Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited?

Purpose: The United Kingdom Small Aneurysm study has demonstrated the low risk of rupture in aneurysms less than 5.5 an in diameter. With the advent of endoluminal techniques, patients considered unfit to undergo laparotomy are now considered for endovascular repair. However, the natural history of aneurysms larger than 5.5 cm remains uncertain, especially when severe comorbidity is present. In our center, we prospectively maintain records of all patients for whom elective aneurysm surgery was refused. This study documented the outcome of all patients referred with abdominal aortic aneurysms (AAAs) larger than 5.5 an in diameter who were turned down for elective open repair and determined the cause of death and risk of rupture in all patients. Methods: Details of all patients with AAAs from January 5, 1989, to January 5, 1999, were recorded, and demographic details on all patients with AAAs larger than 5.5 cm were collected. Copies of death certificates were obtained from the Office of National Statistics, local in-hospital patient records, and general practitioner records. Results of postmortem examinations were also obtained. Aneurysms were stratified according to their size at presentation (5.5-5.9 an, 6.0-7.0 an, and > 7.0 cm), and the reasons no intervention was made were documented. Results: A total of 106 patients were turned down for elective aneurysm surgery in the 10-pear period (10.6 per pear). The mean age of the patients was 78.4 years (SD, 7.4), and 70 were men and 36 were women. At the end of the study, 76 patients (71.7%) had died. Overall, the 3-year survival rate was 17%. Patients with AAAs larger than 7.0 an lived a median of 9 months. A ruptured aneurysm was certified as a cause of death in 36% of the patients with an AAA of 5.5 to 5.9 an, in 50% of the patients with an AAA of 6 to 7.0 an, and 55% of the patients with an AAA larger than 7.0 an. Reasons given for not intervening were patient refusal (31 cases), the patient being "unfit for surgery" (18 cases), the "advanced age" of the patient (18 cases), cardiac disease (9 cases), canter (9 cases), respiratory disease (6 cases), and other (15 cases). Conclusion: Although we recognize the problems with death certification, we found that rupture was a significant cause of death in patients with an untreated AAA that was larger than 5.5 cm. Although little difference in outcome was observed in aneurysms in the 5.5 to 7.0 cm size range, patients with an AAA that was larger than 7.0 cm seemed to have a much poorer prognosis.