Advertisement

Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study

Open AccessPublished:April 16, 2021DOI:https://doi.org/10.1016/j.ejvs.2021.02.047

      Objective

      Age 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. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined.

      Methods

      All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality.

      Results

      This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR.

      Conclusion

      Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.

      Keywords

      This paper examined retrospectively the outcomes of octogenarians that underwent either open surgical repair or endovascular repair for an intact abdominal aortic aneurysm in an obligatory nationwide registry, reflecting daily clinical practice in the Netherlands. The study showed that besides an increased age, comorbidities were clearly associated with impaired peri-operative survival after both open surgical and endovascular repair.

      Introduction

      In the last decade, endovascular aneurysm repair (EVAR) has become the preferred treatment for many patients with an intact abdominal aortic aneurysm (AAA),
      • Lilja F.
      • Mani K.
      • Wanhainen A.
      Editor’s Choice – Trend-break in abdominal aortic aneurysm repair with decreasing surgical workload.
      because of its lower peri-operative risks. Age is a known independent risk factor for post-operative mortality after both elective open surgical repair (OSR) and EVAR.
      • Arhuidese I.J.
      • Salami A.
      • Obeid T.
      • Qazi U.
      • Abularrage C.J.
      • Black J.H.
      • et al.
      The age effect in increasing operative mortality following delay in elective abdominal aortic aneurysm repair presented at the society for clinical vascular surgery 42nd Annual Symposium, Carlsbad, CA, March 18-22, 2014.
      As a result of an ageing population,

      Centraal Bureau voor de Statistiek. Bevolkingspiramide. Available at: https://www.cbs.nl/nl-nl/visualisaties/bevolkingspiramide [Accessed 5 November 2020].

      the number of patients over 80 years (octogenarians) who qualify for elective AAA repair is increasing.
      • Budtz-Lilly J.
      • Venermo M.
      • Debus S.
      • Behrendt C.A.
      • Altreuther M.
      • Beiles B.
      • et al.
      Editor’s Choice – Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.
      ,
      • Mani K.
      • Lees T.
      • Beiles B.
      • Jensen L.P.
      • Venermo M.
      • Simo G.
      • et al.
      Treatment of abdominal aortic aneurysm in nine countries 2005-2009: A vascunet report.
      However, the mortality and morbidity after AAA surgery for octogenarians is increased,
      • Powell J.T.
      • Sweeting M.J.
      • Ulug P.
      • Blankensteijn J.D.
      • Lederle F.A.
      • Becquemin J.P.
      • et al.
      Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years.
      • Henebiens M.
      • Vahl A.
      • Koelemay M.J.W.
      Elective surgery of abdominal aortic aneurysms in octogenarians: A systematic review.
      • Biancari F.
      • Catania A.
      • D’Andrea V.
      Elective endovascular vs. open repair for abdominal aortic aneurysm in patients aged 80 years and older: Systematic review and meta-analysis.
      • 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.
      which is important in the decision making process of when and how to intervene in this usually frailer population.
      In current literature that reports on octogenarians, meta-analyses that include mainly observational studies have not described outcomes with details for octogenarians,
      • Henebiens M.
      • Vahl A.
      • Koelemay M.J.W.
      Elective surgery of abdominal aortic aneurysms in octogenarians: A systematic review.
      • Biancari F.
      • Catania A.
      • D’Andrea V.
      Elective endovascular vs. open repair for abdominal aortic aneurysm in patients aged 80 years and older: Systematic review and meta-analysis.
      • 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.
      while RCTs barely enrolled patients over 80 years.
      • Powell J.T.
      • Sweeting M.J.
      • Ulug P.
      • Blankensteijn J.D.
      • Lederle F.A.
      • Becquemin J.P.
      • et al.
      Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years.
      Peri-operative mortality of octogenarians after primary AAA repair in 11 countries was assessed by the Vascunet collaboration. However, the morbidity of these patients was not described.
      • Budtz-Lilly J.
      • Venermo M.
      • Debus S.
      • Behrendt C.A.
      • Altreuther M.
      • Beiles B.
      • et al.
      Editor’s Choice – Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.
      Therefore, there is a paucity of real life clinical data concerning mortality and morbidity after AAA surgery for octogenarians. Moreover, published studies scarcely report on the peri-operative mortality of subgroups of octogenarians with either low or high peri-operative risks. The recent ESVS guideline state that it is reasonable to consider elective AAA repair of octogenarians with reasonable life expectancy and quality of life after informing them of the pros and cons of different treatment strategies including conservative treatment.
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.
      However, no statements were made on which octogenarians have high peri-operative risks. The aim of this study was to provide peri-operative mortality and major complication rates of octogenarians vs. non-octogenarians following intact AAA repair. This was assessed following both open surgical and endovascular aneurysm repair including separate subanalyses for elective and urgent intact repair using a nationwide prospective registry. Furthermore, which octogenarians have low and high peri-operative risks was identified, examining the influence of age and the presence of comorbidities on peri-operative mortality.

      Materials and Methods

      Data sources and study design

      The dataset was retrieved from the Dutch Surgical Aneurysm Audit (DSAA), a nationwide prospective and compulsory quality registry that registers all patients undergoing aortic aneurysm surgery in the Netherlands. The DSAA was initiated in 2013, and includes all patients who underwent surgical repair of an infrarenal or juxtarenal AAA without previous aortic surgery. Since 2016, patients undergoing revisional aneurysm surgery and/or patients undergoing thoracic or thoraco-abdominal aortic aneurysm repair have been registered as well. Data verification took place through a random sample of hospitals.

      Dutch Institute for Clinical Auditing. Eindrapport dataverificatie DSAA. Available at: https://dica.nl/media/660/Eindrapport_dataverificatie_DSAA_2016.pdf [Accessed 5 November 2020].

      The data were analysed retrospectively and reported following the STROBE guidelines.

      STROBE Statement—checklist of items that should be included in reports of observational studies. Available at: https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_combined.pdf [Accessed 8 November 2020].

      Participants

      For this study, all patients who were registered in the DSAA undergoing primary repair (EVAR or OSR) for an intact AAA between January 2013 and December 2018 were included for analysis, provided that sex, date of birth, date of surgery, survival status at the time of discharge or 30 days post-operatively were registered. Data analyses were performed on an anonymised dataset. Ethical approval was not needed according to Dutch law.

      Definitions

      Patients were considered octogenarians when turning 80 years old or older in the year of surgery. EVAR procedures followed by immediate conversion were categorised by intention to treat. Intact aneurysm repairs included pooled data of both elective repair and urgent intact AAA repair. “Cardiac comorbidity” was defined as the use of diuretic or digoxin, antianginal or antihypertensive therapy, peripheral oedema, warfarin therapy, raised jugular venous pressure, or cardiomegaly.
      • Copeland G.P.
      • Jones D.
      • Walters M.
      POSSUM: A scoring system for surgical audit.
      “Abnormality on ECG” was defined as atrial fibrillation, ischaemia or any other ECG abnormalities.
      • Copeland G.P.
      • Jones D.
      • Walters M.
      POSSUM: A scoring system for surgical audit.
      Because of possible confounding caused by the variables “Cardiac comorbidity” and “Abnormality on ECG”, it was decided to combine these variables into the variable “Cardiac comorbidity including abnormality on ECG” in the analyses. “Pulmonary comorbidity” was defined as dyspnoea on exertion, limiting dyspnoea, dyspnoea at rest, or visible consolidations or fibrosis on chest imaging.
      • Copeland G.P.
      • Jones D.
      • Walters M.
      POSSUM: A scoring system for surgical audit.
      “Renal comorbidity” was defined as an eGFR < 60 mL/min/1.73m2, which is categorised as “chronic kidney disease” by the International Society of Nephrology.
      Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group
      KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
      The eGFR was estimated using the CKD-EPI equation
      • Levey A.S.
      • Stevens L.A.
      • Schmid C.H.
      • Zhang Y.L.
      • Castro 3rd, A.F.
      • Feldman H.I.
      • et al.
      A new equation to estimate glomerular filtration rate.
      and the variables “creatinine”, “sex”, and “age”.

      Outcomes

      All outcomes of octogenarians were compared with the results of non-octogenarians. The primary outcome was peri-operative mortality, which was defined as intra-operative mortality, mortality ≤ 30 days after surgery, or during admission (in hospital mortality). The secondary outcomes were peri-operative major complications (≤ 30 days), defined as either an intra-operative or post-operative complications that needed a re-intervention, induced prolonged stay, or caused death
      • Lijftogt N.
      • Karthaus E.G.
      • Vahl A.
      • van Zwet E.W.
      • van der Willik E.M.
      • Tollenaar R.A.E.M.
      • et al.
      Failure to rescue – a closer look at mortality rates has no added value for hospital comparisons but is useful for team quality assessment in abdominal aortic aneurysm surgery in the Netherlands.
      and the peri-operative mortality in patients with and without comorbidities. Furthermore, subgroup analyses were performed to compare outcomes of octogenarians and non-octogenarians treated in elective and urgent intact settings.

      Statistical methods

      Descriptive analysis was performed using t tests for parametrically distributed data, chi square tests and Fisher exact tests. Baseline characteristics, as well as peri-operative outcomes, were compared between octogenarians and non-octogenarians undergoing either EVAR or OSR. Missing values were shown as separate categories. A p value of <.05 was considered statistically significant.
      To investigate whether age ≥ 80 was associated with peri-operative mortality, multivariable logistic regression analyses were performed for both EVAR and OSR. Patient and aneurysm related variables, based on the V(p)-POSSUM predictive score,
      • Copeland G.P.
      • Jones D.
      • Walters M.
      POSSUM: A scoring system for surgical audit.
      ,

      Smith J, Tekkis P. Risk prediction in surgery. Available at: http://www.riskprediction.org.uk/vasc-index.php. [Accessed 8 November 2020].

      that were potential confounders and available in the DSAA were included as covariates: age ≥80, sex, pulmonary comorbidity, cardiac comorbidity including results of last pre-operative electrocardiogram, renal comorbidity, pre-operative haemoglobin, urgency, location, and diameter of the aneurysm. Factors with a p value of <.10 in univariable analysis were selected for multivariable analysis. Finally, the peri-operative mortality rates of octogenarians and non-octogenarians with no comorbidities, cardiac comorbidity (including abnormality on the ECG), pulmonary comorbidity, and renal comorbidity were shown.

      Missing data

      The data for this study contained some variables with missing values. If patients with any missing data had been excluded from the analyses, information on 2 477 (19.1%) patients including 538 octogenarians who underwent EVAR and 685 (18.0%) patients including 74 octogenarians who underwent OSR would have been lost. To prevent such loss of information, a state of the art method of multiple imputation using chained equations (MICE) was used.
      • White I.R.
      • Royston P.
      • Wood A.M.
      Multiple imputation using chained equations: issues and guidance for practice.
      Missing data were imputed separately for EVAR and OSR patients. The outcome peri-operative mortality was not imputed, and the following variables were used in the imputation process: age, sex, cardiac and pulmonary comorbidity, results of the last electrocardiogram, haemoglobin, creatinine, diameter, location, urgency, peri-operative mortality, pre- and post-operative complications, length of ICU stay, length of hospital stay, re-intervention, and re-admission. Twenty-five completed datasets were generated (each with 10 iterations) for both EVAR and OSR patients.
      • White I.R.
      • Royston P.
      • Wood A.M.
      Multiple imputation using chained equations: issues and guidance for practice.
      Values that were imputed were compared with values that were observed using scatter and density plots. For the multivariable regression models, the results of the imputed datasets were combined to produce a final result using Rubin’s rules.
      • White I.R.
      • Royston P.
      • Wood A.M.
      Multiple imputation using chained equations: issues and guidance for practice.
      For comparison, multivariable regression analyses using the subsets of complete cases were performed.
      All analyses were performed using R version 3.6.1.

      Results

      Between January 2013 and December 2018, 21 950 consecutive patients were registered in the DSAA. Of these patients, 15 906 underwent primary AAA repair for an intact aneurysm, of whom 15 869 (99.8%) were eligible for analysis (Figure 1). In total, 12 054 EVAR patients including 3 015 (25%) octogenarians, and 3 815 OSR patients including 425 (11%) octogenarians, were included.
      Figure 1
      Figure 1Study flow chart of included octogenarians and non-octogenarians who were registered in the Dutch Surgical Aneurysm Audit (DSAA) and who underwent primary repair of an intact abdominal aortic aneurysm (AAA) by endovascular aneurysm repair (EVAR) or open surgical repair (OSR).

      Patient characteristics, aneurysm morphology, and operative data

      Patient characteristics, aneurysm morphology, and operative data comparing octogenarians and non-octogenarians who received either EVAR or OSR are shown in Table 1. In both groups, octogenarians were more often female, had larger aneurysm diameters, and more often had pulmonary and renal comorbidity compared with younger patients. In the EVAR group and after multiple imputation in the OSR group, octogenarians suffered more often from cardiac comorbidity. In both the EVAR and OSR groups, octogenarians were more often treated for urgent intact aneurysms compared with non-octogenarians.
      Table 1Patient characteristics, aneurysm morphology, and operative data for octogenarians vs. non-octogenarians who underwent either endovascular aneurysm repair (EVAR) or open surgical repair (OSR) of an intact abdominal aortic aneurysm
      EVAROSR
      <80 y (n = 9 039)≥80 y (n = 3 015)p value<80 y (n = 3 390)≥80 y (n = 425)p value
      Female sex1095 (12.1) [12.1]495 (16.4) [16.4]<.001 [<.001]624 (18.4) [18.4]108 (25.4) [25.4].001 [<.001]
      Age – y70.76 ± 5.9583.30 ± 2.91N.A.69.27 ± 6.8582.18 ± 2.21N.A.
      Cardiac comorbidity including abnormalities on ECG<.001 [<.001]<.001 [.11]
       No2556 (33.2) [28.3]678 (25.2) [22.5]981 (32.1) [28.9]104 (27.9) [24.5]
       Yes5810 (66.8) [64.3]2190 (74.8) [72.6]2244 (67.9) [66.2]295 (72.1) [69.4]
       Unknown/missing673 (–) [7.4]147 (–) [4.9]165 (–) [4.9]26 (–) [6.1]
      Pulmonary comorbidity<.001 [.014]<.001 [.028]
       No6623 (74.5) [73.3]2143 (72.7) [71.1]2521 (76.3) [74.4]296 (72.9) [69.6]
       Yes2263 (25.5) [25.0]802 (27.3) [26.6]781 (23.7) [23.0]110 (27.1) [25.9]
       Unknown/missing153 (–) [1.7]70 (–) [2.3]88 (–) [2.6]19 (–) [4.5]
      Renal comorbidity<.001 [<.001]<.001 [<.001]
       No, eGFR ≥ 60 mL/min/1.73m26603 (74.8) [73.1]1477 (50.2) [49.0]2371 (72.6) [69.9]209 (50.6) [49.2]
       Yes, eGFR <60 mL/min/1.73m22224 (25.2) [24.6]1471 (49.8) [48.8]893 (27.4) [26.3]206 (49.4) [48.5]
       Unknown/missing212 (–) [2.3]67 (–) [2.2]126 (–) [3.7]10 (–) [2.4]
      Haemoglobin – mmol/L8.75 ± 1.008.36 ± 1.02<.001 [<.001]8.65 ± 1.018.25 ± 0.99<.001 [<.001]
       Missing228 (–) [2.5]74 (–) [2.5]87 (–) [2.6]8 (–) [1.9]
      Urgency: urgent intact606 (6.7) [6.7]274 (9.1) [9.1]<.001 [<.001]425 (12.5) [12.5]92 (21.6) [21.6]<.001 [<.001]
      Location: aortoiliac aneurysm600 (6.6) [6.6]160 (5.3) [9.1].010 [<.001]208 (6.1) [6.1]16 (3.8) [3.8]<.001 [.064]
      Aneurysm diameter – mm58.97 ± 10.7361.41 ± 11.51<.001 [<.001]62.68 ± 13.9967.31 ± 15.48<.001 [<.001]
       Missing109 (–) [1.2]33 (–) [1.1]72 (–) [2.1]10 (–) [2.4]
      Procedure<.001 [.003]
       EVAR8484 (93.9) [93.9]2878 (95.5) [95.5]
       Conversion26 (0.3) [0.3]10 (0.3) [0.3]
       Complex endovascular529 (5.8) [5.8]127 (4.2) [4.2]
      Data are presented as n (%) [%] and for continuous variables as mean ± standard deviation. Values in parentheses “(%)” are percentages after multiple imputation (25 datasets for EVAR patients, 25 datasets for OSR patients). Values in square brackets “[%]” are percentages including missing data with p values presented in square brackets as well.

      Peri-operative outcomes

      Mortality

      As shown in Table 2, octogenarians had statistically significantly higher peri-operative mortality rates than non-octogenarians after surgery for all intact AAA. The odds ratio for peri-operative mortality in octogenarians compared with non-octogenarians was 2.5 for EVAR (1.9% vs. 0.8%, p < .001, OR 2.51) and 2.7 for OSR respectively (11.8% vs. 4.7%, p < .001, OR 2.73). In the Supplementary material, Appendix B shows the distribution of 30 day mortality and in hospital mortality in the composite outcome peri-operative mortality. In subgroup analyses of electively treated AAA patients (both EVAR and OSR), mortality rates were higher for octogenarians compared with non-octogenarians as well (EVAR: 1.4% vs. 0.6%, p < .001, OR 2.28; OSR: 9.3% vs. 4.4%, p < .001, OR 2.24). In patients treated for urgent intact AAAs, octogenarians had higher mortality rates compared with non-octogenarians (EVAR: 6.6% vs. 2.6%, p = .007, OR 2.59; OSR: 20.7% vs. 6.6%, p < .001, OR 3.69).
      Table 2Peri-operative mortality rates and major complications rates for octogenarians vs. non-octogenarians who underwent either endovascular aneurysm repair (EVAR) or open surgical repair (OSR) of abdominal aortic aneurysm in intact, elective, and intact urgent setting
      PatientsPeri-operative mortality
      Peri-operative mortality including intra-operative, 30 day, and in hospital mortality.
      Major complications
      Major complication: post-operative death or a peri- or post-operative complication leading to a re-intervention or prolonged hospital stay.
      <80 y≥80 y<80 y (ref.)≥80 ypOR (95% CI)<80 y (ref.)≥80 ypOR (95% CI)
      EVAR
       Intact9039 (75.0)3015 (25.0)69 (0.8)57 (1.9)<.0012.51 (1.75–3.56)700 (7.7)375 (12.4)<.0011.69 (1.47–1.92)
       Elective8433274153 (0.6)39 (1.4)<.0012.28 (1.50–3.45)600 (7.1)298 (10.9)<.0011.59 (1.37–1.83)
       Urgent intact60627416 (2.6)18 (6.6).0092.59 (1.30–5.22)100 (16.5)77 (28.1)<.0011.98 (1.41–2.79)
      OSR
       Intact3390 (88.9)425 (11.1)158 (4.7)50 (11.8)<.0012.73 (1.93–3.79)672 (19.8)119 (28.0)<.0011.58 (1.25–1.98)
       Elective2965333130 (4.4)31 (9.3)<.0012.24 (1.46–3.33)580 (19.6)86 (25.8).0121.44 (1.10–1.86)
       Urgent intact4259228 (6.6)19 (20.7)<.0013.69 (1.94–6.92)92 (21.6)33 (35.9).0062.02 (1.24–3.27)
      Data are presented as n (%) unless stated otherwise.
      Peri-operative mortality including intra-operative, 30 day, and in hospital mortality.
      Major complication: post-operative death or a peri- or post-operative complication leading to a re-intervention or prolonged hospital stay.

      Major complications

      Table 2 shows that octogenarians more often developed major complications compared with non-octogenarians following both intact EVAR and OSR, as well as following elective and urgent intact repair. Major octogenarian complication rates in the intact setting were 12.4% after EVAR and 28.0% after OSR.

      Associations with mortality

      After univariable analyses, the factor “location” (EVAR) was not selected for multivariable analysis because of a p value > .10 (Table 3). The factor “age ≥ 80” was statistically significantly associated with higher mortality rates after adjusting for confounding factors after both EVAR and OSR (Table 3, Table 4). Sensitivity analysis involving multivariable analysis using complete cases showed a similar association of “age ≥ 80”, with mortality after EVAR (OR 1.67, 95% CI 1.09 – 2.56) and OSR (OR 1.99, 95% CI 1.34 – 2.92) (Supplementary material, Appendix B).
      Table 3Multivariable logistic regression analysis to examine the association between age ≥ 80 and peri-operative mortality in patients with endovascular repair of abdominal aortic aneurysm. Missing data were completed by multiple imputation
      FactorUnivariable analysisMultivariable analysis
      OR (95% CI)p valueaOR (95% CI)p value
      Age ≥ 802.51 (2.33–2.69)<.0011.66 (1.54–1.79)<.001
      Female sex1.48 (1.35–1.62)<.0011.16 (1.06–1.28).002
      Cardiac comorbidity including abnormalities on ECG2.43 (2.21–2.67)<.0011.69 (1.53–1.86)<.001
      Pulmonary comorbidity3.98 (3.46–3.98)<.0013.18 (2.96–3.42)<.001
      Renal comorbidity, eGFR <60 mL/min/1.73m22.66 (2.48–2.86)<.0011.84 (1.70–1.98)<.001
      Haemoglobin0.62 (0.60–0.64)<.0010.75 (0.73–0.78)<.001
      Urgent intact4.84 (4.47–5.24)<.0013.89 (3.57–4.24)<.001
      Aortoiliac location of aneurysm1.01 (0.90–1.16).92
      Aneurysm diameter per 10 mm1.28 (1.25–1.32)<.0011.10 (1.07–1.13)<.001
      OR = odds ratio; aOR = adjusted odds ratio; CI = confidence interval.
      Table 4Multivariable logistic regression analyses to examine the association between age ≥ 80 and peri-operative mortality in patients with open surgical repair of abdominal aortic aneurysm. Missing data were completed by multiple imputation
      FactorUnivariable analysisMultivariable analysis
      OR (95% CI)p valueaOR (95% CI)p value
      Age ≥802.73 (2.55–2.92)<.0012.02 (1.88–2.17)<.001
      Female sex1.73 (1.62–1.84)<.0011.42 (1.33–1.52)<.001
      Cardiac comorbidity including abnormalities on ECG1.99 (1.86–2.13)<.0011.76 (1.64–1.89)<.001
      Pulmonary comorbidity1.98 (1.87–2.10)<.0011.78 (1.67–1.89)<.001
      Renal comorbidity, eGFR <60 mL/min/1.73m22.30 (2.18–2.44)<.0011.85 (1.75–1.96)<.001
      Haemoglobin0.74 (0.72–0.76)<.0010.85 (0.83–0.88)<.001
      Urgent intact1.95 (1.82–2.08)<.0011.81 (1.68–1.95)<.001
      Aortoiliac location of aneurysm0.38 (0.32–0.45)<.0010.48 (0.40–0.58)<.001
      Aneurysm diameter per 10 mm1.07 (1.05–1.09)<.0010.99 (0.97–1.01).25
      OR = odds ratio; aOR = adjusted odds ratio; CI = confidence interval.

      Observed comorbidities and corresponding peri-operative mortality

      Only 317 (10.5% in original data; 12.0% in imputed data) and 42 (9.9% in original data; 12.8% in imputed data) octogenarians undergoing EVAR and OSR had no comorbidities, respectively (Table 5). Observed peri-operative mortality rates following intact AAA repair in patients with no comorbidity, cardiac, pulmonary, or renal comorbidity are shown in Table 5. After EVAR, the mortality rates of octogenarians with a cardiac, pulmonary, or renal comorbidity reached 2.4%, 4.2%, or 2.5%, respectively, while octogenarians with no comorbidities had a rate of 0.4% (all percentages are based on imputed data). After OSR, the mortality rates of octogenarians with cardiac, pulmonary, or renal comorbidity reached 13.4%, 13.6%, and 14.8%, while octogenarians with no comorbidities had a mortality rate of 3.8% (based on imputed data).
      Table 5Peri-operative mortality rates for octogenarians and non-octogenarians who underwent either endovascular aneurysm repair (EVAR) or open surgical repair (OSR) of abdominal aortic aneurysm in intact setting, stratified by the presence of comorbidities
      EVAROSR
      <80 y (n = 9 039)≥80 y (n = 3 015)<80 y (n = 3 390)≥80 y (n = 425)
      Comorbidities
       No comorbidities
      No comorbidities: based on no pulmonary comorbidity, no cardiac comorbidity including no abnormalities on ECG, and no renal dysfunction (eGFR <60 mL/min/1.73m2).
      1654 (22.2) [18.3]317 (12.0) [10.5]612 (21.0) [18.1]42 (12.8) [9.9]
       Cardiac comorbidity including abnormalities on ECG5810 (66.8) [64.3]2190 (74.8) [72.6]2244 (67.9) [66.2]295 (72.1) [69.4]
       Pulmonary comorbidity2263 (25.5) [25.0]802 (27.3) [26.6]781 (23.7) [23.0]110 (27.1) [25.9]
       Renal comorbidity2224 (25.2) [24.6]1471 (49.8) [48.8]893 (27.4) [26.3]206 (49.4) [48.5]
      Peri-operative mortality
       All patients69 (0.8) [0.8]57 (1.9) [1.9]158 (4.7) [4.7]50 (11.8) [11.8]
       No comorbidities
      No comorbidities: based on no pulmonary comorbidity, no cardiac comorbidity including no abnormalities on ECG, and no renal dysfunction (eGFR <60 mL/min/1.73m2).
      4 (0.3) [0.2]1 (0.4) [0.3]11 (1.9) [1.8]2 (3.8) [4.8]
       Cardiac comorbidity including abnormalities on ECG51 (0.9) [0.9]51 (2.4) [2.3]234 (5.5) [5.5]38 (13.4) [12.9]
       Pulmonary comorbidity35 (1.6) [1.5]32 (4.2) [4.0]60 (7.8) [7.7]14 (13.6) [12.7]
       Renal comorbidity31 (1.4) [1.4]36 (2.5) [2.4]67 (7.5) [7.5]30 (14.8) [14.6]
      Data are presented as n (%) [%]. Values in parentheses “(%)” are percentages after multiple imputation (25 datasets for EVAR patients, 25 datasets for OSR patients). Values in square brackets “[%]” are percentages including missing data.
      No comorbidities: based on no pulmonary comorbidity, no cardiac comorbidity including no abnormalities on ECG, and no renal dysfunction (eGFR <60 mL/min/1.73m2).

      Discussion

      The octogenarians in this study were at risk of significantly higher peri-operative mortality and major complication rates after both EVAR and OSR for intact AAA compared with younger patients. Furthermore, the effect of comorbidities in this age group was more pronounced and was clearly associated with impaired survival. In octogenarians, mortality after OSR exceeded 10%, especially when comorbidities were present. After EVAR, octogenarians with pulmonary comorbidities had a mortality rate of approximately 4%. In contrast, mortality was 1.9% for all octogenarians in the EVAR group.
      Surgical risk is at the heart of clinical (shared) decision making, especially when prophylactic surgery is performed on asymptomatic patients such as in elective AAA care.
      • de Mik S.M.L.
      • Stubenrouch F.E.
      • Balm R.
      • Ubbink D.T.
      Systematic review of shared decision-making in surgery.
      To inform patients appropriately before undergoing high risk surgery, robust data are needed concerning morbidity and mortality. The DSAA is a mandatory national verified quality registry, set up to monitor and improve the quality of AAA care by providing benchmarked information to vascular surgeons. Since 2013, all patients undergoing primary abdominal aortic aneurysm surgery in the Netherlands have been registered, providing objective, real world data. Because of its scale and in contrast to other published studies, it enables relevant subanalyses such as the analysis described in this paper.
      • Biancari F.
      • Catania A.
      • D’Andrea V.
      Elective endovascular vs. open repair for abdominal aortic aneurysm in patients aged 80 years and older: Systematic review and meta-analysis.
      ,
      • 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.
      Additionally, local data on outcomes of octogenarians could be valuable to inform patients and family accurately, for example because of a potential hospital related volume outcome relationship for OSR.
      • Gray W.K.
      • Day J.
      • Horrocks M.
      Volume–outcome relationships in elective abdominal aortic aneurysm surgery: analysis of the UK Hospital Episodes Statistics Database for the Getting It Right First Time (GIRFT) Programme.
      Since 2019, a specific dashboard called the Codman Dashboard has enabled all Dutch vascular surgeons to analyse their registered outcomes of particular subgroups.
      • Beck N.
      • van Bommel A.C.
      • Eddes E.H.
      • van Leersum N.J.
      • Tollenaar R.A.
      • Wouters M.W.
      The Dutch Institute for Clinical Auditing: achieving Codman’s Dream on a nationwide basis.
      This study describes a mortality rate of 11.8% for all octogenarians after OSR, and this seems to exceed the yearly rupture risks of smaller aneurysms. Moreover, octogenarians with comorbidities have mortality rates > 10% after OSR, in contrast to the mortality rate of 3.6% in the (small) group of octogenarians without comorbidities (12.8% of all octogenarians in this cohort, based on imputed data). In the literature, a mortality rate of 7.5% for octogenarians who were treated electively by OSR was described in a meta-analysis.
      • Henebiens M.
      • Vahl A.
      • Koelemay M.J.W.
      Elective surgery of abdominal aortic aneurysms in octogenarians: A systematic review.
      For intact aneurysm repair, a mortality rate of 9.5% for octogenarians was described in an international study by Budtz-Lilly et al., which combined the results of 11 vascular registries,
      • Budtz-Lilly J.
      • Venermo M.
      • Debus S.
      • Behrendt C.A.
      • Altreuther M.
      • Beiles B.
      • et al.
      Editor’s Choice – Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.
      similar to the results from the present study. However, mortality rates in these studies were rarely specified for either high or low risk octogenarians.
      • Berry A.J.
      • Smith R.B.
      • Weintraub W.S.
      • Chaikof E.L.
      • Dodson T.F.
      • Lumsden A.B.
      • et al.
      Age versus comorbidities as risk factors for complications after elective abdominal aortic reconstructive surgery.
      In previous studies that examined the safety of surveillance for small aneurysms up to 5.5 cm, 30 day operative mortality rates of only 5.5%
      • Brady A.R.
      • Brown L.C.
      • Fowkes F.G.R.
      • Greenhalgh R.M.
      • Powell J.T.
      • Ruckley C.V.
      • et al.
      Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms.
      and 2.1%
      • Lederle F.A.
      • Samuel E.W.
      • Johnson G.R.
      • Reinke D.B.
      • Littooy F.N.
      • Acher C.W.
      • et al.
      Immediate repair compared with surveillance of small aortic aneurysms.
      were described. This poses the question of whether operative mortality rates exceeding these numbers are acceptable, in particular in elderly patients undergoing preventive aneurysm repair at relatively small diameters that are at low risk of rupture.
      After EVAR, this study reports a mortality rate of 1.9% for octogenarians. This is in line with the previously mentioned international study by Budtz-Lilly et al., which reported a mortality rate of 1.8% of octogenarians after EVAR. Meta-analyses that included older studies have described mortality rates for octogenarians of 3.7%
      • 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.
      and 4.6%
      • Henebiens M.
      • Vahl A.
      • Koelemay M.J.W.
      Elective surgery of abdominal aortic aneurysms in octogenarians: A systematic review.
      after EVAR. The impact of improved device technology (lower profile devices), peri-operative management including better anaesthetic techniques,
      • Armstrong R.A.
      • Squire Y.G.
      • Rogers C.A.
      • Hinchliffe R.J.
      • Mouton R.
      Type of anesthesia for endovascular abdominal aortic aneurysm repair.
      and cardioprotective medication
      • Salata K.
      • Syed M.
      • Hussain M.A.
      • De Mestral C.
      • Greco E.
      • Mamdani M.
      • et al.
      Statins reduce abdominal aortic aneurysm growth, rupture, and peri-operative mortality: a systematic review and meta-analysis.
      might play a role in improved survival of octogenarians in this study compared with the meta-analyses with older data.
      • Budtz-Lilly J.
      • Venermo M.
      • Debus S.
      • Behrendt C.A.
      • Altreuther M.
      • Beiles B.
      • et al.
      Editor’s Choice – Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.
      In the present study, a peri-operative mortality rate of 4.2% was observed for octogenarians with a pulmonary comorbidity. This mortality rate was low compared with the mortality rate of 7.3% reported in the EVAR-2 study in patients who were considered not physically fit enough to undergo OSR.
      • Greenhalgh R.M.
      • Brown L.C.
      • Powell J.T.
      • Thompson S.G.
      • Epstein D.
      United Kingdom EVAR Trial Investigators
      Endovascular repair of abdominal aortic aneurysm in patients physically ineligible for open repair.
      Apart from the mortality rates following intact AAA repair, other outcomes for octogenarians are important as well and could assist in the clinical decision making process. First, to deal with the heterogeneity in the group of intact AAA repairs, subanalyses were performed for elective and urgent intact repair including adjustment for urgent intact repair in the multivariable analyses. Furthermore, in the present study, major complication rates were examined. As expected, octogenarians had higher major complication rates compared with non-octogenarians. Obviously, other outcome parameters, such as quality of life,
      • Prinssen M.
      • Buskens E.
      • Blankensteijn J.D.
      • Buth J.
      • Tielbeek A.V.
      • Verhoeven E.L.G.
      • et al.
      Quality of life after endovascular and open AAA repair. Results of a randomised trial.
      re-intervention rate,
      • Powell J.T.
      • Sweeting M.J.
      • Ulug P.
      • Blankensteijn J.D.
      • Lederle F.A.
      • Becquemin J.P.
      • et al.
      Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years.
      long term outcomes,
      • Li B.
      • Khan S.
      • Salata K.
      • Hussain M.A.
      • de Mestral C.
      • Greco E.
      • et al.
      A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm.
      and costs,
      • Burgers L.T.
      • Vahl A.C.
      • Severens J.L.
      • Wiersema A.M.
      • Cuypers P.W.M.
      • Verhagen H.J.M.
      • et al.
      Cost-effectiveness of elective endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysms.
      are also important to consider in the clinical decision making process for octogenarians, but these are not captured in the DSAA registry.
      In this study, no association between aneurysm size and mortality was found in OSR patients, which might suggest that postponing OSR does not result in higher mortality rates. Remarkably, in EVAR patients, aneurysm size was associated with mortality. The diameter threshold for elective abdominal aneurysm repair is based on both peri-operative risk and the risk of rupture. However, the risk of rupture according to aneurysm diameter was not investigated. In the literature, little is known about the diameters of ruptured aneurysms between octogenarians and non-octogenarians.
      • Sweeting M.J.
      • Thompson S.G.
      • Brown L.C.
      • Powell J.T.
      Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms.
      In studies up to 2010, the mean annual risk of rupture of a 5 cm aneurysm was 0.6% in men and 2.9% in women. It is stated that the mean diameter of ruptured aneurysms in all patients has increased during the last decade, possibly because of increased statin therapy.
      • Salata K.
      • Syed M.
      • Hussain M.A.
      • De Mestral C.
      • Greco E.
      • Mamdani M.
      • et al.
      Statins reduce abdominal aortic aneurysm growth, rupture, and peri-operative mortality: a systematic review and meta-analysis.
      A previous study demonstrated that some patients with severe comorbidities and large aneurysms could be managed conservatively with acceptable results for long periods (7 – 76 months).
      • Tanquilut E.M.
      • Veith F.J.
      • Ohki T.
      • Lipsitz E.C.
      • Shaw P.M.
      • Suggs W.D.
      • et al.
      Nonoperative management with selective delayed surgery for large abdominal aortic aneurysms in patients at high risk.
      Therefore, the question remains of whether the diameter threshold at which to intervene should be increased for octogenarians because of a much higher peri-operative risk, in particular when octogenarians experience comorbidities and OSR is considered to be the treatment modality.
      Despite the relatively large number of octogenarians in this cohort, this study has some limitations. First, the DSAA includes only patients who were considered fit enough to undergo surgery, which was a clinical decision by the surgeon. Because of this selection bias, predictions of mortality rates based on the number of comorbidities of octogenarians who could be incorporated in the decision making process could not be made, as the decision to perform surgery had already been made. Therefore, the reported peri-operative outcomes of octogenarians in this study will probably be better than peri-operative outcomes of all octogenarians with an intact AAA. Second, information bias might have taken place, as age was calculated as the year of surgery minus the year of birth. This calculation included some patients of age 79 in the group “octogenarians”, which might have led to an underestimation of the outcomes of octogenarians. Furthermore, this was a retrospective study of a retrieved dataset from the DSAA, a prospectively maintained national quality registry. As this audit is not designed purely for scientific research, information on some potential confounders such as peripheral artery obstructive disease,
      • Pini R.
      • Gallitto E.
      • Faggioli G.
      • Mascoli C.
      • Vacirca A.
      • Fenelli C.
      • et al.
      Predictors of peri-operative and late survival in octogenarians undergoing elective endovascular abdominal aortic repair.
      type of anaesthetic, anatomical details, surgeon experience, or frailty were not available. It would be interesting to examine the influence of frailty, as it has been reported that frailty is associated with age as well as with peri-operative mortality.
      • Houghton 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.
      Furthermore, Joseph et al. stated that a frailty index was better for predicting mortality compared with age in emergency general surgery in the elderly,
      • Joseph B.
      • Zangbar B.
      • Pandit V.
      • Fain M.
      • Mohler M.J.
      • Kulvatunyou N.
      • et al.
      Emergency general surgery in the elderly: too old or too frail?.
      while age was a predictor of mortality in vascular studies that did not report on frailty.
      • Ambler 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.
      ,
      • Grant S.W.
      • Hickey G.L.
      • Grayson A.D.
      • Mitchell D.C.
      • McCollum C.N.
      National risk prediction model for elective abdominal aortic aneurysm repair.
      Another limitation of this study is that the specific categories in the groups cardiac and pulmonary comorbidity were potentially not equally weighted between octogenarians and non-octogenarians, which might have caused heterogeneity in the groups of octogenarians vs. non-octogenarians and thus, these groups were not compared. Finally, the dataset had some missing data and thus, for multivariable logistic regression analyses and analyses stratified for the presence of comorbidities, missing data were imputed using multiple imputation. Sensitivity analyses using complete cases were performed for the multivariable analyses that examined the association of age ≥ 80 with mortality, with similar results.
      In conclusion, age ≥ 80 and comorbidities are significantly associated with mortality after endovascular and open repair for abdominal aortic aneurysms. Mortality after OSR in octogenarians is exceedingly high, especially in the presence of comorbidities. Reported observed rates in this study can be used by everyone involved in the decision making process considering optimal care for aneurysm patients. More research focused on optimal treatment thresholds for elective AAA repair in both low and high risk subgroups of octogenarians is needed. For now, awareness of the presence of comorbidities is key in the decision making process.

      Conflicts of interest

      HV: consultant for Medtronic, WL Gore, Terumo, Endologix, and Arsenal AAA.

      Funding

      None.

      Acknowledgements

      The authors would like to thank the members of the Dutch Society for Vascular Surgery who registered their patients in the DSAA, the Dutch Institute for Clinical Auditing that facilitated the registry, and the Steering Committee of the Dutch Surgical Aneurysm Audit.

      Appendix A. Collaborators

      Van den Akker PJ, Akkersdijk GJ, Akkersdijk GP, Akkersdijk WL, van Andringa de Kempenaer MG, Arts CH, Avontuur JA, Bakker OJ, Balm R, Barendregt WB, Bekken JA, Bender MH, Bendermacher BL, van den Berg M, Berger P, Beuk RJ, Blankensteijn JD, Bleker RJ, Blok JJ, Bode AS, Bodegom ME, van der Bogt KE, Boll AP, Booster MH, Borger van der Burg BL, de Borst GJ, Bos- van Rossum WT, Bosma J, Botman JM, Bouwman LH, Brehm V, de Bruijn MT, de Bruin JL, Brummel P, van Brussel JP, Buijk SE, Buijs MA, Buimer MG, Burger DH, Buscher HC, Cancrinus E, Castenmiller PH, Cazander G, Coester AM, Cuypers PH, Daemen JH, Dawson I, Dierikx JE, Dijkstra ML, Diks J, Dinkelman MK, Dirven M, Dolmans DE, van Doorn RC, van Dortmont LM, Drouven JW, van der Eb MM, Eefting D, van Eijck GJ, Elshof JW, Elsman BH, van der Elst A, van Engeland MI, van Eps RG, Faber MJ, de Fijter WM, Fioole B, Fokkema TM, Frans FA, Fritschy WM, Fung Kon Jin PH, Geelkerken RH, van Gent WB, Glade GJ, Govaert B, Groenendijk RP, de Groot HG, van den Haak RF, de Haan EF, Hajer GF, Hamming JF, van Hattum ES, Hazenberg CE, Hedeman Joosten PP, Helleman JN, van der Hem LG, Hendriks JM, van Herwaarden JA, Heyligers JM, Hinnen JW, Hissink RJ, Ho GH, den Hoed PT, Hoedt MT, van Hoek F, Hoencamp R, Hoffmann WH, Hogendoorn W, Hoksbergen AW, Hollander EJ, Hommes M, Hopmans CJ, Huisman LC, Hulsebos RG, Huntjens KM, Idu MM, Jacobs MJ, van der Jagt MF, Jansbeken JR, Janssen RJ, Jiang HH, de Jong SC, Jongbloed-Winkel TA, Jongkind V, Kapma MR, Keller BP, Khodadade Jahrome A, Kievit JK, Klemm PL, Klinkert P, Koedam NA, Koelemaij MJ, Kolkert JL, Koning GG, Koning OH, Konings R, Krasznai AG, Krol RM, Kropman RH, Kruse RR, van der Laan L, van der Laan MJ, van Laanen JH, van Lammeren GW, Lamprou DA, Lardenoye JH, Lauret GJ, Leenders BJ, Legemate DA, Leijdekkers VJ, Lemson MS, Lensvelt MM, Lijkwan MA, Lind RC, van der Linden FT, Liqui Lung PF, Loos MJ, Loubert MC, van de Luijtgaarden KM, Mahmoud DE, Manshanden CG, Mattens EC, Meerwaldt R, Mees BM, von Meijenfeldt GC, Menting TP, Metz R, Minnee RC, de Mol van Otterloo JC, Molegraaf MJ, Montauban van Swijndregt YC, Morak MJ, van de Mortel RH, Mulder W, Nagesser SK, Naves CC, Nederhoed JH, Nevenzel-Putters AM, de Nie AJ, Nieuwenhuis DH, Nieuwenhuizen J, van Nieuwenhuizen RC, Nio D, Noyez VJ, Oomen AP, Oranen BI, Oskam J, Palamba HW, Peppelenbosch AG, van Petersen AS, Petri BJ, Pierie ME, Ploeg AJ, Pol RA, Ponfoort ED, Post IC, Poyck PP, Prent A, ten Raa S, Raymakers JT, Reichart M, Reichmann BL, Reijnen MM, de Ridder JA, Rijbroek A, van Rijn MJ, de Roo RA, Rouwet EV, Saleem BR, Salemans PB, van Sambeek MR, Samyn MG, van ’t Sant HP, van Schaik J, van Schaik PM, Scharn DM, Scheltinga MR, Schepers A, Schlejen PM, Schlosser FJ, Schol FP, Scholtes VP, Schouten O, Schreve MA, Schurink GW, Sikkink CJ, te Slaa A, Smeets HJ, Smeets L, Smeets RR, de Smet AA, Smit PC, Smits TM, Snoeijs MG, Sondakh AO, Speijers MJ, van der Steenhoven TJ, van Sterkenburg SM, Stigter DA, Stokmans RA, Strating RP, Stultiëns GN, Sybrandy JE, Teijink JA, Telgenkamp BJ, Teraa M, Testroote MJ, Tha-In T, The RM, Thijsse WJ, Thomassen I, Tielliu IF, van Tongeren RB, Toorop RJ, Tournoij E, Truijers M, Türkcan K, Tutein Nolthenius RP, Ünlü Ç, Vaes RH, Vafi AA, Vahl AC, Veen EJ, Veger HT, Veldman MG, Velthuis S, Verhagen HJ, Verhoeven BA, Vermeulen CF, Vermeulen EG, Vierhout BP, van der Vijver-Coppen RJ, Visser MJ, van der Vliet JA, Vlijmen - van Keulen CJ, Voorhoeve R, van der Vorst JR, Vos AW, de Vos B, Vos CG, Vos GA, Voute MT, Vriens BH, Vriens PW, de Vries AC, de Vries DK, de Vries JP, de Vries M, van der Waal C, Waasdorp EJ, Wallis de Vries BM, van Walraven LA, van Wanroij JL, Warlé MC, van de Water W, van Weel V, van Well AM, Welten GM, Welten RJ, Wever JJ, Wiersema AM, Wikkeling OR, Willaert WI, Wille J, Willems MC, Willigendael EM, Wilschut ED, Wisselink W, Witte ME, Wittens CH, Wong CY, Wouda R, Yazar O, Yeung KK, Zeebregts CJ, van Zeeland ML.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

      References

        • Lilja F.
        • Mani K.
        • Wanhainen A.
        Editor’s Choice – Trend-break in abdominal aortic aneurysm repair with decreasing surgical workload.
        Eur J Vasc Endovasc Surg. 2017; 53: 811-819
        • Arhuidese I.J.
        • Salami A.
        • Obeid T.
        • Qazi U.
        • Abularrage C.J.
        • Black J.H.
        • et al.
        The age effect in increasing operative mortality following delay in elective abdominal aortic aneurysm repair presented at the society for clinical vascular surgery 42nd Annual Symposium, Carlsbad, CA, March 18-22, 2014.
        Ann Vasc Surg. 2015; 29: 1181-1187
      1. Centraal Bureau voor de Statistiek. Bevolkingspiramide. Available at: https://www.cbs.nl/nl-nl/visualisaties/bevolkingspiramide [Accessed 5 November 2020].

        • Budtz-Lilly J.
        • Venermo M.
        • Debus S.
        • Behrendt C.A.
        • Altreuther M.
        • Beiles B.
        • et al.
        Editor’s Choice – Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.
        Eur J Vasc Endovasc Surg. 2017; 54: 13-20
        • Mani K.
        • Lees T.
        • Beiles B.
        • Jensen L.P.
        • Venermo M.
        • Simo G.
        • et al.
        Treatment of abdominal aortic aneurysm in nine countries 2005-2009: A vascunet report.
        Eur J Vasc Endovasc Surg. 2011; 42: 598-607
        • Powell J.T.
        • Sweeting M.J.
        • Ulug P.
        • Blankensteijn J.D.
        • Lederle F.A.
        • Becquemin J.P.
        • et al.
        Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years.
        Br J Surg. 2017; 104: 166-178
        • Henebiens M.
        • Vahl A.
        • Koelemay M.J.W.
        Elective surgery of abdominal aortic aneurysms in octogenarians: A systematic review.
        J Vasc Surg. 2008; 47: 676-681
        • Biancari F.
        • Catania A.
        • D’Andrea V.
        Elective endovascular vs. open repair for abdominal aortic aneurysm in patients aged 80 years and older: Systematic review and meta-analysis.
        Eur J Vasc Endovasc Surg. 2011; 42: 571-576
        • 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
        • Wanhainen A.
        • Verzini F.
        • Van Herzeele I.
        • Allaire E.
        • Bown M.
        • Cohnert T.
        • et al.
        Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.
        Eur J Vasc Endovasc Surg. 2019; 57: 8-93
      2. Dutch Institute for Clinical Auditing. Eindrapport dataverificatie DSAA. Available at: https://dica.nl/media/660/Eindrapport_dataverificatie_DSAA_2016.pdf [Accessed 5 November 2020].

      3. STROBE Statement—checklist of items that should be included in reports of observational studies. Available at: https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_combined.pdf [Accessed 8 November 2020].

        • Copeland G.P.
        • Jones D.
        • Walters M.
        POSSUM: A scoring system for surgical audit.
        Br J Surg. 1991; 78: 355-360
        • Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group
        KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
        Kidney Int Suppl. 2013; 3: 1-150
        • Levey A.S.
        • Stevens L.A.
        • Schmid C.H.
        • Zhang Y.L.
        • Castro 3rd, A.F.
        • Feldman H.I.
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2018; 150: 604-612
        • Lijftogt N.
        • Karthaus E.G.
        • Vahl A.
        • van Zwet E.W.
        • van der Willik E.M.
        • Tollenaar R.A.E.M.
        • et al.
        Failure to rescue – a closer look at mortality rates has no added value for hospital comparisons but is useful for team quality assessment in abdominal aortic aneurysm surgery in the Netherlands.
        Eur J Vasc Endovasc Surg. 2018; 56: 652-661
      4. Smith J, Tekkis P. Risk prediction in surgery. Available at: http://www.riskprediction.org.uk/vasc-index.php. [Accessed 8 November 2020].

        • White I.R.
        • Royston P.
        • Wood A.M.
        Multiple imputation using chained equations: issues and guidance for practice.
        Stat Med. 2011; 30: 377-399
        • de Mik S.M.L.
        • Stubenrouch F.E.
        • Balm R.
        • Ubbink D.T.
        Systematic review of shared decision-making in surgery.
        Br J Surg. 2018; 105: 1721-1730
        • Gray W.K.
        • Day J.
        • Horrocks M.
        Volume–outcome relationships in elective abdominal aortic aneurysm surgery: analysis of the UK Hospital Episodes Statistics Database for the Getting It Right First Time (GIRFT) Programme.
        Eur J Vasc Endovasc Surg. 2020; 60: 509-517
        • Beck N.
        • van Bommel A.C.
        • Eddes E.H.
        • van Leersum N.J.
        • Tollenaar R.A.
        • Wouters M.W.
        The Dutch Institute for Clinical Auditing: achieving Codman’s Dream on a nationwide basis.
        Ann Surg. 2020; 271: 627-631
        • Berry A.J.
        • Smith R.B.
        • Weintraub W.S.
        • Chaikof E.L.
        • Dodson T.F.
        • Lumsden A.B.
        • et al.
        Age versus comorbidities as risk factors for complications after elective abdominal aortic reconstructive surgery.
        J Vasc Surg. 2001; 33: 345-352
        • Brady A.R.
        • Brown L.C.
        • Fowkes F.G.R.
        • Greenhalgh R.M.
        • Powell J.T.
        • Ruckley C.V.
        • et al.
        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.
        • Samuel E.W.
        • Johnson G.R.
        • Reinke D.B.
        • Littooy F.N.
        • Acher C.W.
        • et al.
        Immediate repair compared with surveillance of small aortic aneurysms.
        N Engl J Med. 2002; 346: 1437-1444
        • Armstrong R.A.
        • Squire Y.G.
        • Rogers C.A.
        • Hinchliffe R.J.
        • Mouton R.
        Type of anesthesia for endovascular abdominal aortic aneurysm repair.
        J Cardiothorac Vasc Anesth. 2019; 33: 462-471
        • Salata K.
        • Syed M.
        • Hussain M.A.
        • De Mestral C.
        • Greco E.
        • Mamdani M.
        • et al.
        Statins reduce abdominal aortic aneurysm growth, rupture, and peri-operative mortality: a systematic review and meta-analysis.
        J Am Heart Assoc. 2018; 7e008657
        • Greenhalgh R.M.
        • Brown L.C.
        • Powell J.T.
        • Thompson S.G.
        • Epstein D.
        • United Kingdom EVAR Trial Investigators
        Endovascular repair of abdominal aortic aneurysm in patients physically ineligible for open repair.
        N Engl J Med. 2010; 362: 1872-1880
        • Prinssen M.
        • Buskens E.
        • Blankensteijn J.D.
        • Buth J.
        • Tielbeek A.V.
        • Verhoeven E.L.G.
        • et al.
        Quality of life after endovascular and open AAA repair. Results of a randomised trial.
        Eur J Vasc Endovasc Surg. 2004; 27: 121-127
        • Li B.
        • Khan S.
        • Salata K.
        • Hussain M.A.
        • de Mestral C.
        • Greco E.
        • et al.
        A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm.
        J Vasc Surg. 2019; 70: 954-969
        • Burgers L.T.
        • Vahl A.C.
        • Severens J.L.
        • Wiersema A.M.
        • Cuypers P.W.M.
        • Verhagen H.J.M.
        • et al.
        Cost-effectiveness of elective endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysms.
        Eur J Vasc Endovasc Surg. 2016; 52: 29-40
        • Sweeting M.J.
        • Thompson S.G.
        • Brown L.C.
        • Powell J.T.
        Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms.
        Br J Surg. 2012; 99: 655-665
        • Tanquilut E.M.
        • Veith F.J.
        • Ohki T.
        • Lipsitz E.C.
        • Shaw P.M.
        • Suggs W.D.
        • et al.
        Nonoperative management with selective delayed surgery for large abdominal aortic aneurysms in patients at high risk.
        J Vasc Surg. 2002; 36: 41-46
        • Pini R.
        • Gallitto E.
        • Faggioli G.
        • Mascoli C.
        • Vacirca A.
        • Fenelli C.
        • et al.
        Predictors of peri-operative and late survival in octogenarians undergoing elective endovascular abdominal aortic repair.
        J Vasc Surg. 2019; 69: 1405-1411
        • Houghton 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: 266-276
        • Joseph B.
        • Zangbar B.
        • Pandit V.
        • Fain M.
        • Mohler M.J.
        • Kulvatunyou N.
        • et al.
        Emergency general surgery in the elderly: too old or too frail?.
        J Am Coll Surg. 2016; 222: 805-813
        • Ambler 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: 35-43
        • Grant S.W.
        • Hickey G.L.
        • Grayson A.D.
        • Mitchell D.C.
        • McCollum C.N.
        National risk prediction model for elective abdominal aortic aneurysm repair.
        Br J Surg. 2013; 100: 645-653

      Linked Article

      • Abdominal Aortic Aneurysm Repair in Advanced Age: Is Age Really the Problem?
        European Journal of Vascular and Endovascular SurgeryVol. 61Issue 6
        • Preview
          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).1
        • Full-Text
        • PDF
        Open Archive

      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.