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Octogenarians undergoing Open Repair Have Higher Mortality compared to Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving Visceral Vessels.
Satinderjit S. Locham, Besma Nejim, MD, MPH, Hanaa Dakour Aridi, MD, Muhammad Faateh, MD, Rami Srouji, Mahmoud Malas, MD, MHS.
John Hopkins Hospital, Baltimore, MD, USA.

Objective(s):
Fenestrated-endovascular repair (F-EVAR) has been populated as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared to traditional open repair (OAR). The aim of the study is to compare 30-day outcomes of F-EVAR vs. OAR in octogenarians undergoing repair of Abdominal Aortic Aneurysm (AAA) involving visceral vessels. Methods:
All patients with post-operative diagnosis of non-ruptured AAA involving visceral vessels who underwent F-EVAR and OAR were identified in NSQIP database (2006-2015). Primary outcome of interest was mortality. Secondary outcomes included renal failure, cardio-pulmonary failure and stroke. Univariate and multivariate analyses were implemented to examine 30-day post-operative mortality adjusting for patient demographics and comorbidities. Results:
A total of 548 octogenarians underwent AAA repair involving visceral vessels [F-EVAR (44%), OAR (56%)]. Octogenarians undergoing F-EVAR were on average 1 year older (mean age (S.D.): 84.0(3.1) vs. 83.0(2.8), p<0.001) and more likely to be males (82% vs. 64%, p<0.001) than patients undergoing OAR. Prevalence of diabetes (13% vs. 6%, p=0.005) and progressive renal failure (57% vs. 47%), p=0.02) was also higher in patients undergoing F-EVAR. Total length of hospital stay (LOS) {(S.D.): 11.7(9.5) vs. 4.5(6.4) days, p=0.01} and total operative time {(S.D.): 243.2(100.2) vs. 208(113.4) minutes, p=0.0001) were higher in octogenarians undergoing OAR. Patients undergoing OAR also had more frequent return to OR (11% vs. 5%, p=0.02). Furthermore, 30-day post-operative mortality was higher after an OAR (8.5% vs. 4.1%, p=0.04). Secondary outcomes including cardio-pulmonary (27% vs. 6%, p<0.001) and renal (16% vs. 5%, p<0.001) complications were also significantly higher in OAR compared to F-EVAR (Figure). After adjusting for patients demographics and comorbidities, OAR had more than three and a half folds increase in 30-day post-operative mortality compared to F-EVAR (OR (95%CI): 3.68(1.40-9.64), p=0.008). Other predictors of mortality were smoking history, bleeding disorders, sepsis, and acute renal failure/dialysis.

Conclusions:
In this large study, we showed that OAR is associated with significant increase risk of morbidity and mortality compared to F-EVAR. These findings support the utilization of minimally invasive approach in this frail population. Further studies needed to evaluate the benefit of any repair in Octogenarians.


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