Outcomes of Sub-threshold Abdominal Aortic Aneurysms Undergoing Surveillance in Patients Aged 85 Years or Over

Abstract

Evidence on the surveillance of small abdominal aortic aneurysms (AAAs) in patients aged 85 years is limited. This study suggests that it might be safe to discontinue surveillance in patients aged 85 years with an AAA <40 mm, and that early assessment of surgical fitness in patients with larger aneurysms may reduce unnecessary investigations.Objective: Despite an increasing elderly population there is limited evidence regarding the surveillance and management of small abdominal aortic aneurysms (AAAs) in octogenarians. This study investigated outcomes of patients aged 85 years undergoing AAA surveillance to identify whether discontinuation of surveillance might be safe. Methods: This was a retrospective cohort study of all patients aged 85 years undergoing surveillance with a small (30e54 mm) AAA between January 2007 and November 2017. Patients were stratified depending on aneurysm diameter at index (<40 mm, 40e50 mm, > 50 mm). A threshold of 55 mm was used to decide intervention in all patients. Subsequent management of threshold aneurysms, aneurysm related and all cause mortality were also collected. Results: One hundred and one patients were included (88 male, mean diameter at index 45 mm, median follow up 56.0 months). The majority of patients (72.3%) undergoing surveillance had not reached threshold at the end of follow up. Only one patient in the <40 mm group developed a threshold aneurysm, compared with five (11.6%) and 22 (75.9%) in the 40e50 mm and >50 mm groups, respectively (p < .0001). Of the 28 patients reaching threshold, eight (28.6%) underwent surgical repair (5 standard endovascular, one complex endovascular, and two open). Twenty-six (25.7%) patients died during follow up, with cardiorespiratory pathologies being the leading cause of death. Only three aneurysm related deaths were observed, including two fatal ruptures and one death following repair from an infected stent graft (all in the >50 mm index group). Conclusion:The present data suggests that discontinuation of aneurysm surveillance in patients aged 85 years with aneurysms < 40 mm might be safe. In patients with a larger aneurysm or those approaching threshold, early assessment of fitness for surgery may prevent unnecessary surveillance. The decision to treat aneurysms reaching threshold is complex but is appropriate in selected patients.

A Systematic Review and Meta-Analysis of the Incidence and Risk Factors for Major Adverse Cardiovascular Events in Patients with Unrepaired Abdominal Aortic Aneurysms

“…A total of 14 studies included 69,579 participants with unrepaired AAA with a mean follow-up time of 5.4 years ( Figure 1 ). Nine studies were prospective cohort studies [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ], and five studies were retrospective cohort studies [ 17 , 18 , 19 , 20 , 21 ]. Twelve studies reported the incidence of cardiovascular death in 35,936 participants [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 20 , 21 ].…”

“…Nine studies were prospective cohort studies [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ], and five studies were retrospective cohort studies [ 17 , 18 , 19 , 20 , 21 ]. Twelve studies reported the incidence of cardiovascular death in 35,936 participants [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 20 , 21 ]. Five studies reported the incidence of non-fatal MI and non-fatal stroke in 35,860 participants [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 20 , 21 ].…”

“…Twelve studies reported the incidence of cardiovascular death in 35,936 participants [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 20 , 21 ]. Five studies reported the incidence of non-fatal MI and non-fatal stroke in 35,860 participants [ 6 , 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 20 , 21 ]. Where reported, a weighted average of 41.1%, 11.1%, 75.7%, and 27.4% of the participants had hypertension, diabetes, had ever smoked, and currently smoked, respectively ( Table 1 ).…”

Small Aneurysm Surveillance Over 80: Is it Worthwhile?

“…Contemporary evidence suggests that not offering AAA surveillance to those aged > 85 years with an AAA diameter < 40 mm is a justified approach. 2 Certainly, based on the findings in this study, an earlier determination of fitness for surgery should be made to prevent unnecessary surveillance of patients who are unlikely ever to be candidates for intervention. Ideally, such a decision should be made after multidisciplinary team review and discussion with patient and family.…”

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

“…A retrospective cohort study of elderly pts, aged ! 85 years, with AAA 3.0-5.4 cm in diameter at baseline, showed that discontinuation of follow-up might be safe in aneurysms measuring < 4 cm in diameter at baseline [316]. For elderly pts with aneurysms measuring 4-5.4 cm in diameter, assessment of fitness for surgery may prevent unnecessary surveillance [316].…”