Outcome of abdominal aortic endografting in high-risk patients: a 4-year single-center study

Purpose: To evaluate feasibility, safety, and effectiveness of endovascular abdominal aortic aneurysm (AAA) repair in patients whose fitness for surgery is questionable. Methods: Between April 1997 and December 2001, 389 consecutive patients underwent endovascular AAA repair. Of these, 51 (13.1%) were ASA grade IV. The perioperative and late outcomes of this group were compared to the remaining 338 patients with ASA grades <IV. Failure of AAA exclusion was defined as late conversion to open repair, AAA rupture, increased aneurysm diameter, or persisting graft-related endoleak. Gender, age, ASA grade IV, EUROSTAR class E, and AAA diameter were examined by logistic regression analysis for their influence on perioperative death, survival, and failure of AAA exclusion. Results: Four (7.8%) perioperative deaths occurred in the ASA IV group compared to 1 (0.3%) in the ASA <IV group (p=0.001). Median follow-up was 22 months (range 1-56). Failure of AAA exclusion occurred in 3 (5.9%) patients in ASA IV group and in 25 (7.4%) in ASA <IV group (p>0.05). Actuarial survival at 30 months was 62.9% in ASA IV group and 88.0% in ASA <IV group (p=0.001, log-rank test). There were no independent predictors for failure of AAA exclusion; ASA IV was independently associated with perioperative mortality (HR 17.8; 95% CI 1.6 to 188; p=0.016). Conclusions: Endovascular AAA repair in ASA IV patients is feasible and effective in preventing AAA rupture in the mid term. High-risk patients experience a worse prognosis than their good-risk counterparts. An individualized approach in selecting high-risk patients for endoluminal repair is mandatory.