ABDOMINAL AORTIC-ANEURYSMS IN OCTOGENARIANS

The decision on whether to operate or not abdominal aortic aneurysms ( AAA) in elderly depends on the relative risk of the operation versus t he natural course of the unoperated AAA. From January 1984 to December 996, 138 patients, aged 80 years and older, were referred to our depa rtment for an aneurysm of 40 mm or more (transverse diameter) of the i nfrarenal abdominal aorta (95 asymptomatic, 15 painful, and 28 rupture d AAA). For 58 patients with asymptomatic AAA, operation was denied at referral because of transverse diameter less than 50 mm (n = 21), pat ient refusal (n = 10) or unacceptable operative risk or poor general c ondition (n = 27). Thirty-four of these observed AAA were ultimately o perated after a mean delay of 41 months because of aneurysm enlargemen t (n 15), aneurysm tenderness (n = 6) or rupture (n = 13). Overall, 52 patients had immediate (n = 37) or delayed (n = 15) elective repair o f their AAA, with an in-hospital mortality of 5.7%. Urgent operation w as done for 21 patients with a painful AAA. Six patients died at hospi tal (28% mortality rate). Emergent surgery was applied to 41 patients with ruptured AAA (including 13 AAA who ruptured during surveillance). The operative mortality in this subgroup attained 68%. Follow-up for the 77 survivors and the 24 non-operated patients averaged 43 months. The 5-year survival (operative mortality included) is 47% for elective ly operated patients, 30% for urgently and 20% for emergently operated patients. For comparison, the 5-year survival of an age and sex match ed Belgian population is 63%. For the 24 medically followed AAA, the 5 -year survival was 33%. In six cases, the cause of death was rupture o f the AAA. Of the 58 patients for whom operation was initially not con sidered, 19 (33%) presented AAA rupture (13 operated in emergency and 6 who never came to surgery). The operative outcome of AAA repair in o ctogenarians is less favourable than in the younger age group (3.6% mo rtality after elective repair, 44% after operation for AAA rupture, ac cording to our institution data). The authors conclude that AAA surger y should not be denied to octogenarians on the basis of advanced age a lone. They recommend a straightforward surgery for otherwise healthy o ctogenarians with AAA of 50 mm diameter, surveillance up to 60 mm for high-risk patients and no surgery for unfit, bedridden or demented pat ients.