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• W3136395273 abstract "In line with population ageing, vascular specialists are seeing more patients of an advanced age. As techniques and technology improve, treating these patients has never been easier. The question of how we make the shared decision for treatment with an octogenarian is the real problem; and the study by Alberga et al. goes some way towards helping us with that for patients with abdominal aortic aneurysms (AAAs).1Alberga A.J. Karthaus E.G. van Zwet E.W. de Bruin J.L. van Herwaarden J.A. Wever J.J. et al.Outcomes of octogenarians and the effect of comorbidities after intact abdominal aortic aneurysm repair in the Netherlands: a nationwide cohort study.Eur J Vasc Endovasc Surg. 2021; 61: 920-928Abstract Full Text Full Text PDF Scopus (5) Google Scholar Using rigorous statistical analysis of a large patient registry, Alberga et al.1Alberga A.J. Karthaus E.G. van Zwet E.W. de Bruin J.L. van Herwaarden J.A. Wever J.J. et al.Outcomes of octogenarians and the effect of comorbidities after intact abdominal aortic aneurysm repair in the Netherlands: a nationwide cohort study.Eur J Vasc Endovasc Surg. 2021; 61: 920-928Abstract Full Text Full Text PDF Scopus (5) Google Scholar found that AAA repair is a high risk surgical procedure in octogenarians. Even in the elective setting, they found a peri-operative mortality rate of 1.4% for endovascular repair (EVAR) and 9.3% for open surgical repair, and major morbidity rates of 12% and 28%, respectively. The vast majority (88%) of octogenarians in the study had at least one major comorbidity, and mortality rates were even higher when considering only patients with cardiac, respiratory, or renal comorbidities. This is helpful for the clinical discussion, especially bearing in mind that online actuarial life tables tell us that life expectancy is less than five years for an 80 year old with a major comorbidity. There is an ongoing argument in the literature about the value of age as an independent predictor of outcome after surgery. This has led to claims of doctors being ageist for “refusing” older people treatment, which has spilled out into the international press.2ABC NewsDoctors are ageist – and it's harming older patients.https://www.nbcnews.com/think/opinion/doctors-are-ageist-it-s-harming-older-patients-ncna1022286Date accessed: February 3, 2021Google Scholar Studies such as that of Alberga et al.1Alberga A.J. Karthaus E.G. van Zwet E.W. de Bruin J.L. van Herwaarden J.A. Wever J.J. et al.Outcomes of octogenarians and the effect of comorbidities after intact abdominal aortic aneurysm repair in the Netherlands: a nationwide cohort study.Eur J Vasc Endovasc Surg. 2021; 61: 920-928Abstract Full Text Full Text PDF Scopus (5) Google Scholar have shown advancing age to be an independent predictor of outcome and argue against this rhetoric. However, others have shown that age is not an independent predictor of outcome after surgery, and that frailty is more important.3Watt J. Tricco A.C. Talbot-Hamon C. Pham B. Rios P. Grudniewicz A. et al.Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis.BMC Med. 2018; 16: 2Crossref PubMed Scopus (80) Google Scholar, 4Ambler G.K. Kotta P.A. Zielinski L. Kalyanasundaram A. Brooks D.E. Ali A. et al.The effect of frailty on long term outcomes in vascular surgical patients.Eur J Vasc Endovasc Surg. 2020; 60: 264-272Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 5Houghton J.S.M. Nickinson A.T.O. Morton A.J. Nduwayo S. Pepper C.J. Rayt H.S. et al.Frailty factors and outcomes in vascular surgery patients: a systematic review and meta-analysis.Ann Surg. 2020; 272: 266-276Crossref PubMed Scopus (42) Google Scholar Frailty is a poorly defined term that incorporates both functional capacity and comorbidity, so can be difficult to capture in registries. This is why it tends to be missing from retrospective analyses such as this one. This is a shame, as this study would be more definitive if frailty could be used to adjust the data. There have been recent moves towards capturing it in registries, with the National Vascular Registry in the UK now including a component on frailty. Results from 2020 suggested that, perhaps unsurprisingly, patients undergoing EVAR were over twice as likely to be frail as patients undergoing open surgery (37% vs. 15%).6Waton S. Johal A. Birmpili P. Li Q. Cromwell D. O’Neill R. et al.National Vascular Registry Annual Report. Vascular Society of Great Britain and Ireland, London2020Google Scholar So, where does this leave us for the over 80 year old with an AAA in our clinic? It is fair to say that being over 80 years of age puts one in a higher risk group for AAA repair. But this study cannot conclusively prove that age alone is an independent risk factor until frailty can be adjusted for within analyses. Resetting treatment thresholds to a larger AAA size in this group is also unlikely to be helpful, as this study, as well as many others, have found worsening morbidity and mortality with increasing AAA size.7Ambler G.K. Gohel M.S. Mitchell D.C. Loftus I.M. Boyle J.R. The Abdominal Aortic Aneurysm Statistically Corrected Operative Risk Evaluation (AAA SCORE) for predicting mortality after open and endovascular interventions.J Vasc Surg. 2015; 61: 35-43Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar This means that clinical judgement on comorbidity and frailty remains paramount, and that the peri-operative risk of age alone should not be overplayed to such patients while choosing a treatment pathway that best aligns with their values. Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort StudyEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 6PreviewAge is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. Full-Text PDF Open Access" @default.
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• W3136395273 title "Abdominal Aortic Aneurysm Repair in Advanced Age: Is Age Really the Problem?" @default.
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