Outcomes in Octogenarians Offered EVAR and Electing for Conservative Management: A Retrospective Cohort Study

Aims: Historically, conservative management of above-threshold abdominal aortic aneurysm (AAA) is associated with poor outcomes; however, there is limited contemporary data on risk of premature mortality in elderly patients either unfit for intervention or self-selecting conservative management. This exploratory study investigates whether amongst octogenarians deemed fit for endovascular aneurysm repair (EVAR), long-term survival differs for conservative management compared with elective EVAR. Methods: The cohort comprised octogenarians with infrarenal AAA considered for EVAR in the Somerset and North Devon Vascular Network between 1 January 2010 to 1 January 2024. Exclusion criteria were age <80, consideration for open repair, and nonelective procedures. Propensity score matching was performed to compare patients undergoing elective EVAR and self-selecting conservative management. Results: 393 octogenarians were identified. Of them, 159 (40.3%) underwent EVAR, 190 (48.1%) were unfit for intervention, and 44 (11.6%) were offered EVAR but self-selected conservative management. Patients self-selecting conservative management were older ( P < .001), had smaller aneurysms ( P = .048), and were less frequently male ( P = .182) than those undergoing EVAR. On unadjusted analysis, median survival was 2.01 years longer for EVAR patients ( P < .001). After propensity-score matching, survival was 152 days longer for the EVAR group ( P = .13). Conservative management of AAA < 6cm was associated with longer survival than larger aneurysms (3.73 vs 2.26 years, P = .003). Patients self-selecting conservative management had lower mortality compared with the published literature. Conclusions: In our cohort, octogenarians undergoing EVAR experience low periprocedural mortality, but no statistically significant difference in long-term survival was observed over patients self-selecting conservative management. An abdominal aortic aneurysm > 6cm is associated with shorter survival. These results inform shared decision-making and support further investigation of treatment thresholds in octogenarians. Clinical Impact As the population ages an increasing number of octogenarians will be diagnosed with above-threshold AAA. Decision making for octogenarians with AAA is challenging, as procedure-related morbidity and mortality, aneurysm rupture risk, and life expectancy must be considered. This study investigates the outcomes of octogenarians that declined elective intervention for above-threshold AAA. This is the first study we are aware of investigating this patient group; historically, conservatively managed patients have been considered together. The results suggest that for octogenarians the benefit of elective EVAR is marginal, mostly due to high incidence of non-aneurysm-related mortality. This informs shared decision making for octogenarians.