Cause of death among patients following repair of juxtarenal aneurysm with physician-modified endografts

Abstract

Objective

The use of physician-modified endografts (PMEGs) to treat juxtarenal aortic aneurysms has increased significantly over the past 10 years. However, there exists a paucity of data beyond 5 years. This study compares long-term outcomes and cause of death between patients who did and did not survive beyond 5 years after PMEG for juxtarenal aneurysm.

Methods

All patients with >5 years of follow-up data enrolled in a prospective, physician-sponsored investigational device exemption clinical trial treated with PMEG for juxtarenal aneurysm were included. Univariate analysis was used to compare demographics, anatomical and operative characteristics, late outcomes, and cause of death between patients who survived beyond 5 years and those who did not. Death on hospice, clinical follow-up status, and whether patients declined a secondary intervention were also evaluated. Survival was assessed with Kaplan-Meier analysis. Predictors of overall mortality and mortality before 5 years were determined using Cox regression analysis.

Results

We included 98 patients with juxtarenal aneurysm wgo underwent PMEG from 2011 to 2018; 64 (65.3%) survived beyond 5 years and 34 (34.7%) did not. Patients who survived beyond 5 years were younger (73 years vs 78 years; P = .04) with a greater prevalence of preoperative antiplatelet use (81.3% vs 61.8%; P = .047). There were no differences in comorbidities, symptomatic presentation, or anatomical or operative characteristics. Patients who survived beyond 5 years were less likely to experience a perioperative adverse event (10.9% vs 38.2%; P < .01) and pulmonary complication (1.6% vs 17.7%; P = .01). There were no differences in late outcomes, including reintervention, aortic sac behavior, endoleak, or visceral patency. Patients who survived beyond 5 years more frequently died on hospice (58.6% vs 17.6%; P < .01), were lost to aortic-specific clinical follow-up (48.4% vs 5.9%; P < .01), and declined a secondary intervention (9.4% vs 2.9%; P = .04). For the entire study cohort, aortic-related mortality was 9.5%. Survival was 87% at 1 year, 65% at 5 years, and 10% at 10 years. Cardiac comorbidities (15.9%), systemic decline (15.9%), stroke (14.2%), and cancer (12.9%) accounted for the leading causes of death, with no differences between the two cohorts. On adjusted analysis, sac regression was associated with reduced mortality for the entire patient cohort (hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.18-0.76) and those who died before 5 years (HR, 0.37; 95% CI, 0.16-0.92). Meanwhile, congestive heart failure (HR, 6.02; 95% CI, 1.60-22.65) was associated with increased mortality for patients who did not survive beyond 5 years.

Conclusions

Patients who undergo PMEG for juxtarenal aneurysm are more likely to die from underlying medical comorbidities; aortic-related mortality accounts for <10% of total deaths. Patients who do not survive beyond 5 years are older and experience more perioperative complications, whereas patients who survive beyond 5 years are more likely to die on hospice, be lost to clinical follow-up, and decline a secondary intervention. These findings reflect the high degree of chronic disease burden for this patient population, even after successful treatment of their aortic pathology.