Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort

Thomas F.X. O'Donnell, Jacqueline E. Wade, Patric Liang, Chun Li, Nicholas J. Swerdlow, Randall R De Martino, Mahmoud B. Malas, Bruce E. Landon, Marc L. Schermerhorn

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background: Endovascular aneurysm repair (EVAR) has decreased the perioperative mortality for patients undergoing abdominal aortic aneurysm repair and has increased the rates of elective aneurysm repair in the elderly. However, Medicare will not cover abdominal aortic aneurysm screening for beneficiaries over 75 years of age. Consequently, abdominal aortic aneurysm treatment in this population depends on incidental detection. Targeted coverage for screening in this population, however, might be beneficial for a subgroup of patients. Methods: To identify a subset of elderly patients who would potentially benefit from an expanded screening policy, we reviewed all patients greater than 75 years old undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2016. We used Cox regression with multivariable fractional polynomials to construct a risk model for 5-year survival in elderly patients to identify a subpopulation who might benefit the most from screening and performed internal validation using the bootstrapping technique. Results: We identified 10,676 patients greater than 75 years old undergoing elective EVAR. Although perioperative mortality varied with age, it was only 2.1% in the oldest group of patients (>85 years). Significant predictors included in our final risk model for 5-year survival in the elderly included age, aortic diameter, hemoglobin, current smoking, white race, body mass index, renal function, congestive heart failure, statin use, chronic obstructive pulmonary disease, and ejection fraction. The risk model produced risk scores ranging from a possible −2 to 33. The mean and median risk score were 6.9 and 6.0, respectively, with a right skew. We categorized the risk scores into four groups: −2 to 4 points, 5-8 points, 9-13 points, and more than 13 points, with associated 5-year survivals of 88%, 79%, 68%, and 49%, respectively. The model showed adequate discrimination and calibration, with a C-statistic of 0.69 and a calibration score of 0.99 (predicted 5-year survival of 0.78 compared with an observed 5-year survival of 0.77) and a Brier score of 0.15. Internal validation demonstrated an optimism-corrected C-statistic of 0.69 and a calibration slope of 1.0. Conclusions: Elective EVAR in elderly patients chosen to undergo repair is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening into all but the highest risk group based on expected postoperative 5-year survival to justify removing this Medicare coverage restriction.

Original languageEnglish (US)
JournalJournal of Vascular Surgery
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Aneurysm
Survival
Abdominal Aortic Aneurysm
Calibration
Medicare
Mortality
Hydroxymethylglutaryl-CoA Reductase Inhibitors
Chronic Obstructive Pulmonary Disease
Population
Blood Vessels
Hemoglobins
Body Mass Index
Heart Failure
Smoking
Kidney

Keywords

  • Abdominal aortic aneurysm
  • Endovascular aneurysm repair
  • Long-term survival
  • Risk model
  • Vascular Quality Initiative

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort. / O'Donnell, Thomas F.X.; Wade, Jacqueline E.; Liang, Patric; Li, Chun; Swerdlow, Nicholas J.; De Martino, Randall R; Malas, Mahmoud B.; Landon, Bruce E.; Schermerhorn, Marc L.

In: Journal of Vascular Surgery, 01.01.2018.

Research output: Contribution to journalArticle

O'Donnell, Thomas F.X. ; Wade, Jacqueline E. ; Liang, Patric ; Li, Chun ; Swerdlow, Nicholas J. ; De Martino, Randall R ; Malas, Mahmoud B. ; Landon, Bruce E. ; Schermerhorn, Marc L. / Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort. In: Journal of Vascular Surgery. 2018.
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abstract = "Background: Endovascular aneurysm repair (EVAR) has decreased the perioperative mortality for patients undergoing abdominal aortic aneurysm repair and has increased the rates of elective aneurysm repair in the elderly. However, Medicare will not cover abdominal aortic aneurysm screening for beneficiaries over 75 years of age. Consequently, abdominal aortic aneurysm treatment in this population depends on incidental detection. Targeted coverage for screening in this population, however, might be beneficial for a subgroup of patients. Methods: To identify a subset of elderly patients who would potentially benefit from an expanded screening policy, we reviewed all patients greater than 75 years old undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2016. We used Cox regression with multivariable fractional polynomials to construct a risk model for 5-year survival in elderly patients to identify a subpopulation who might benefit the most from screening and performed internal validation using the bootstrapping technique. Results: We identified 10,676 patients greater than 75 years old undergoing elective EVAR. Although perioperative mortality varied with age, it was only 2.1{\%} in the oldest group of patients (>85 years). Significant predictors included in our final risk model for 5-year survival in the elderly included age, aortic diameter, hemoglobin, current smoking, white race, body mass index, renal function, congestive heart failure, statin use, chronic obstructive pulmonary disease, and ejection fraction. The risk model produced risk scores ranging from a possible −2 to 33. The mean and median risk score were 6.9 and 6.0, respectively, with a right skew. We categorized the risk scores into four groups: −2 to 4 points, 5-8 points, 9-13 points, and more than 13 points, with associated 5-year survivals of 88{\%}, 79{\%}, 68{\%}, and 49{\%}, respectively. The model showed adequate discrimination and calibration, with a C-statistic of 0.69 and a calibration score of 0.99 (predicted 5-year survival of 0.78 compared with an observed 5-year survival of 0.77) and a Brier score of 0.15. Internal validation demonstrated an optimism-corrected C-statistic of 0.69 and a calibration slope of 1.0. Conclusions: Elective EVAR in elderly patients chosen to undergo repair is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening into all but the highest risk group based on expected postoperative 5-year survival to justify removing this Medicare coverage restriction.",
keywords = "Abdominal aortic aneurysm, Endovascular aneurysm repair, Long-term survival, Risk model, Vascular Quality Initiative",
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T1 - Endovascular aneurysm repair in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort

AU - O'Donnell, Thomas F.X.

AU - Wade, Jacqueline E.

AU - Liang, Patric

AU - Li, Chun

AU - Swerdlow, Nicholas J.

AU - De Martino, Randall R

AU - Malas, Mahmoud B.

AU - Landon, Bruce E.

AU - Schermerhorn, Marc L.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Endovascular aneurysm repair (EVAR) has decreased the perioperative mortality for patients undergoing abdominal aortic aneurysm repair and has increased the rates of elective aneurysm repair in the elderly. However, Medicare will not cover abdominal aortic aneurysm screening for beneficiaries over 75 years of age. Consequently, abdominal aortic aneurysm treatment in this population depends on incidental detection. Targeted coverage for screening in this population, however, might be beneficial for a subgroup of patients. Methods: To identify a subset of elderly patients who would potentially benefit from an expanded screening policy, we reviewed all patients greater than 75 years old undergoing elective EVAR in the Vascular Quality Initiative between 2003 and 2016. We used Cox regression with multivariable fractional polynomials to construct a risk model for 5-year survival in elderly patients to identify a subpopulation who might benefit the most from screening and performed internal validation using the bootstrapping technique. Results: We identified 10,676 patients greater than 75 years old undergoing elective EVAR. Although perioperative mortality varied with age, it was only 2.1% in the oldest group of patients (>85 years). Significant predictors included in our final risk model for 5-year survival in the elderly included age, aortic diameter, hemoglobin, current smoking, white race, body mass index, renal function, congestive heart failure, statin use, chronic obstructive pulmonary disease, and ejection fraction. The risk model produced risk scores ranging from a possible −2 to 33. The mean and median risk score were 6.9 and 6.0, respectively, with a right skew. We categorized the risk scores into four groups: −2 to 4 points, 5-8 points, 9-13 points, and more than 13 points, with associated 5-year survivals of 88%, 79%, 68%, and 49%, respectively. The model showed adequate discrimination and calibration, with a C-statistic of 0.69 and a calibration score of 0.99 (predicted 5-year survival of 0.78 compared with an observed 5-year survival of 0.77) and a Brier score of 0.15. Internal validation demonstrated an optimism-corrected C-statistic of 0.69 and a calibration slope of 1.0. Conclusions: Elective EVAR in elderly patients chosen to undergo repair is associated with acceptable perioperative mortality. Our risk score can be used to define optimal patients for expanded screening into all but the highest risk group based on expected postoperative 5-year survival to justify removing this Medicare coverage restriction.

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KW - Abdominal aortic aneurysm

KW - Endovascular aneurysm repair

KW - Long-term survival

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KW - Vascular Quality Initiative

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