Selecting Patients for Aortic Aneurysm Repair and Outcomes Associated with Operative and Non-operative Management: Low Aneurysm Related Mortality in Elective patients Managed Non-operatively

Introduction: Studies reporting the fate of patients with aortic aneurysms managed non-operatively are sparse. To determine judicious patient selection we aimed to (i) compare outcomes between patients managed operatively and those managed non-operatively and (ii) identify factors that dictate non-operative management. Methods: Data were collected on all patients with an aortic aneurysm referred to a tertiary referral centre over an 18-month period beginning April 2016. Kaplan-Meier analysis was used to measure survival and multivariate analysis to determine factors that predicted turn down. Results: 567 patients were considered for intervention; complete data were available for 533 (infra-renal: 299, juxta-renal: 104, thoracic: 41, thoraco-abdominal: 89). Mean age was 76.4yrs, and 80.0% were male. 333 patients (71 emergent) were managed operatively (endovascular: 266, open: 67). 91 [17.1%] patients were turned-down (infra-renal: 45, juxta-renal: 18, thoracic: 5, thoraco-abdominal: 23). Median follow-up was 156 (38- 343) days. Combining elective and emergency cases for univariate analysis, significant predictors of non-operative management were: increasing age, female gender, increasing aneurysm size, renal and cardiac disease, history of TIA/stroke, smoking history and presenting as an emergency (P<0.05 for all). For elective cases alone, all of these held true in univariate analysis bar cardiac disease. The type of aneurysm did not affect the decision to manage nonoperatively. In multivariate analysis significant predictors of nonoperative management were increasing age, history of stroke/TIA, renal disease and presenting as an emergency (P<0.05 for all). For elective cases alone, increasing age and renal disease proved significant P<0.05 for both). One-year all-cause mortality for elective open and endovascular procedures was 2.4% (1/42) and 5.9% (13/220), respectively and for aneurysm related mortality was 2.4%(1/42) and 3.6%(8/220). One-year aneurysm related and all-cause mortality for those turned down for elective surgery was 6.8% (4/59) and 22% (13/59), respectively, with almost a third (4/13) of these patients dying from cancer rather than aneurysm rupture. Conclusion: The short-term aneurysm-related mortality in elective turndowns is low, with a significant number of patients succumbing for other reasons. Given the plethora of treatment options available, objective selection of patients who will benefit most from intervention is increasingly important.