de intensivist

Teaser: Een geruptureerd aorta abdominalis aneurysma heeft mét behandeling een hoge mortaliteit en morbiditeit, waarbij leeftijd een ongunstige factor is. Of het behandelen van tachtigjarigen proportionele zorg is werd middels literatuuronderzoek onderzocht. Recent Nederlands onderzoek toonde een 1-jaarsoverleving van 50%, ongeacht endovasculair of open herstel, waarbij ruim 80% uiteindelijk terugkeerde naar de thuissituatie. Leeftijd alleen lijkt onvoldoende reden voor een behandelbeperking.

Background: Rupture of an abdominal aortic aneurysm (rAAA) has a fatal course. The only possibility for survival is surgical repair. Quick decision-making is of utmost importance. Regarding octogenarians, it remains unclear whether benefit of a medical intervention outweighs possible harm. Validated screening tools are unavailable for this age category. The aim of the present study is to give insight into survival chances and quality of life after surgical repair of rAAA in Dutch octogenarians.

Methods: The Pubmed database was searched for articles reporting outcome in octogenarians treated for rAAA. Because outcomes may depend on healthcare system and surgical development, we selected articles regarding Dutch patients, published in the last 5 years.

Results: 2 articles were selected. Figures of the Dutch Surgical Aneurysm Audit (DSAA) regarding 792 octogenarians undergoing surgical repair of rAAA, showed overall perioperative mortality of 42,8%, compared to 24,1% in non-octogenarians. However, in 34,6% and 22% of the octogenarians treated with endovascular and open repair respectively, the clinical course was uncomplicated. Quality of life of survivors was not reported. Loss of consciousness, cardiac and/or pulmonary comorbidity were associated with unfavorable outcome. (1)

Another Dutch retrospective, multicenter trial, including 157 octogenarians, showed a one-year survival rate of 50% after surgical repair. Quality of life remained unreported. However, it did show 86% respectively 80% of endovascular and open repair survivors were able to return to their home situation. High body mass index was associated with unfavorable outcome. Of the 47 untreated patients, 30 decided to forgo surgical treatment themselves. (2)

Conclusion: One fifth to one third of Dutch octogenarians with surgically managed rAAA have an uncomplicated clinical course. After 1 year, half of the population has survived of whom over 80% has returned to their home situation. In conclusion, age alone does not warrant palliative care. Factors to be taken into account in absence of validated screening tools, should include medical history and patient autonomy.