Date of Award

2020

Degree Name

Master of Medical Science (Physician Assistant)

Department

Physician Assistant; College of Health Sciences

First Advisor

Erin Wolf, PA-C

Abstract

INTRODUCTION: An abdominal aortic aneurysm (AAA) is a permanent ballooning of the abdominal aorta greater than 3cm in diameter. A small AAA is often asymptomatic. However, as time passes the risk of rupture increases as the diameter of the aneurysm widens. This can ultimately lead to massive internal bleeding and fatality. Surgery is the most common course of treatment for AAA. Most patients will undergo traditional open surgery, but this is often associated with prolonged in-hospital recovery and is contraindicated in an aging population that have a higher prevalence of comorbidities. With this in thought, some clinicians have been turning towards the less invasive endovascular aneurysm repair (EVAR) procedure as another option for AAA. However, there seems to be some conflicting research about EVAR’s long term efficacy. Therefore, this review will analyze the efficacy and rate of complications of EVAR, compared to traditional open surgical repair (OSR), in patients 60 y.o. and older with AAA.

METHODS: A literature search was completed though PubMed, ClinicalKey, and Google Scholar in November 2018. Six articles were selected based on publication date, presence of significant data in regard to the topic, study design, and quality of research.

RESULTS: Some studies demonstrated that EVAR patients who are 60-79 years of age have a higher rate of post-operative complications compared to traditional open repair. One study reported no statistical difference in cumulative survival rates between OSR and EVAR at 1 year and at 3 years. Another study revealed that pursuing EVAR can lead to higher rates of vascular reintervention. Conversely, other studies have revealed data showing how EVAR leads to shorter hospital stays, lower perioperative complications, and fewer major complications compared to OSR in the same age group. Interestingly, there is a handful of studies that reveal how EVAR might be more favorable in octogenarians. One study discovered that the rate of postoperative complications after EVAR was at 28% for octogenarians compared to the younger cohort (less than 80 years old) at 36%. Overall, there are mixed reviews about the safety and efficacy of EVAR in AAA patients 60 years old and older compared to OSR.

DISCUSSION: Many studies have been done that either supports or rejects EVAR being associated with decreased reintervention rate and increased overall benefit to patients in comparison to OSR. However, there were significant limitations such as inability to exclude bias, small sample size, short-term follow up periods, lack of randomization, etc. Also, there is limited research on the efficacy and impact of EVAR vs OSR in different age groups above 60 years old. Therefore, further research that can include comparison of age groups and focus on specific types of AAA that require elective treatment is necessary.

CONCLUSION: EVAR’s technical success rate is high and perioperative complications in short term follow up is lower compared with OSR. However, in mid-term and long-term appointments late complications from EVAR are more likely in patients who are 60-79 years old. Octogenarians seems to have better benefit from EVAR than their younger cohort. Most likely EVAR is an effective and reliable procedure for AAA repair, but more research in a randomized multicenter trial setting is encouraged to determine if elective EVAR can be set as the standard of care.

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Capstone AAA Poster Presentation 2020.pptx (1003 kB)
PPT version of poster presentation

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In Adult Patients 60+ y.o. With AAA, Would (F)EVAR Lead to Least Amount of Post-operative Complications Than Traditional OSR?

INTRODUCTION: An abdominal aortic aneurysm (AAA) is a permanent ballooning of the abdominal aorta greater than 3cm in diameter. A small AAA is often asymptomatic. However, as time passes the risk of rupture increases as the diameter of the aneurysm widens. This can ultimately lead to massive internal bleeding and fatality. Surgery is the most common course of treatment for AAA. Most patients will undergo traditional open surgery, but this is often associated with prolonged in-hospital recovery and is contraindicated in an aging population that have a higher prevalence of comorbidities. With this in thought, some clinicians have been turning towards the less invasive endovascular aneurysm repair (EVAR) procedure as another option for AAA. However, there seems to be some conflicting research about EVAR’s long term efficacy. Therefore, this review will analyze the efficacy and rate of complications of EVAR, compared to traditional open surgical repair (OSR), in patients 60 y.o. and older with AAA.

METHODS: A literature search was completed though PubMed, ClinicalKey, and Google Scholar in November 2018. Six articles were selected based on publication date, presence of significant data in regard to the topic, study design, and quality of research.

RESULTS: Some studies demonstrated that EVAR patients who are 60-79 years of age have a higher rate of post-operative complications compared to traditional open repair. One study reported no statistical difference in cumulative survival rates between OSR and EVAR at 1 year and at 3 years. Another study revealed that pursuing EVAR can lead to higher rates of vascular reintervention. Conversely, other studies have revealed data showing how EVAR leads to shorter hospital stays, lower perioperative complications, and fewer major complications compared to OSR in the same age group. Interestingly, there is a handful of studies that reveal how EVAR might be more favorable in octogenarians. One study discovered that the rate of postoperative complications after EVAR was at 28% for octogenarians compared to the younger cohort (less than 80 years old) at 36%. Overall, there are mixed reviews about the safety and efficacy of EVAR in AAA patients 60 years old and older compared to OSR.

DISCUSSION: Many studies have been done that either supports or rejects EVAR being associated with decreased reintervention rate and increased overall benefit to patients in comparison to OSR. However, there were significant limitations such as inability to exclude bias, small sample size, short-term follow up periods, lack of randomization, etc. Also, there is limited research on the efficacy and impact of EVAR vs OSR in different age groups above 60 years old. Therefore, further research that can include comparison of age groups and focus on specific types of AAA that require elective treatment is necessary.

CONCLUSION: EVAR’s technical success rate is high and perioperative complications in short term follow up is lower compared with OSR. However, in mid-term and long-term appointments late complications from EVAR are more likely in patients who are 60-79 years old. Octogenarians seems to have better benefit from EVAR than their younger cohort. Most likely EVAR is an effective and reliable procedure for AAA repair, but more research in a randomized multicenter trial setting is encouraged to determine if elective EVAR can be set as the standard of care.