This study sought to identify factors associated with the occurrence of in-hospital serious adverse events (SAE) after elective endovascular aortic repair (EVAR) in elderly patients within the Global Registry for Endovascular Aortic Treatment (GREAT).

Consecutive patients ≥75 years who received GORE® EXCLUDER® AAA Endoprosthesis (W.L. Gore & Associates Inc., Flagstaff, AZ, USA) for elective EVAR. The main exposure variable for this study was age at index EVAR. Therefore, for the analysis, patients were categorized into three groups: those of 75 to 79, 80 to 84, and at least 85 years. The primary endpoints for this study were incidence of SAE and all-cause mortality

Overall, 1,333 elderly patients (75-79, n=601; 80-84, n=474; ≥85, n=258) underwent elective EVAR in the GREAT dataset and were included in the present analysis. In total, 12 patients (0.9%) died peri-operatively, and 127 patients (9.5%) experienced at least one in-hospital SAE, with 18 subjects experiencing >1 in-hospital complication. No significant differences were seen between age groups in the rates of in-hospital SAE (7.3% vs 8.2% vs 7.8%, p=.86). In logistic regression analysis, history of chronic obstructive pulmonary disease (OR 2.014, 95%CI 1.215-3.340, p=.006) and prior requirement for dialysis (OR 4.655, 95%CI 1.087-19.928, p=.038) resulted as predictors for occurrence of in-hospital SAE. The overall 5-year survival rate for the whole cohort was 61.9% (95%CI 58.4%-65.1%). After stratification by age groups , the 5-year survival rate was significantly higher for patients aged 75-79 as compared with subjects aged 80-84 and those ≥85 years (71% vs 60% vs 43% respectively, p<.001; Figure 1). For the entire cohort, the 5-year survival rate was 63% for subjects who did not experience any in-hospital SAE as compared with 51% for those who experienced any complications (p=.003; Figure 2). Survival analysis was repeated with stratification by age groups and presence of in-hospital SAE, showing higher survival rates at 5 years for patients without any complications and always significantly lower mortality in younger individuals (without SAE: 71% vs 61% vs 45%, p<.001; with SAE: 71% vs 45% vs 30%, p<.001). Using multivariate Cox proportional hazards models, it was found that occurrence of in-hospital SAE (HR 6.2, 95%CI 1.796-21.317, p=.003) and being underweight (HR 7.0, 95%CI 1.371-35.783, p=.019) were the only independent predictors of death within 30 days from the initial intervention. The multivariate models confirmed that in-hospital SAE carried significant risk of death within 31 and 180 days from the initial intervention (HR 3.629, 95%CI 1.832-7.188, p<.001), although they were not independently associated with risk of death beyond three months from index EVAR (HR 1.443, 95%CI 0.919-2.264, p=.111). While age did not independently affect the risk for all-cause mortality in the first 180 days after the initial intervention, increasing age was independently associated with higher risk for long-term death (i.e. ≥181 days from index EVAR) in the multivariate analysis (age 75 to 79:HR 0.379, 95%CI 0.281-0.512, p<.001; age 80 to 84:HR 0.562, 95%CI 0.419-0.754, p<.001).

After elective EVAR in elderly patients (i.e. 75 years or older), occurrence of in-hospital SAE appear to increase the risk of death particularly within the first 180 days following the initial EVAR intervention and might be related to patient baseline characteristics, including history of pulmonary and renal disease.