Whittaker JD, Meecham L, Summerour V, Khalil S, Layton G, Yousif
M, Jennings A, Wall M, Newman J

Eur J Vasc Endovasc Surg. 2017 Nov;54(5):579-586. doi:
10.1016/j.ejvs.2017.07.023.

OBJECTIVES: The aim was to assess the survival of patients who had been turned
down for repair of an abdominal aortic aneurysm (AAA) and to examine the factors
influencing this.
METHODS: This was a retrospective observational study of a prospectively
maintained database of all patients turned down for AAA intervention by the Black
Country Vascular Network multidisciplinary team (MDT) from January 2013 to
December 2015. Data on AAA size, cardiopulmonary exercise testing (CPET) and
cause of death were recorded.
RESULTS: There were 112 patients. The median age at turndown was 83.9 years (IQR
10.2 years). The median AAA size at turndown was 63 mm (IQR 16.7 mm). The median
follow-up time after turndown was 324 days (IQR 537.5 days). Sixty-four patients
(57.1%) were deceased after 2 years, with a median survival time of 462 days (IQR
579 days). Patients who died had a significantly larger AAA dimension (median
65 mm, IQR 18.5 mm) than those surviving to date (median 59 mm, IQR 10 mm,
p = .004). Using Cox regression analysis, the probability of 1 year survival in
the whole population was 0.614. The probability of 2 year survival was 0.388.
When accounting for age, gender, AAA dimension, and British Aneurysm Repair risk
score, no factors had significant influence over survival. Of the 64 deceased
patients, 30 had an accessible cause of death: 36.7% of these were due to
ruptured AAAs. There was no significant difference in AAA size between those
dying of ruptures and those dying of other causes (p = .225, mean 74 mm and 67 mm
respectively).
CONCLUSIONS: Being turned down for AAA repair carries a significant short-term
risk of mortality. Those turned down for repair carried significant levels of
comorbid disease but no factors considered were found to be independently
predictive of the length of survival.

Comment in
Eur J Vasc Endovasc Surg. 2017 Nov;54(5):587

“There will inevitably be heterogeneity between institutions in terms of fitness threshold levels for offering abdominal aortic aneurysm (AAA) repair. If the threshold is set too high, there is a risk of denying a proportion of patients who would have otherwise potentially benefited from repair and had their AAA rupture prevented. If the threshold is set too low, this may result in high peri-operative mortality, and in the longer term, lower overall life expectancy among those repaired which will negate any long-term benefit from AAA repair………”