Impact of Preoperative Risk Factors on 5-year Survival after F/BEVAR

To investigate which preoperative factors are most impactful on the 5-year survival of patients undergoing fenestrated/branched endovascular aortic repair (F/BEVAR) and to identify modifiable elements that, if time allows, should be actively managed and adequately controlled preoperatively. Patients treated for complex anatomy aortic aneurysms using either a custom-manufactured or an off-the-shelf device were included. The exposure of interest was aneurysm type (group 1 [which included types I-III thoracoabdominal aneurysms] vs group 2 [which included type IV thoracoabdominal aneurysms] vs group 3 [which included juxtarenal or suprarenal aneurysms]). The primary outcome was 5-year risk of all-cause mortality. Generalized linear models were used to estimate the crude 5-year risk of death in each group and the 5-year risk of death across groups. Each preoperative factor was added to the model individually and a change in estimate was calculated between the new risks and the crude risk. Preoperative factors with a change of estimate of ≥10% were used to create inverse probability of treatment weights for multivariable analysis. We included 408 F/BEVAR patients who were 71.6% male (mean age, 72.0 ± 7.9 years). Ten of 21 preoperative factors analyzed had a change in estimate of ≥10% (Table). The greatest changes in estimates were observed for history of chronic heart failure, body mass index of ≥30, and arrhythmia. Almost 60% of patients with CHF in group1 died within 5 years. Current smoking or overweight at the time of F/BEVAR increases the 5-year risk of death more significantly than having a history of myocardial infarction. After adjustment, patients in group 1 had a significantly higher risk of 5-year all-cause mortality compared with those in group 3 (Figure) (log-rank P = .0082). These findings suggest that cardiac pathologies are relevant preoperative elements that impact the 5-year survival after F/BEVAR. More specifically, chronic heart failure and arrhythmias should be used to alter patient selection and identify those patients more likely to benefit from repair. Moreover, modifiable risk factors such as weight loss and smoking cessation before F/BEVAR and during the surveillance period, might improve survival in this population.TableChange in risk of 5-year all-cause mortality for a variety of preoperative risk factors by aneurysm typeModelsGroup 1: type I, type II, type III TAAA (n = 123)Group 2: Type IV TAAA (n = 65)Group 3: Juxtarenal or suprarenal AAA (n = 220)5-Year mortality risk (%)Change in estimate (%)5-Year mortality risk (%)Change in estimate (%)5-Year mortality risk (%)Change in estimate (%)Crude risk33.3% (25.9%, 42.8%)--29.2% (20%-42.6%)--25% (19.8%-31.4%)--+ History of arrhythmia47.8% (35.5%-64.5%)+43.6%40% (26.8%-59.6%)+36.9%35.9% (26.9%-47.9%)+43.7%+ History of CHF59.2% (41.1%-85.1%)+77.6%47.9% (31.3%-73.4%)+64.1%43.2% (30.6%-61%)+72.9%+ History of COPD42.9% (32.1%-57.3%)+28.9%36.2% (24.4%-53.7%)+23.8%31.8% (24.2%-41.8%)+27.4%+ History of CAD39.8% (29.1%-54.6%)+19.7%31.8% (21.6%-46.7%)+8.8%28.6% (21.8%-37.4%)+14.5%+ History of diabetes39.9% (27.1%-58.6%)+17.0%34.5% (21.7%-55.1%)+18.3%29.9% (20.5%-43.6%)+19.9%+ History of MI38.6% (26%-57.5%)+16.1%33.1% (21%-52.4%)+13.5%28.6% (19.9%-40.9%)+14.4%+ History of PVD38.9% (25.8%-58.6%)+16.9%33.9% (20.8%-55.39%)+16.2%28.9% (19.7%-42.5%)+16.0%+ Current smoker39.9% (13.4%-118%)+19.8%35% (10.7%-113.9%)+19.8%28.8% (9.2%-89.8%)+15.6%+ Overweight (25 ≤ body mass index ≤ 30)39.3% (29.5%-52.3%)+18.0%35.2% (23.2%-53.3%)+20.6%32.4% (24.5%-43%)+29.9%+ Obese (body mass index >30)53.6% (29.5%-97.3%)+60.8%48% (24.5%-94.1%)+64.4%44.2% (24.4%-80.2%)+77.1%CAD, Coronary artery disease; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction; PVD, peripheral vascular disease.aAge, sex, cerebrovascular accident, family history of aneurysm, history of cancer, hypertension, former smoker, hyperlipidemia, and glomerular filtration rate all had a change in estimate OF <10%.bHistory of dissection, coagulopathy, end-stage renal disease, paraplegia, and paresis were all considered, but ultimately excluded owing to low prevalence of disease in our population. Open table in a new tab