A significant proportion of patients with abdominal and thoracic aortic aneurysms do not proceed to intervention after reaching treatment threshold diameter (55mm for abdominal aneurysms and 60mm for thoracic aneurysms) due to a combination of poor cardiovascular reserve, frailty and aortic morphology. This patient cohort has a high mortality1, however, there exist no studies on the palliative care and advance care planning they receive following discharge from the clinic.

This is a retrospective multicentre cohort study of 220 conservatively managed abdominal aortic aneurysm patients referred to the Leeds Vascular Institute (U.K.) and the Maastricht University Medical Centre (Netherlands) for intervention between 2017 and 2021. This was from a combined total of 1506 patients seen over this time period, giving a non-intervention rate of 15%. Demographic details, mortality, cause of death, advance care planning and palliative care outcomes were analysed to examine predictors of palliative care referral and efficacy of palliative care consultation.

There was a 3-year mortality rate of 60% and rupture was the reported cause of death in 17% of the decedents. Only 9% of all patients and 17% of decedents received palliative care referrals, which took place a median of 3.5 (IQR 61.5) days before death. Patients over 80 years of age were more likely to have a palliative care consultation. Almost half (44%) of decedents were readmitted to hospital before death and 37% of decedents died in hospital. Only 3 (1%) hospice referrals, a recognised marker of palliative care, were recorded in total. Only 5% of conservatively managed patients had a documented preferred place of death. Patients with palliative care consultations were more likely to have preferred place of death and care priorities documented.

Only a small proportion of conservatively treated patients with AAA had advance care planning and this was far below National Institute for Health and Care Excellence (NICE) 2019 guidance on end-of-life care for adults, which recommend it in every person at risk of dying from a sudden acute crisis in their condition2. It is also far below the level currently offered to oncology patients3, despite the 3-year mortality rate in our cohort being higher than the majority of cancers4. Pathways and guidance should be implemented to ensure patients not offered aortic aneurysm intervention receive end-of-life care and advance care planning.

1.Conway KP, Byrne J, Townsend M, et al. Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited? J Vasc Surg 2001;33(4):752-7. doi: 10.1067/mva.2001.112800 [published Online First: 2001/04/11] 2.NICE. End of life care for adults: service delivery. In: Excellence NIoHaC, ed., 2019. 3.Craigs CL, West RM, Hurlow A, et al. Access to hospital and community palliative care for patients with advanced cancer: A longitudinal population analysis. PLOS ONE 2018;13(8):e0200071. doi: 10.1371/journal.pone.0200071 4. UK CR. Cancer survival statistics for all cancers combined [Available from: https://www.cancerresearchuk.org/health-professional/cancer-statistics/survival/all-cancers-combined#collapseZero accessed 28, Nov 2021 2021.