Commentary: How Old Is Too Old for EVAR?

The study from Mwipatayi et al1 in the October 2020 issue of the JEVT is important for a variety of reasons. First of all, it reports an interesting subanalysis of the prospective, observational, single-arm ENGAGE registry, which involves almost 80 centers worldwide and represents a clear image of the real-world performance of a modern endovascular solution for most abdominal aortic aneurysms (AAA). The value of this paper takes on even greater importance if one considers that it deals with one of the main clinical dilemmas of the contemporary vascular surgeon, which is the treatment decision process in patients >80 years old. In,fact, the mean age of the general population is onstantly increasing; in Europe, for example, from 2008 to 2018 the overall life expectancy increased by 2 years.2 The revalence of asymptomatic AAAs is significantly higher in older people, and it exceeds 8% in male smokers >80 years old.3 This has led to a significant, steady increase in patients >80 years old submitted to endovascular aneurysm repair (EVAR) in some studies4; however, current guidelines do not specifically address the indication to repair according to age. The only age specification available in both the Society for Vascular Surgery and European Society for Vascular Surgery guidelines refers to life expectancy; thus, we are faced with a clinical scenario and no specific indications. Consistent with previous reports on this subject, the Engage registry study shows that all-cause mortality in the octogenarian population submitted to EVAR is higher than in younger patients; however, aneurysm-related mortality is not significantly different in the two groups. As a matter of fact, it is evident from previous works that the natural history of octogenarians submitted to EVAR is dependent on their preoperative conditions. Some authors have found a significantly higher overall mortality in octogenarians submitted to EVAR compared with younger patients5; however, this may be the effect of a higher number of risk factors in this population, as shown by other authors. For example, in the paper by Crespy et al,6 the two populations have similar clinical characteristics, and the 3-year survival is comparable in the groups. Pini et al4 have shown that an American Society of Anesthesiologists (ASA) score of IV is an independent predictor of 30-day mortality in octogenarians undergoing EVAR; however, the most important finding of that study is that several factors other than ASA IV, such as peripheral artery disease, chronic obstructive pulmonary disease, and chronic renal disease, play significant roles in midterm survival. The outcomes reported by Mwipatayi and colleagues1 are consistent with these findings, since several factors were found to predict all-cause mortality. It is also interesting to observe that quality of life has an important role in late survival. This is an aspect that deserves an increasing degree of attention when dealing with aneurysm, as already anticipated in a study from our group.7 Overall, the finding that all-cause mortality is greater in >80-year-old people cannot be easily dismissed, and the indication to repair should be very carefully considered in this group, with particular caution in octogenarians with multiple comorbidities. With judicious selection of patients to be treated, the follow-up can be specifically tailored to avoid unnecessary imaging surveillance in these patients.