TY - JOUR
T1 - Nonoperative management with selective delayed surgery for large abdominal aortic aneurysms in patients at high risk
AU - Tanquilut, Eugene M.
AU - Veith, Frank J.
AU - Ohki, Takao
AU - Lipsitz, Evan C.
AU - Shaw, Palma M.
AU - Suggs, William D.
AU - Wain, Reese A.
AU - Mehta, Manish
AU - Cayne, Neal S.
AU - McKay, Jamie
N1 - Funding Information:
From the Division of Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine. Supported by grants from the James Hilton Manning and Emma Austin Manning Foundation, the Anna S. Brown Trust, the New York Institute for Vascular Studies, and the William J. von Liebig Foundation. Competition of interest: nil. Presented at the Fifteenth Annual Meeting of The Eastern Vascular Society, Washington, DC, May 3-6, 2001. Reprint requests: Frank J. Veith, MD, 111 E 210th St, New York, NY 10467 (e-mail: fjvmd@msn.com). Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 + 0 24/6/122889 doi:10.1067/mva.2002.122889
PY - 2002/7
Y1 - 2002/7
N2 - Objective: An accepted fact is that abdominal aortic aneurysms (AAAs) larger than 5.5 cm should undergo elective repair. However, subsets of these patients have serious comorbid conditions, which greatly increase operative risk. This study evaluated the outcomes of periods of protracted nonoperative observational management with selective delayed surgery in patients at high risk with large infrarenal and pararenal AAAs. Methods: Among 226 patients with AAAs more than 5.5 cm, we selected 72 with AAAs from 5.6 to 12.0 cm (mean, 7.0 cm) for periods of nonoperative management because of their prohibitive surgical risks. Comorbid factors included a low ejection fraction of 15% to 34% (mean, 22%) in 18 patients, 1 second forced expiratory volume less than 50% (mean, 38%) in 25, prior laparotomy in 10, and morbid obesity in 22. Follow-up examination was complete in the 72 patients for the 6 to 76 months (mean, 23 months) that they underwent nonoperative treatment. Fifty-three patients ultimately underwent operation because of AAA enlargement or onset of symptoms after 6 to 72 months (mean, 19 months) of nonoperative treatment. Results: Of the 72 selected patients, 54 (75%) are living and 18 (25%) are dead. Seven patients who underwent only nonoperative treatment presently survive after 28 to 76 months (mean, 48 months). Of the 18 deaths, AAA rupture occurred in only three patients (4%) who were observed for 12, 31, and 72 months before rupture. Nine other deaths (13%) occurred after 6 to 72 months from comorbidities unrelated to the AAA. Six of the 53 patients who underwent delayed operation died within 30 days of operation (11% mortality rate). The mortality rate for the 154 good-risk patients with an AAA who underwent prompt open or endovascular repair was 2.2%. Conclusion: These data indicate that some patients with large AAAs and serious comorbidities are acceptably managed for long periods (6 to 76 months) with nonoperative means. Substantial delays of 12 to 76 months resulted in an AAA rupture rate of only 4%, and 13% of these patients (nine of 72) died of comorbidities unrelated to AAA rupture or surgery. Mortality rate in this group of patients, when operated, was 11% (six of 53). These findings support the selective use of nonoperative management in some patients with large AAAs and serious comorbidities.
AB - Objective: An accepted fact is that abdominal aortic aneurysms (AAAs) larger than 5.5 cm should undergo elective repair. However, subsets of these patients have serious comorbid conditions, which greatly increase operative risk. This study evaluated the outcomes of periods of protracted nonoperative observational management with selective delayed surgery in patients at high risk with large infrarenal and pararenal AAAs. Methods: Among 226 patients with AAAs more than 5.5 cm, we selected 72 with AAAs from 5.6 to 12.0 cm (mean, 7.0 cm) for periods of nonoperative management because of their prohibitive surgical risks. Comorbid factors included a low ejection fraction of 15% to 34% (mean, 22%) in 18 patients, 1 second forced expiratory volume less than 50% (mean, 38%) in 25, prior laparotomy in 10, and morbid obesity in 22. Follow-up examination was complete in the 72 patients for the 6 to 76 months (mean, 23 months) that they underwent nonoperative treatment. Fifty-three patients ultimately underwent operation because of AAA enlargement or onset of symptoms after 6 to 72 months (mean, 19 months) of nonoperative treatment. Results: Of the 72 selected patients, 54 (75%) are living and 18 (25%) are dead. Seven patients who underwent only nonoperative treatment presently survive after 28 to 76 months (mean, 48 months). Of the 18 deaths, AAA rupture occurred in only three patients (4%) who were observed for 12, 31, and 72 months before rupture. Nine other deaths (13%) occurred after 6 to 72 months from comorbidities unrelated to the AAA. Six of the 53 patients who underwent delayed operation died within 30 days of operation (11% mortality rate). The mortality rate for the 154 good-risk patients with an AAA who underwent prompt open or endovascular repair was 2.2%. Conclusion: These data indicate that some patients with large AAAs and serious comorbidities are acceptably managed for long periods (6 to 76 months) with nonoperative means. Substantial delays of 12 to 76 months resulted in an AAA rupture rate of only 4%, and 13% of these patients (nine of 72) died of comorbidities unrelated to AAA rupture or surgery. Mortality rate in this group of patients, when operated, was 11% (six of 53). These findings support the selective use of nonoperative management in some patients with large AAAs and serious comorbidities.
UR - http://www.scopus.com/inward/record.url?scp=19044373432&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=19044373432&partnerID=8YFLogxK
U2 - 10.1067/mva.2002.122889
DO - 10.1067/mva.2002.122889
M3 - Article
C2 - 12096255
AN - SCOPUS:19044373432
SN - 0741-5214
VL - 36
SP - 41
EP - 46
JO - Journal of Vascular Surgery
JF - Journal of Vascular Surgery
IS - 1
ER -