% CI, 1.04–1.29; p=0.01). Postoperative pneumonia was associated with a 7.47-fold increase in 30-day mortality (OR, 7.47; 95% CI, 1.00–55.70; p=0.05). Postoperative vasopressor use dramatically increased the 30-day mortality risk (OR, 44.57; 95% CI, 4.65–426.84; p<0.01).
Table 6.
Logistic regression for 30-day mortality
| Variable | Odds ratio (95% CI) | p-value |
|---|---|---|
| Emergent procedure | 6.18 (1.09–34.98) | 0.04 |
| Bedridden state | 9.67 (0.53–175.07) | 0.12 |
| Antiplatelet use | 0.14 (0.02–1.24) | 0.08 |
| Comorbidities | ||
| Diabetes mellitus | 2.55 (0.42–15.45) | 0.62 |
| Hypertension | 0.68 (0.14–3.36) | 0.64 |
| Sex | 0.41 (0.08–2.08) | 0.28 |
| Smoking | 0.67 (0.12–3.77) | 0.65 |
| Age | 1.11 (0.84–1.46) | 0.47 |
| Red blood cell transfusion | 1.16 (1.04–1.29) | 0.01 |
| Rupture | 5.57 (1.03–30.26) | <0.01 |
| Pneumonia | 7.47 (1.00–55.70) | 0.05 |
| Vasopressor use | 44.57 (4.65–426.84) | <0.01 |
| Reintervention | 1.8 (0.78–18.08) | 0.62 |
CI, confidence interval.
The Cox proportional hazards regression analysis of the overall mortality rate is presented in Table 7. Increasing age raised mortality risk by 1.19-fold per additional year (HR, 1.19; 95% CI, 1.03–1.37; p=0.02). Preoperative bedridden status was associated with a substantially higher mortality risk compared to ambulatory patients (HR, 22.24; 95% CI, 3.03–163.23; p<0.01). Sacrifice of both IIAs during the procedure increased mortality risk by 5.26-fold (HR, 5.26; 95% CI, 1.10–25.09; p=0.04). Postoperative vasopressor use markedly increased mortality risk by 30.04-fold (HR, 30.04; 95% CI, 6.63–136.05; p<0.01).
Table 7.
Cox proportional hazards regression for overall mortality
| Variable | Hazard ratio (95% CI) | p-value |
|---|---|---|
| Age | 1.19 (1.03–1.37) | 0.02 |
| Bedridden state | 22.24 (3.03–163.23) | <0.01 |
| Emergent procedure | 0.70 (0.22–2.21) | 0.55 |
| Rupture | 0.50 (0.11–2.32) | 0.37 |
| Treatment modality | 0.33 (0.08–1.30) | 0.11 |
| Red blood cell transfusion | 1.06 (0.96–1.16) | 0.23 |
| Pneumonia | 2.91 (0.68–12.49) | 0.15 |
| Both internal iliac artery sacrifice | 5.26 (1.10–25.09) | 0.04 |
| Vasopressor use | 30.04 (6.63–136.05) | <0.01 |
CI, confidence interval.
Fig. 1 illustrates overall survival among all patients. The overall survival rates at 1, 3, and 5 years were 75.8%, 65.4%, and 37.8%, respectively. OSR group survival rates at these intervals were 65.4%, 56.7%, and 24.8%, respectively, whereas EVAR group rates were 82.5%, 71.4%, and 41.9%, respectively, with no statistically significant differences between groups.
Fig. 1.
Kaplan-Meier survival curve for overall survival in all patients.
Fig. 2 illustrates the reintervention-free rate. The 5-year reintervention-free rate in the EVAR group was 83.1%, while there were no reinterventions reported in the OSR group.
Fig. 2.
Kaplan-Meier survival curve for the reintervention-free rate in the endovascular aneurysm repair (EVAR) group.
Discussion
The present study reports the treatment outcomes of patients aged >80 years who underwent AAA repair. Treatment modality (OSR or EVAR) did not influence the 30-day or overall mortality rates. In patients aged >80 years, factors significantly influencing 30-day mortality were aneurysm rupture, emergency surgery, the occurrence of postoperative pneumonia, and vasopressor use. Factors significantly affecting overall mortality included preoperative bedridden status, sacrifice of both IIAs, and postoperative vasopressor use.
Charbonneau et al. [27] reported that patients aged >80 years undergoing AAA repair were older in the EVAR group than in the OSR group. Age was a significant determinant of treatment modality in that study. Conversely, in our study, the OSR group was younger than the EVAR group. OSR was often selected for ruptured AAAs, primarily due to the infeasibility of EVAR caused by limited availability of devices during impending rupture or emergent states. The OSR group thus included a higher proportion of ruptured AAAs, potentially influencing outcomes such as mortality and complications. However, no significant differences in 30-day mortality, overall mortality, or complication rates were observed between the 2 groups.
In our EVAR group, 30% of cases were outside the IFU. Igari et al. [28] reported outcomes of EVAR performed in AAA anatomies outside at least 1 IFU criterion, noting perioperative mortality rates similar between within-IFU and outside-IFU cases. In contrast, Charbonneau et al. [27] reported that the 10-year survival rate for EVAR cases outside IFU was significantly lower compared to within-IFU cases (4.0% vs. 20.1%). Although no differences in short-term mortality rates have been noted when IFUs were unmet, the long-term therapeutic efficacy of EVAR is reduced. Consequently, if a patient’s overall condition is favorable and life expectancy is not short, EVAR outside the IFU should not be recommended based solely on advanced age.
A meta-analysis of patients aged >80 years by Roosendaal et al. [26] showed that the EVAR group had lower 30-day mortality (risk ratio [RR], 0.5; 95% CI, 0.38–0.67; p<0.01) and 1-year mortality rates (RR, 0.65; 95% CI, 0.44–0.96; p<0.01) than the OSR group. In contrast, our study did not show significant differences in these mortality rates between the 2 groups. This difference may be attributed to the higher proportion of patients with poorer general conditions or advanced disease stages in the EVAR group and because most ruptured AAAs underwent open surgical repair.
Rao et al. [29] found that non-ambulatory patients had higher ORs for complications (OR, 1.46; 95% CI, 1.11–1.91), 30-day mortality (OR, 1.22; 95% CI, 0.82–1.81), and 1-year mortality (OR, 1.46; 95% CI, 1.06–1.99). Consistent with these findings, our study showed that preoperative bedridden status significantly influenced overall mortality, underscoring the importance of preoperative physical activity status as a predictive factor.
Bae et al. [30] reported that sacrificing both IIAs significantly influenced long-term mortality (HR, 2.16; 95% CI, 1.23–5.78; p<0.01). Similarly, our study, which exclusively involved patients aged >80 years, identified bilateral IIA sacrifice as a significant predictor of overall mortality. This finding likely results from chronic pelvic ischemia associated with bilateral IIA sacrifice, particularly impacting elderly patients with advanced atherosclerotic disease. Additionally, compromised postoperative ambulation due to bilateral iliac artery sacrifice could increase the risk of complications such as pneumonia and cardiovascular events in older adults.
Hicks et al. [15] identified postoperative vasopressor use as a strong predictor of perioperative and 1-year mortality in AAA patients aged >80 years. Our study similarly showed that postoperative vasopressor use significantly influenced both 30-day and overall mortality. The requirement for postoperative vasopressors likely reflects perioperative blood loss severity and the patient’s overall cardiopulmonary status, acid-base balance, and preoperative anemia, thus making it a critical prognostic indicator.
This study has several limitations, including its single- center retrospective design and relatively small sample size. While treatment outcomes in octogenarians were examined, comparisons with non-octogenarian populations were not made; thus, further comparative research is needed. Additional comparative studies on overall survival and causes of death in patients aged >80 years who chose not to undergo aggressive treatment are also necessary. The data in this study were collected between 2010 and 2022, potentially not reflecting current improvements in AAA repair strategies and surgical techniques, which might affect outcomes. Furthermore, variations in treatment preferences among the 6 physicians performing AAA repairs may have influenced outcomes. Due to the small sample size, balancing baseline characteristics among groups was not feasible, leading to the use of simpler statistical approaches in a heterogeneous clinical setting.
In conclusion, for patients aged >80 years undergoing AAA repair, aneurysm rupture and emergency surgery significantly increased the 30-day mortality rate. Preoperative bedridden status, IIA management during treatment, and postoperative vasopressor use were significant predictors of overall mortality. Elderly patients aged >80 years receive less absolute benefit from AAA treatment, as indicated by the smaller improvement in life expectancy compared to younger patients. When determining surgical indications and predicting outcomes, it is crucial to carefully consider factors influencing mortality throughout the entire surgical process.
Acknowledgments
We thank Professor Miju Bae for her invaluable mentorship and unwavering support throughout the study.
Funding Statement
Funding This work was supported by a 2-Year Research Grant of Pusan National University.
Article information
Author Contributions
Conceptualization: JongwonK, MB. Data curation: JuanK. Formal analysis: JongwonK, MB. Funding acquisition: none. Investigation: JuanK. Methodology: JongwonK, MB. Project administration: JongwonK, MB. Resources: JuanK, MB. Software: JongwonK, MB, UH. Supervision: SWC, MB, CWL. Validation: SWC, MB, CWL. Visualization: Up Huh. Writing–original draft: JuanK, JongwonK. Writing–review & editing: JuanK. Final approval of the manuscript: all authors.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
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