R.F. Stolk (1,2), H.J.P. Fokkenrood (3), J.E.M. Sybrandy (7), J-W. H.P. Lardenoije (4), J.E.M. Vernooij (5), J. van Vliet (2,5), H.J. van Leeuwen (2,6)
1 Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands Departments of 2 Intensive Care, 3 Surgery, 4 Vascular Surgery, 5 Anaesthesiology and 6 Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands 7 Department of Vascular Surgery, Gelderse Vallei Hospital, Ede, the Netherlands
R.F. Stolk - firstname.lastname@example.org
A case series of ruptured abdominal aortic aneurysm in octogenarians: what is the impact of frailty?
Ruptured abdominal aortic aneurysm is a life-threatening condition that occurs mainly in the elderly patient. The decision whether or not to operate on an elderly patient with a ruptured aneurysm is complicated and should include an evaluation of frailty. Three cases of octogenarians who presented with a ruptured abdominal aneurysm and had varying premorbid degrees of frailty are described, including the decision whether or not to operate on these patients, and their clinical course. A ruptured abdominal aneurysm in the over-80s remains a condition with high mortality and morbidity. However, an acceptable quality of life can be achieved with surgical intervention for selected patients. Currently, there is a lack of specific preoperative tools for prognostication in the elderly patient. Assessment of frailty can contribute to the decision whether surgery will be worthwhile. In addition, the ethics
surrounding decisions in the acutely and critically ill elderly patients are discussed.
A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition occurring mainly in the elderly. Previous guidelines recommended refraining from treating octogenarians surgically. Although the current guidelines are less firm in this advice, the decision whether or not to surgically treat octogenarians with a ruptured aneurysm remains complicated. A rapid preoperative evaluation of the patient’s premorbid condition is critical. In addition, the assessment of frailty can provide useful additional information for shared decision-making, as it can importantly impact outcome. In this case report, we describe the course of three octogenarians with varying degrees of frailty who were diagnosed with rAAA.
Patient A, an 86-year-old woman, was found confused at home and then collapsed. During transportation to the hospital, she was briefly resuscitated for bradycardia. In the emergency department, she was comatose (Glasgow Coma Score 3) and haemodynamically stable with an increased lactate (15 mmol/l). After resuscitation, she gradually regained consciousness. Her past medical history was significant for transcatheter aortic valve implantation and pacemaker placement. Until recently she was in good health and lived without medical or supportive care at home, compatible with a clinical frailty score (CFS) of ≤4. Her CT scan showed a ruptured abdominal aneurysm. The decision whether to operate or not was complex: on one hand, this elderly patient had a severe condition with signs of prolonged shock, on the other hand it was technically feasible to perform an endovascular aortic repair (EVAR) procedure. None of the specialists involved (emergency physician, intensivist, vascular surgeon) could provide a decisive argument whether or not to operate. In consultation with family, the consultants decided not to perform surgery. She received comfort care and died on the ward.
Patient B, a 92-year-old man, was taken to the emergency room after collapsing in the street. His history included COPD, hypertension and bronchial carcinoma which was curatively treated with a lobectomy in 1977. He only went outside with a mobility scooter, indicative of an advanced premorbid CFS of 5-7. His CT scan showed a 7 cm infrarenal aortic aneurysm with evidence of rupture. In consultation with the patient's family, and knowing the patient’s strong desire to be treated, the surgeon decided on an emergency EVAR, despite the high perioperative and postoperative risks. The operation was uneventful. An intensive care unit (ICU) admission followed postoperatively, during which the patient initially showed good recovery; he awoke one day after surgery. Thereafter he developed an ileus, aspiration pneumonia and delirium. Finally, extubation followed at five days. He was transferred to the medium care unit and the physicians and family agreed on a non-reintubation policy due to his poor condition. Ten days postoperatively he became acutely dyspnoeic and showed haemoptysis. Because of suspicion of pulmonary or high digestive tract bleeding, it was decided to start palliative care. The patient died the next day.
Patient C, an 85-year-old woman, developed sudden progressive pain in her lower abdomen and collapsed. Her past medical history was unremarkable, she was not taking any medication but smoked heavily. She lived independently with her husband, for whom she was an informal carer; there were no signs of increased frailty, compatible with a CFS of ≤3. She was hypotensive on arrival of the ambulance. In the emergency department she was awake but had persistent hypotension with signs of shock. An aneurysm with intra-abdominal fluid and a retroperitoneal haematoma, anatomically unsuitable for endovascular treatment, was seen on CT of the abdomen. After consultation with the patient and family, the vascular surgeon decided to perform an open surgical procedure. The operation was uneventful. After surgery, the patient was transferred to the ICU, was kept on mechanical ventilation and treated with noradrenaline for haemodynamic instability. Within 24 hours she could be extubated, showed no signs of neurological or
cognitive impairment and was transferred to the surgical ward. Thereafter, the patient developed pneumonia, cardiac failure and a delirium, for which she received pharmacological treatment. Twelve days postoperatively, she could be discharged home. Four months after discharge, she was doing well at home, easily tired but able to manage the household without support.
A ruptured abdominal aortic aneurysm is almost always fatal without intervention. Therefore, after the initial resuscitation, a surgical repair of the aorta should be performed urgently to increase the chance of survival. Two methods are available, open repair or EVAR. In an emergency setting, use of EVAR is increasing and in many centres even the preferred procedure. A meta-analysis showed no difference in mortality between the two modalities, although recent data from the Dutch Surgical Aneurysm Audit suggest that the introduction of EVAR has contributed to lower mortality after rAAA.
Survival in the elderly patient and long-term outcomes
Limited data exist regarding survival and long-term outcome in octogenarians after rAAA. For open repair, a 30-day hospital mortality of 59% was reported and for EVAR, a 30-day mortality of 41.9% was shown. Data from Rijnstate Hospital from 2013-2018 showed 18 octogenarians with an rAAA. Of these patients, 78% underwent EVAR, with a 30-day mortality of 44.4% and a mortality of 55.6% after 48 months (unpublished data). Incidentally, 89% of the rAAA patients who were not eligible for surgery had surpassed the age of 80. A recent systematic review found a one-year mortality in octogenarians similar to younger patients with ruptured aneurysms. Mortality was 38.6% for the octogenarians and 42.8% for the general rAAA population. Data on long-term quality of life are scarce. In one Dutch observational study, quality of life was assessed up to five years after rAAA repair. Remarkably, the quality of life in rAAA survivors was found to be comparable to age- and gender-matched elderly people. Importantly, the mean age of the participants was 74 years, and no subgroup analysis of octogenarians was performed. Furthermore, quality-of-life studies run the risk of bias as patients with poorer functional status are less likely to respond to questionnaires.
Treatment of severely ill elderly patients with rAAA can raise several ethical dilemmas. Most important is the question whether or not treatment will be worthwhile. After the initial insult caused by haemodynamic shock and subsequent surgery, virtually all patients have to be admitted to the ICU. If the patient survives, there is often a long-term period of rehabilitation and dependency on ambulant care, which can mean a significant decrease in quality of life. Not all patients are attributed with enough physiological reserve to have a meaningful chance of an acceptable outcome, and treatment could even be viewed as harmful. In addition, repair of rAAA is associated with a significant use of resources and high financial costs. While generally regarded as a ‘cost-effective’ treatment, these analyses have not been performed specifically for octogenarians, and increased use of long-term care facilities after treatment could drastically increase costs at a societal level. Therefore, it is crucial to assess the chances of a good outcome in the individual patient to determine whether surgery (EVAR or open repair) will be worthwhile.
Currently there is a lack of externally validated tools for octogenarians in the acute setting of an rAAA. Several risk scores have been developed to estimate postoperative risk for the general population, encompassing age, chronic renal failure, loss of consciousness, hypotension and anaemia. However, these scoring systems have insufficient clinical validity to establish treatment decisions. In the elective setting of an abdominal aneurysm, preoperative multidomain vulnerability assessment (also called frailty) is already used to assess surgical risk in the elderly. This is often discussed in multidisciplinary team (MDT) meetings, including a vascular surgeon, geriatrician, anaesthesiologist and cardiologist. Older adults classified as frail have a higher risk of poor outcomes after elective aortic surgery. A quick assessment of frailty is to ask whether the patient is still able to climb two flights of stairs. Another example of frailty assessment is the use of the clinical frailty scale (CFS), a visual tool with which frailty can be assessed easily and quickly (figure 1). On this scale, patients can be divided into nine categories. In category 1-3 patients are classified as non-frail, category 4 counts as pre-frail and in category 5-9 patients are classified as frail. In intensive care medicine, assessment of frailty is increasingly incorporated in the consideration whether an ICU admission is suitable in older, critically ill patients. Furthermore, observational data support the use of the CFS system. In 5021 ICU patients aged 80 years or older, frailty was assessed using the CFS, and patients were classified as frail when a score >5 was found. In this cohort a near linear correlation between increased frailty and 30-day mortality was observed in acutely admitted medical patients. In addition, the mortality in patients classified as frail was 41% compared with 24% in fit patients and increased frailty was found to be an independent risk factor for mortality.
Unfortunately, no separate analysis was performed for the subgroup of emergency surgery patients. We did find two reports evaluating frailty in patients presenting with rAAA. In the first, the authors developed their own risk score, consisting of an Activities of Daily Living (ADL) scale, a comorbidity index, number of drugs used before admission, visual/hearing impairment, haemoglobin levels and statin use. Combined, this score had a ROC value (sensitivity / 1-specificity) of 0.84 for one-year mortality. However, the need for ADL care after hospital discharge was less predictable with this score. In addition, this score requires a relatively comprehensive preoperative assessment, which is not always possible in the acute setting of rAAA. A modified frailty index (mFI) was calculated using eleven variables in another small retrospective study. The variables are, for example, diabetes mellitus, heart failure and reliance upon care. Unfortunately, frailty assessment based on mFI could not predict 30-day mortality in this cohort. Future research will have to show whether the simple clinical frailty scale - which, given its easy and rapid application can also have a place in acute settings - is a valuable predictive instrument for octogenarians presenting with rAAA. Even in the absence of conclusive evidence, it is plausible that assessing frailty in rAAA can be of added value to preoperatively evaluating the harm-benefit ratio of surgical intervention. In addition, we argue that the type of operation (EVAR or open repair) should also be considered. Since EVAR is less invasive and usually has less severe postoperative complications, a higher degree of frailty might be accepted when deciding on surgery or not.
A relatively new modality to reach a shared decision with multiple specialties is an ad hoc MDT meeting. This is a short, small panel with 3-6 care providers and is already installed for elderly patients presenting with an acute abdomen in the RadboudUMC. Based on the patient’s frailty, values and goals, a fitted treatment plan is determined. Of course, the acute setting of rAAA leaves no time for extensive consultation. Additional input from an anaesthesiologist and geriatrician will be valuable for an optimised treatment plan beforehand. In addition, intensivists, as consultants for critically ill patients, should be present during the MDT meeting.
According to Beauchamp and Childress clinical ethics is based on four principles: Respect for autonomy, beneficence, non-aleficence and justice. Their approach is also known as ‘principalism’ since the four principles should be weighed against each other. Care providers try to help patients and inevitably risk harming them. Healthcare workers, therefore, have to consider the principles of beneficence and non-maleficence together and aim at producing net benefit over harm. The autonomy of the patient should be respected and resources should be divided justly and fairly. To be able to decide which principle should prevail, it is important to listen carefully to patients and their family. For patient A the prevailing principle was the idea that the harm-benefit ratio would be negative. For patient B, respect for the autonomy of the patient prevailed but in hindsight the net benefit was low. For patient C respect for autonomy and expected positive benefit made the team decide upon an open repair of the aneurysm. There is no evidence that the principle of justice prevailed in any of the patients, but it is conceivable that costs were weighed in the decisions taken.
Retrospect and conclusions
In the patients from this case series, frailty assessment or an ad hoc MDT meeting were not explicitly incorporated in the decision to operate or provide comfort care. In retrospect Patient A had a good pre-operative condition and no indication of advanced frailty. This would have improved her chances after surgery, especially considering EVAR was possible. Although this might have been offset by her prolonged shock at presentation. Patient B had increased preoperative frailty due to his comorbidities and therefore a worse chance of good outcome, despite surgical intervention. The low premorbid frailty score of patient C improved her chances of good postoperative recovery, even after open repair. Formal assessment of frailty, perhaps incorporated in an ad hoc MDT meeting, would have facilitated decision-making for the care providers for these patients and might have altered the shared decision-making process regarding treatment options with the patients and their families.
In conclusion, ruptured abdominal aneurysm in octogenarians remains a condition with high postoperative mortality. Limited data suggest that acceptable mortality rates in the perioperative period are achievable although data on long-term survival and quality of life in these patients are scarce. This indicates that treatment should not be withheld based on age alone. However, preoperative selection of patients who would benefit from surgery is complex and there is a lack of clinically valid tools for estimating prognosis in elderly patients with rAAA. Lower frailty scores have predictive value for critically ill older patients in general, but it is unknown whether these are important in the overwhelming physiological disturbance caused by rAAA. Further research is highly warranted to validate frailty assessment. Additionally, incorporation of this assessment in an ad hoc MDT meeting including the vascular surgeon, anaesthesiologist, intensivist and geriatrician might prove helpful for evaluation of the harm benefit ratio of the surgery for the patient.
We thank Tijmen Nederstigt and Roelie Tijssen for their contributions to this manuscript.
All authors declare no conflict of interest. No funding or financial support was received.
Informed consent was obtained from the patient/the patient’s legal representative for the publication of this case report.
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