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Older age, emergent timing linked to higher mortality risk after TEVAR
Among older patients with descending thoracic artery disease undergoing thoracic endovascular aortic repair, age older than 75 years and timing of intervention are associated with mortality risk, researchers reported in the Journal of Vascular Surgery.
“Older patients represent a large proportion of the recipients of thoracic endovascular aortic repair that is applied today for a variety of acute and chronic descending thoracic artery disease,” the researchers wrote.
The study focused on data from 141 patients (mean age, 67 ± 16.7 years; 72% men) in a prospective electronic database that documented preoperative, intraoperative and postoperative data on all thoracic endovascular aortic repairs (TEVAR) performed between 2003 and 2015. The researchers stratified the cohort of patients with descending thoracic artery disease by age and compared presentation, baseline characteristics and outcomes between patients older than 75 years (n = 57; 40.4%) vs. those younger than 75 years. Additional stratified analyses compared patients younger than 80 years vs. older than 80 years (n = 28). The researchers also assessed the effects of TEVAR timing on the risk for death in older patients, and classified cases as: elective procedures; any emergency (intervention necessitated within 15 days of onset, including non-ruptured dissection and false aneurysm); and a subgroup of “any emergency” comprising true acute aortic ruptures.
the index hospitalization for less than 30 days of the procedure. Overall, 83 TEVAR procedures were elective, 58 were emergent and 42 involved true aortic rupture.
nine deaths at 30 days among patients older than 75 years vs. four among those younger than 75 years. The overall 30-day rate of mortality was 15.8% in patients older than 75 years and 4.8% in those younger than 75 years (OR = 3.8; 95% CI, 1.1-2.8). This age-associated disparity in mortality became more pronounced when mortality was evaluated at 90 days (17.5% in the older patients vs. 4.8% in the younger patients; OR = 4.2; 95% CI, 1.3-14.3). Analyses using the 80-year cutoff for the octogenarian subgroup revealed that perioperative mortality risks were further elevated at both the 30-day follow-up (25% in patients older than 80 years vs. 5.3% in patients younger than 80 years; P = .004) and the 90-day follow-up (25% vs. 6.2%; P = .008). In the analysis of elective procedures, the 30-day mortality rate was 5% for patients older than 75 years vs. 0% for patients younger than 75 years (OR = 1.1; 95% CI, 0.98-1.1), and the 90-day mortality rate was 7.5% for patients older than 75 years vs. 0% for patients younger than 75 years (P = .11). There were no octogenarian deaths among elective procedures.
years (OR = 6.5; 95% CI, 1.6-26.6), and these rates persisted at 90 days. Octogenarians in the emergency scenario had a 50% mortality rate. Among the acute rupture procedures, the 30-day mortality rate was 40% for patients older than 75 years vs. 11.1% for patients younger than 75 years (OR = 5.3; 95% CI, 1.1-25.99). The 30-day mortality for octogenarians vs. younger patients was 46% vs. 10% (OR = 7.5; 95% CI, 1.47-37.46). The rates did not change at 90 days. The mean survival for patients older than 75 years was 53.98 ± 7.7 months post-TEVAR.
For procedures performed in the emergency setting, the mortality risk exposure is expected to be more than three times higher in older patients with respect to their younger counterparts,” the researchers wrote. “However, despite the risk increase when compared to young healthier populations, the overall mortality exposure of emergency TEVAR for older, frail patients is not prohibitive and should be balanced against the excess risk mortality of not offering any intervention for [descending thoracic artery disease].” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.