EVAR May Provide a Survival Advantage in Patients Deemed Physiologically Ineligible for Open Abdominal Aortic Aneurysm Repair.

Fisher O, Gates Z, Parkes E, Shakespeare J, Goodyear SJ, Imray CHE, Benson RA;

Ann Vasc Surg. 2019 Aug 5. pii: S0890-5096(19)30542-4. doi:
10.1016/j.avsg.2019.05.047. [Epub ahead of print]

INTRODUCTION: Cardiopulmonary exercise testing (CPET) provides an objective
assessment of functional capacity and fitness. It can be used to guide decision
making prior to major vascular surgery. The EVAR-2 trial suggested endovascular
aneurysm repair (EVAR) in patients unfit for open repair failed to provide a
significant survival advantage over non surgical management. The aim of this
study was to assess contemporary survival differences between patients with poor
CPET measures who underwent EVAR or were not offered surgical intervention.
METHODS: A prospectively maintained database of CPET results of patients
considered for elective infrarenal aortic aneurysm repair was interrogated.
Anaerobic threshold (AT) of <11ml/min/kg was used to indicate poor physical
fitness. Hospital electronic records were then reviewed for peri-operative,
re-intervention and long term outcomes.
RESULTS: Between November 2007 and October 2017 532 aortic aneurysm repairs were
undertaken, of which 376 underwent pre-operative CPET. 70 patients were
identified as having an AT<11ml/min/kg. 37 patients underwent EVAR and 33 were
managed non surgically. All cause survival at 1, 3 and 5 years for those patients
who underwent EVAR was 97% 92% and 81% respectively. For those not offered
surgical intervention survival at the same points was 72%, 48% and 24% HR=5.13
(1.67-15.82) p=0.004. Aneurysm specific survival at 1, 3 and 5 years for those
patients who underwent EVAR was 97% 94% and 94% respectively. Survival at the
same time points for those not offered surgical intervention was 90% 69% 39%.
HR=7.48 (1.37-40.82) p=0.02.
CONCLUSIONS: In this small, retrospective, single centre, non-randomised cohort
EVAR may provide a survival advantage in patients with poor physical fitness
identified via CPET. Randomised studies with current generation EVAR are required
to validate the results shown here. Risk prediction, CPET, Survival.