Influence of Age, Aneurysm Size, and Patient Fitness on Suitability for Endovascular Aortic Aneurysm Repair

Prior to approval by the U.S. Food and Drug Administration of larger endografts (main body diameters up to 36 mm), small abdominal aortic aneurysms (AAAs, <5.5 cm) were shown to be more suitable for endovascular repair (EVAR) than large AAAs (≥5.5 cm). The purpose of this study was to assess changes in EVAR suitability with the potential use of larger endografts in unselected consecutive patients. The influence of age, aneurysm size, and patient fitness on EVAR suitability was also assessed. We studied 186 male patients referred for evaluation of nonruptured AAAs who underwent contrast-enhanced computed tomographic scans with three-dimensional reconstructions. Morphologicall AAA features and neck characteristics were measured according to Society for Vascular Surgery reporting standards to determine EVAR suitability. Patient fitness for repair was assessed using the customized probability index, a validated fitness score for vascular surgery procedures. Suitability for EVAR was determined by neck anatomy, iliac artery morphology, and total aortic aneurysm angulation and tortuosity according to the clinicians' experience and current practice. The median age of the study cohort was 72 years (interquartile range [IQR] 65-79 years). The median maximum AAA diameter was 5.4 cm (IQR 4.1-5.9). Median fitness score was +7 (IQR -7 to +14). EVAR suitability for large AAAs significantly increased with larger endografts (35-63%, p < 0.001). Changes in EVAR suitability for small AAAs were not significant (69-75%, p = 0.06). Maximum AAA diameter was not an independent predictor for EVAR suitability with larger endografts after adjusting for neck anatomy. Aortic neck length (odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.1-1.2) and diameter (OR = 0.78, 95% CI 0.63-0.96) were the only independent predictors for EVAR suitability with larger endografts. Age, AAA size, and fitness did not differ between patients suitable and unsuitable for EVAR with larger endografts. In conclusion, introduction of larger endografts (up to 36 mm in main body diameter) in the United States has resulted in significantly increased anatomic suitability for EVAR for large AAAs. Conversely, suitability has not significantly changed for small AAAs. Overall, EVAR suitability is not influenced by age, aneurysm size, or patient fitness.