Advertisement

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

Open ArchivePublished:July 08, 2019DOI:https://doi.org/10.1016/j.ejvs.2019.02.002

      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 (30–54 mm) AAA between January 2007 and November 2017. Patients were stratified depending on aneurysm diameter at index (<40 mm, 40–50 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 40–50 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.

      Keywords

      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.

      Introduction

      Life expectancy continues to increase in the Western world, with >1.5 million over 85 year olds now living in the UK. This number is predicted to double by 2036.
      • Office for National Statistics
      Overview of the UK population.
      Previous data has shown that abdominal aortic aneurysm (AAA) prevalence is 23.3% in those aged > 80, with 4.1% having a threshold aneurysm.
      • Morris G.E.
      • Hubbard C.S.
      • Quick C.R.
      An abdominal aortic aneurysm screening programme for all males over the age of 50 years.
      There is debate in the literature regarding the surveillance and subsequent management of AAAs in octogenarians; however, evidence remains limited. Prior to the advent of endovascular aneurysm repair (EVAR), many patients would be refused repair by this age as open surgery was the only option. The inception of EVAR however has lead to profound change in how we manage patients. Despite this, randomised trials investigating aneurysm surveillance only included patients up to 79 years.
      • Powell J.T.
      • Brady A.R.
      • Brown L.C.
      • Fowkes F.G.
      • Greenhalgh R.M.
      • Ruckley C.V.
      • et al.
      The United Kingdom Small Aneurysm Trial Participants
      Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms.
      • Lederle F.A.
      • Wilson S.E.
      • Johnson G.R.
      • Reinke D.B.
      • Littooy F.N.
      • Acher C.W.
      • et al.
      Immediate repair compared with surveillance of small abdominal aortic aneurysms.
      The current European Society of Vascular Surgery
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert M.
      • et al.
      European society of vascular surgery (ESVS) 2019 clinical practice guidelines on the management of adbominal aorto-iliac artery aneurysms.
      (ESVS) guidelines provide little clarity on the management of small aneurysms in elderly patients. Thirty day mortality following aneurysm repair in this group has been reported to be up to 20%, with increased length of procedure, hospital stay, and morbidity.
      • Sonesson B.
      • Dias N.
      • Resch T.
      Is there an age limit for abdominal aortic aneurysm repair?.
      There is also broad consensus among vascular surgeons within the UK that patients aged ≥85 should not be transferred to a vascular centre for treatment in the event of a rupture.
      • Hinchliffe R.J.
      • Ribbons T.
      • Ulug P.
      • Powell J.T.
      Transfer of patients with ruptured abdominal aortic aneurysm from general hospitals to specialist vascular centres: results of a Delphi consensus study.
      The aim of this study was to investigate outcomes for patients aged ≥85 years undergoing surveillance with small AAAs to help identify whether discontinuation of small aneurysm surveillance might be safe and to clarify the natural history of the disease in this cohort.

      Method

      A retrospective cohort study was performed collecting data from patients who underwent ultrasound surveillance of small (30–54 mm) AAAs at the Norfolk and Norwich University Hospitals NHS Foundation Trust between January 2007 and November 2017. Patients were identified from a prospectively maintained surveillance database. All patients undergoing surveillance with a small AAA (measured antero-posterior inner to inner diameter) were included following their first surveillance scan (index scan) after reaching 85 years. Patients who entered surveillance after the age of 85 years were also included. Those patients with an AAA <30 mm or >55 mm at index scan were excluded. All patients were scanned within the vascular studies laboratory within the Norfolk and Norwich University Hospital. All aneurysms were initially detected incidentally with none entering surveillance through the National Abdominal Aortic Aneurysm Screening Programme (NAAASP). Aneurysm surveillance was nurse led and patients were not routinely seen by a vascular surgeon until reaching threshold. Patients were consented for surveillance at the time of entry into the programme. Surveillance intervals of 12 months and six months were used for aneurysms of 30–39 mm and 40–54 mm diameter, respectively.
      Clinic and general practice letters, electronic patient records and paper notes were assessed to ensure data completion. Data at index on demographics, medical history, active medications, and smoking status in addition to surveillance results and cause of death were recorded. Out of hospital cause of death was established from interrogating individual general practice records.
      In line with ESVS
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert M.
      • et al.
      European society of vascular surgery (ESVS) 2019 clinical practice guidelines on the management of adbominal aorto-iliac artery aneurysms.
      guidelines, a threshold for decision on intervention was set at 55 mm in men. Given the frailty of this age group, this threshold was extended to all women. After reaching threshold, all aneurysms were reviewed in a departmental multidisciplinary meeting. Aneurysm morphology was evaluated against indications for use (IFU) to assess radiological suitability for standard infrarenal, or if necessary, complex endovascular repair. All patients underwent clinical and functional assessment by the treating surgeon to assess fitness for repair, in the light of the treatment modality offered. Furthermore, tailored testing (e.g. echocardiogram) and formal anaesthetic assessment were undertaken in all patients deemed potentially suitable for treatment. Where doubt remained, suitability for repair was discussed in the multidisciplinary setting.
      Patients were stratified into three groups according to AAA diameter at the index scan (<40 mm, 40–50 mm, > 50 mm). Aneurysms reaching threshold, subsequent management, and reasons for refusal to treat were recorded. Information on aneurysm related and all cause mortality was also collected. Follow up continued until death or January 1, 2018. Follow up and mortality data were completed for all patients.
      Binary data were reported using frequency and percentages. The chi-square test was used to determine any association between index AAA diameter (<40 mm, 40–50 mm, > 50 mm) and the proportion subsequently reaching threshold for repair. All analyses were performed using IBM SPSS Statistics 22 (IBM, Armonk, NY, USA), with p < .05 deemed to be indicative of statistical significance.
      Ethical approval was not applicable for this study.

      Results

      Overall, 101 patients with a sub-threshold AAA at index scan (range 85–89 years at index) were identified and included. The mean aneurysm diameter at index was 45 mm (SD 9.2 mm). Median follow up was 56.0 months (IQR 36.8–80.5). Twenty-eight patients (27.7%) reached threshold for repair, of whom eight underwent elective surgical repair (5 standard endovascular, one complex endovascular, and two open). Characteristics of the study group are shown in Table 1 and reflect a standard cohort of patients with aneurysms. No aneurysms with saccular morphology were identified within the cohort.
      Table 1Characteristics of 101 patients under abdominal aortic aneurysm surveillance
      Characteristicn (%)
      Male sex88 (87.1)
      Age range at index in years85–89
      Mean aneurysm diameter (mm) at index45 (SD 9.2)
      Comorbidity
       Hypertension56 (55.5)
       Ischaemic heart disease45 (44.6)
       Atrial fibrillation33 (32.7)
       Chronic obstructive pulmonary disease17 (16.8)
       Diabetes mellitus15 (14.9)
       Renal disease20 (19.8)
       Congestive cardiac failure12 (11.9)
       Cerebrovascular disease16 (15.8)
      Smoking status
       Smoker/ex-smoker49 (48.5)
       Never38 (37.6)
       Unknown14 (13.8)
      Medication history
       Aspirin52 (51.5)
       Clopidogrel13 (12.9)
       Warfarin26 (25.8)
       Statin86 (85.1)
       Aspirin + statin46 (45.5)
       Clopidogrel + statin10 (9.9)
       Warfarin + statin21 (20.8)

      Mortality in surveillance

      Twenty-six (25.7%) deaths were recorded at a median age of 87 (range 85–90). Of these, only three of the 26 deaths (11.5%) were aneurysm related (Table 2).
      Table 2Cause of death as recorded on death certificate
      Cause of deathAll deaths (n = 26)Deaths: anterior-posterior diameter (APD) <55 mm at last scan (n = 18)Deaths: APD ≥55 mm at last scan and not repaired (n = 6)Deaths: underwent aneurysm repair (n = 2)
      Non-aneurysm related
       Pneumonia10811
       Cerebrovascular accident6510
       Sepsis1100
       Malignancy4310
       Ischaemic heart disease110
       Ischaemic bowel1010
      Aneurysm related
       Rupture (operated)0000
       Ruptured (not operated)2020
      Other
      Complication of infected stent graft; APD = anterior-posterior diameter.
      1001
      a Complication of infected stent graft; APD = anterior-posterior diameter.
      Eighteen out of 26 deaths (69.2%) occurred in surveillance patients with a small aneurysm. Six (26.9%) patients died with a threshold aneurysm without undergoing repair because of significant cardiovascular comorbidity, metastatic malignancy, or patient wishes. Two patients died from a ruptured AAA, both with a conservatively managed threshold aneurysm (108 and 468 days following decision not to treat). Overall, the median time to death following decision not to treat a threshold aneurysm was 10.6 months (IQR 4.5–15.2). Eight patients underwent repair with no 30 day mortality recorded. Two patients who underwent repair died, one from an infected endovascular stent graft at 13.0 months, and one from community acquired pneumonia 64.3 months post-operatively. Median follow up in surviving patients following aneurysm repair was 16.0 months (10.8–36.3).

      Relationship between initial surveillance AAA size and outcome

      Table 3 shows the outcomes of aneurysms from initial index scan. An association was observed between aneurysm diameter at index and proportion reaching threshold (p < .0001).
      Table 3Outcomes of aneurysm from index scan
      Aneurysm diameter at index, mmn (%)Total reaching threshold (% total)p
      Chi-square test.
      Surgical repair (% threshold)Ruptured abdominal aortic aneurysm (% total)Median follow up, in months (interquartile range)
      <4029 (28.7)1 (3.4)<.00010 (0.0)0 (0.0)62 (40–90)
      40–5043 (42.6)5 (11.6)2 (40.0)0 (0.0)56 (42–78)
      >5029 (28.7)22 (75.9)6 (27.3)2 (6.9)58 (32–67)
      a Chi-square test.

      Patient with AAA diameter <40 mm

      Twenty-nine patients (28.7%) had an AAA of <40 mm diameter at index. One patient reached threshold for consideration of repair at the age of 90 years. He was subsequently declined surgery as deemed unfit. No ruptures were observed within this group.

      Patient with AAA diameter 40–50 mm

      Forty-three (42.6%) patients had an AAA of 40–50 mm diameter at index. Five patients reached the threshold diameter, and, of these, two patients had elective repair. Surgery was declined for the other three patients as either they were deemed unfit for repair (n = 1) or to comply with the patient's wishes (n = 2). The age range at threshold was 88–90 years. No ruptures were observed within this group.

      Patient with AAA diameter >50 mm

      A total of 29 (28.7%) patients had an AAA of diameter > 50 mm at threshold. Twenty-two patients reached the threshold for treatment. Of these, six patients underwent elective repair with the remaining declined surgery because they were either deemed unfit for repair (n = 13) or to comply with the patient's wishes (n = 3). The age range at threshold was 85–91 years. Two ruptures were observed within this group, both occurring in patients reaching threshold and subsequently being declined repair. Furthermore, one patient died as a results of a complications from an infected stent-graft following repair.

      Discussion

      This study followed 101 patients, aged ≥85 years at index, undergoing surveillance for a small AAA. 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 diameter group developed a threshold aneurysm (managed non-operatively), compared with five (11.6%) and 22 (75.9%) patients in the 40–49 mm and >50 mm groups, respectively. The mortality rate was high by the end of follow up (25.7%), with cardiorespiratory pathologies representing the leading cause of death. Only two ruptured aneurysms were observed in this cohort, both occurring in patients within the >50 mm group. No 30 day post-operative mortality was observed following aneurysm repair.
      The management of elderly patients with AAAs presents a significant challenge, especially because of their comorbid and frail nature. Two issues in particular are of note, firstly the decision on whether to continue surveillance and, secondly, whether to offer treatment if an aneurysm reaches threshold.
      Continuing surveillance in this group is contentious. Evidence on surveillance in this age group is very limited with both the UK Small Aneurysm Trial
      • Powell J.T.
      • Brady A.R.
      • Brown L.C.
      • Fowkes F.G.
      • Greenhalgh R.M.
      • Ruckley C.V.
      • et al.
      The United Kingdom Small Aneurysm Trial Participants
      Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms.
      (UKSAT) and Aneurysm Detection and Management Study
      • Lederle F.A.
      • Wilson S.E.
      • Johnson G.R.
      • Reinke D.B.
      • Littooy F.N.
      • Acher C.W.
      • et al.
      Immediate repair compared with surveillance of small abdominal aortic aneurysms.
      (ADAM) only including patients up to 79 years of age. Given mean aneurysm growth rates identified by Powell et al.,
      • Powell J.T.
      • Sweeting M.J.
      • Brown L.C.
      • Gotensparre S.M.
      • Fowkes F.G.
      • Thompson S.G.
      Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms.
      many patients will be unlikely to reach the threshold for treatment within their lifetime. Furthermore, a significant proportion will be unsuitable for repair when they eventually do reach threshold. This is especially pertinent in the <40 mm group, where the mean aneurysm growth rate is 2.6 mm/year.
      • Powell J.T.
      • Sweeting M.J.
      • Brown L.C.
      • Gotensparre S.M.
      • Fowkes F.G.
      • Thompson S.G.
      Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms.
      The recent preliminary guidelines on the management of AAAs published by the National Institute of Health and Care Excellence
      National Institute for Health and Care Excellence
      Abdominal Aortic Aneurysm: Diagnosis and Management.
      will probably extenuate this further.
      Despite this uncertainty, the 2019 update of the ESVS
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert M.
      • et al.
      European society of vascular surgery (ESVS) 2019 clinical practice guidelines on the management of adbominal aorto-iliac artery aneurysms.
      AAA guidelines provides vascular surgeons little clarity on this matter, only recommending against starting surveillance in incidentally discovered small aneurysms in those with “very limited life expectancy.” Further to this, the guidelines also recommend surveying a <40 mm aneurysm every three years; however, they are ambiguous regarding this cohort of patients, where scanning at this frequency seems counterintuitive.
      This study provides evidence that it might be safe to discontinue surveillance in patients with aneurysms <40 mm at the age of 85 and helps clarify some degree of the uncertainty seen within the new guidelines.
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert M.
      • et al.
      European society of vascular surgery (ESVS) 2019 clinical practice guidelines on the management of adbominal aorto-iliac artery aneurysms.
      In patients with larger aneurysms the risk of rupture is low, although ongoing surveillance remains warranted given the proportion reaching threshold, especially in the >50 mm group. A prudent approach of early assessment of fitness for repair, however, may prevent unnecessary surveillance in frail and comorbid patients.
      The management of aneurysms reaching threshold is also highly challenging. Age alone is not a contraindication to aneurysm repair; however, increasing age, frailty, and sarcopenia are independent risk factors for post-operative mortality.
      • Brady A.R.
      • Fowkes F.G.
      • Greenhalgh R.M.
      • Powell J.T.
      • Ruckley C.V.
      • Thompson S.G.
      Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial.
      • Tsilimparis N.
      • Perez S.
      • Dayama A.
      • Ricotta J.J.
      Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently?.
      • Arya S.
      • Kim S.I.
      • Duwayri Y.
      • Brewster L.P.
      • Veeraswamy R.
      • Salam A.
      • et al.
      Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.
      • Hale A.L.
      • Twomey K.
      • Ewing J.A.
      • Langan E.M.
      • Cull D.L.
      • Gray B.H.
      Impact of sarcopenia on long-term mortality following endovascular aneurysm repair.
      • Han Y.
      • Zhang S.
      • Zhang J.
      • Ji C.
      • Eckstein H.H.
      Outcomes of endovascular abdominal aortic aneurysm repair in octogenarians: meta-analysis and systematic review.
      Thirty day and mid-term mortality results from both open and endovascular repair in octogenarians are acceptable, however, mortality, hospital stay, and adverse events are all higher in this group compared with younger patients.
      • Sonesson B.
      • Dias N.
      • Resch T.
      Is there an age limit for abdominal aortic aneurysm repair?.
      • Tsilimparis N.
      • Perez S.
      • Dayama A.
      • Ricotta J.J.
      Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently?.
      • Han Y.
      • Zhang S.
      • Zhang J.
      • Ji C.
      • Eckstein H.H.
      Outcomes of endovascular abdominal aortic aneurysm repair in octogenarians: meta-analysis and systematic review.
      Meta-analysis by Han et al.
      • Han Y.
      • Zhang S.
      • Zhang J.
      • Ji C.
      • Eckstein H.H.
      Outcomes of endovascular abdominal aortic aneurysm repair in octogenarians: meta-analysis and systematic review.
      identified a 9.2% one year mortality following elective EVAR in octogenarians. In this study only two ruptures were identified in 19 patients with a threshold aneurysm managed conservatively. Furthermore, the long-term results from the EVAR-2
      • Sweeting M.J.
      • Patel R.
      • Powell J.T.
      • Greenhalgh R.M.
      EVAR Trial Investigators
      Endovascular repair of abdominal aortic aneurysm in patients physically ineligible for open repair: very long-term follow-up in the EVAR-2 randomized controlled trial.
      trial show that endovascular repair does not improve overall mortality in patients deemed unfit for open repair.
      Ultimately, the best management option for a patient will be based on the joint decision of surgeon and patient. The present findings complement the current literature in highlighting the need for careful patient selection when offering aneurysm repair in this age group.
      There are a number of limitations to this study. Firstly, it is a single centre observational study. Despite including all patients over a 10 year period, the population size is small and only a limited number of repairs and ruptures were observed. The study is therefore at risk of type 2 statistical error. Selection bias is possible as comorbid patients may have been removed from surveillance prior to 85 years, or never referred. Furthermore, the rate of repair could be biased by local practices; however, the rate of rupture was low in patients declined repair.
      Regarding mortality, data presented in this study relied on death certificates to establish the cause of death. Post-mortems are not routinely carried out in the UK and therefore it is possible that ruptured aneurysms were missed or incorrectly assumed to be the cause of death.
      Finally, the study did not investigate post-operative morbidity, which could be significant in this group and give further evidence on the safety of repairing threshold aneurysms in this cohort. Given the paucity of evidence related to the surveillance and management of aneurysms in octogenarians, further studies are required.

      Conclusion

      Aneurysm rated mortality is low in patients with small AAAs aged ≥85 years, with the majority of threshold aneurysms being treated conservatively. The present data suggest that discontinuation of aneurysm surveillance in patients with aneurysms <40 mm at the age of 85 years might be safe. In patients with larger aneurysms or those approaching threshold, surveillance remains warranted; however, 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.

      Funding

      None.

      Conflict of interest

      None.

      Acknowledgement

      Mr Ian Nunney, Norfolk and Norwich University Hospital and University of East Anglia, assisted with statistical analysis.

      References

        • Office for National Statistics
        Overview of the UK population.
        Office for National Statistics, London2017
        • Morris G.E.
        • Hubbard C.S.
        • Quick C.R.
        An abdominal aortic aneurysm screening programme for all males over the age of 50 years.
        Eur J Vasc Surg. 1994; 8: 156-160
        • Powell J.T.
        • Brady A.R.
        • Brown L.C.
        • Fowkes F.G.
        • Greenhalgh R.M.
        • Ruckley C.V.
        • et al.
        • The United Kingdom Small Aneurysm Trial Participants
        Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms.
        N Engl J Med. 2002; 346: 1445-1452
        • Lederle F.A.
        • Wilson S.E.
        • Johnson G.R.
        • Reinke D.B.
        • Littooy F.N.
        • Acher C.W.
        • et al.
        Immediate repair compared with surveillance of small abdominal aortic aneurysms.
        N Engl J Med. 2002; 346: 1437-1444
        • Wanhainen A.
        • Verzini F.
        • Van Herzeele I.
        • Allaire E.
        • Bown M.
        • Cohnert M.
        • et al.
        European society of vascular surgery (ESVS) 2019 clinical practice guidelines on the management of adbominal aorto-iliac artery aneurysms.
        Eur J Vasc Endovasc Surg. 2019; 57: 8-93
        • Sonesson B.
        • Dias N.
        • Resch T.
        Is there an age limit for abdominal aortic aneurysm repair?.
        J Cardiovasc Surg (Torino). 2018; 59: 190-194
        • Hinchliffe R.J.
        • Ribbons T.
        • Ulug P.
        • Powell J.T.
        Transfer of patients with ruptured abdominal aortic aneurysm from general hospitals to specialist vascular centres: results of a Delphi consensus study.
        Emerg Med J. 2013; 30: 483-486
        • Powell J.T.
        • Sweeting M.J.
        • Brown L.C.
        • Gotensparre S.M.
        • Fowkes F.G.
        • Thompson S.G.
        Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms.
        Br J Surg. 2011; 98: 609-618
        • National Institute for Health and Care Excellence
        Abdominal Aortic Aneurysm: Diagnosis and Management.
        National Institute for Health and Care Excellence, London2018
        • Brady A.R.
        • Fowkes F.G.
        • Greenhalgh R.M.
        • Powell J.T.
        • Ruckley C.V.
        • Thompson S.G.
        Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial.
        Br J Surg. 2000; 87: 742-749
        • Tsilimparis N.
        • Perez S.
        • Dayama A.
        • Ricotta J.J.
        Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently?.
        J Am Coll Surg. 2012; 21: 690-701
        • Arya S.
        • Kim S.I.
        • Duwayri Y.
        • Brewster L.P.
        • Veeraswamy R.
        • Salam A.
        • et al.
        Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.
        J Vasc Surg. 2015; 61: 324-331
        • Hale A.L.
        • Twomey K.
        • Ewing J.A.
        • Langan E.M.
        • Cull D.L.
        • Gray B.H.
        Impact of sarcopenia on long-term mortality following endovascular aneurysm repair.
        Vasc Med. 2016; 21: 217-222
        • Han Y.
        • Zhang S.
        • Zhang J.
        • Ji C.
        • Eckstein H.H.
        Outcomes of endovascular abdominal aortic aneurysm repair in octogenarians: meta-analysis and systematic review.
        Eur J Vasc Endovasc Surg. 2017; 54: 454-463
        • Sweeting M.J.
        • Patel R.
        • Powell J.T.
        • Greenhalgh R.M.
        • EVAR Trial Investigators
        Endovascular repair of abdominal aortic aneurysm in patients physically ineligible for open repair: very long-term follow-up in the EVAR-2 randomized controlled trial.
        Ann Surg. 2017; 266: 713-719

      Comments

      Commenting Guidelines

      To submit a comment for a journal article, please use the space above and note the following:

      • We will review submitted comments as soon as possible, striving for within two business days.
      • This forum is intended for constructive dialogue. Comments that are commercial or promotional in nature, pertain to specific medical cases, are not relevant to the article for which they have been submitted, or are otherwise inappropriate will not be posted.
      • We require that commenters identify themselves with names and affiliations.
      • Comments must be in compliance with our Terms & Conditions.
      • Comments are not peer-reviewed.