Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited?

Purpose: The United Kingdom Small Aneurysm study has demonstrated the low r isk of rupture in aneurysms less than 5.5 an in diameter. With the advent o f endoluminal techniques, patients considered unfit to undergo laparotomy a re now considered for endovascular repair. However, the natural history of aneurysms larger than 5.5 cm remains uncertain, especially when severe como rbidity is present. In our center, we prospectively maintain records of all patients for whom elective aneurysm surgery was refused. This study docume nted the outcome of all patients referred with abdominal aortic aneurysms ( AAAs) larger than 5.5 an in diameter who were turned down for elective open repair and determined the cause of death and risk of rupture in all patien ts. Methods: Details of all patients with AAAs from January 5, 1989, to January 5, 1999, were recorded, and demographic details on all patients with AAAs larger than 5.5 cm were collected. Copies of death certificates were obtain ed from the Office of National Statistics, local in-hospital patient record s, and general practitioner records. Results of postmortem examinations wer e also obtained. Aneurysms were stratified according to their size at prese ntation (5.5-5.9 an, 6.0-7.0 an, and > 7.0 cm), and the reasons no interven tion was made were documented. Results: A total of 106 patients were turned down for elective aneurysm sur gery in the 10-pear period (10.6 per pear). The mean age of the patients wa s 78.4 years (SD, 7.4), and 70 were men and 36 were women. At the end of th e study, 76 patients (71.7%) had died. Overall, the 3-year survival rate wa s 17%. Patients with AAAs larger than 7.0 an lived a median of 9 months. A ruptured aneurysm was certified as a cause of death in 36% of the patients with an AAA of 5.5 to 5.9 an, in 50% of the patients with an AAA of 6 to 7. 0 an, and 55% of the patients with an AAA larger than 7.0 an. Reasons given for not intervening were patient refusal (31 cases), the patient being "un fit for surgery" (18 cases), the "advanced age" of the patient (18 cases), cardiac disease (9 cases), canter (9 cases), respiratory disease (6 cases), and other (15 cases). Conclusion: Although we recognize the problems with death certification, we found that rupture was a significant cause of death in patients with an un treated AAA that was larger than 5.5 cm. Although little difference in outc ome was observed in aneurysms in the 5.5 to 7.0 cm size range, patients wit h an AAA that was larger than 7.0 cm seemed to have a much poorer prognosis .