Eur J Vasc Endovasc Surg (2020) 59, 219e225

Impact of Endovascular Repair on the Outcomes of Octogenarians with

Ruptured Abdominal Aortic Aneurysms: A Nationwide Japanese Study
Tetsuo Yamaguchi a,b,*, Michikazu Nakai c, Yoko Sumita c, Kunihiro Nishimura c, Toshiyuki Nagai d, Toshihisa Anzai d,
Yasushi Sakata e, Hitoshi Ogino f
a
Department of Cardiovascular Centre, Toranomon Hospital, Tokyo, Japan
b
Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
c
National Cerebral and Cardiovascular Centre, Osaka, Japan
d
Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University, Sapporo, Japan
e
Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
f
Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan

WHAT THIS PAPER ADDS

This nationwide claim based data analysis demonstrated that open surgical repair was less probably to be
performed for elderly patients (aged
80 y) with ruptured abdominal aortic aneurysm (rAAA), but endovascular
repair (EVAR) was performed similarly. Although old age was an independent predictor of in hospital death for
the overall cohort, a small subgroup of elderly patients currently selected for EVAR enjoyed favourable out-
comes. Although EVAR for rAAA is not recommended as a first line treatment in current Japanese guidelines, its
further implementation, especially in elderly patients with suitable anatomy, may be justified.

Objective: This study aimed to clarify the impact of endovascular aneurysm repair (EVAR) on clinical outcomes in
Japanese patients of advanced age with ruptured abdominal aortic aneurysm (rAAA).
Methods: This was a national registry based retrospective comparative study, using data from the Japanese
Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination (JROAD-DPC), a nationwide
claim based database from more than 600 hospitals. Patients admitted with rAAA between April 1, 2012, and
March 31, 2015 were included in the study. Patient characteristics, management, and outcomes were
compared between the elderly (aged
80 y) and the less old. The primary endpoint was in hospital
mortality; the secondary endpoint was the functional status at discharge.
Results: Of 3 969 eligible patients, 49.9% were categorised as elderly. Elderly patients had a higher prevalence of
female gender (41.8% vs. 17.0%, p < .001) and disturbance of consciousness on admission (28.6% vs. 20.7%,
p < .001). They were less likely to undergo open surgical repair (31.6% vs. 56.7%, p < .001), although EVAR
was performed similarly in both groups (13.7% vs. 14.8%, p ¼ .33). The unadjusted mortality rate (61.8% vs.
37.6%, p < .001) and mean Barthel index at discharge (73.0 vs. 91.8, p < .001) were statistically significantly
worse in the elderly. Multilevel mixed effect logistic regression analyses showed that old age was detected as
an independent predictor of in hospital death (odds ratio 2.75; 95% confidence interval, 2.39e3.17;
p < .001). However, for patients who received EVAR, old age was not statistically significant (odds ratio 1.13;
95% confidence interval, 0.77e1.66; p ¼ .53).
Conclusion: Elderly patients with rAAA were less likely to be offered open surgical repair, and the mortality
among those who received surgery was high. However, for the small subgroup of elderly patients currently
selected for EVAR there was a favourable outcome. The further implementation of EVAR for rAAA in Japan,
especially for elderly patients with suitable anatomy, may be justified.

Keywords: Elderly patients, Endovascular aneurysm repair, JROAD, Ruptured abdominal aortic aneurysms
Article history: Received 28 March 2019, Accepted 14 July 2019, Available online 13 December 2019
Ó 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Cardiovascular Centre, Toranomon
Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105e8470, Japan.
E-mail address: tetsuo5672@yahoo.co.jp (Tetsuo Yamaguchi).
1078-5884/Ó 2019 European Society for Vascular Surgery. Published by
Elsevier B.V. All rights reserved.
https://doi.org/10.1016/j.ejvs.2019.07.016
INTRODUCTION
A ruptured abdominal aortic aneurysm (rAAA) still carries a
high mortality.1e3 Previous studies4e6 have reported that
only 25e29% of elderly patients (aged
80 years) were
offered open surgical repair or endovascular repair (EVAR)
for rAAA. Indeed, advanced age is considered a major risk
220
factor for early post-operative death.7,8 However, EVAR is
potentially suitable and beneficial for elderly patients
because of its low invasiveness. Indeed, lower peri-
operative morbidity rates and similar in hospital mortality
rates with EVAR rather than open surgery for rAAA have
been shown in previous studies.9e11 EVAR for rAAA and
suitable anatomy is recommended as the first line option in
the European Society for Vascular Surgery (ESVS)
guidelines.12
According to Japanese guidelines,13 EVAR is not recom-
mended for emergency surgery (including rupture) and may
be considered only in cases of rupture with stable haemo-
dynamics. Furthermore, few data exist concerning the
impact of EVAR on the clinical outcomes in Japanese pa-
tients of advanced age with rAAA.
The present study compared patient characteristics,
management (EVAR, open surgical repair, or conservative
treatment) and the outcomes of elderly (aged
80 y) and
younger patients with rAAA using the Japanese Registry Of
All cardiac and vascular Diseases-Diagnostic Procedure
Combination (JROAD-DPC) database. The primary endpoint
was in hospital mortality; the secondary endpoint was the
functional status at discharge.
METHODS
Database explanation
The JROAD-DPC is a nationwide claim based database based
on data from the Japanese DPC/Per Diem Payment System
in hospitals participating in the JROAD survey.14 The JROAD
database has been described in detail previously.15e17 In
brief, all teaching hospitals with cardiovascular beds
participate in the JROAD. Hospital doctors must record all
admission and discharge data for each patient and are
obliged to guarantee their accuracy. This study analysed the
JROAD-DPC data from 610 hospitals in 2012, 637 hospitals
in 2013, and 742 hospitals in 2014 from all regions in Japan
between April 1, 2012, and March 31, 2015.
Study participants
Patients hospitalised for ruptured aortic aneurysms were
identified primarily based on the International Classification
of Diseases (ICD)-10 diagnosis codes (ruptured thoracic
aortic aneurysm: I711; ruptured abdominal aortic aneu-
rysm: I713; and ruptured thoracic-abdominal aortic aneu-
rysm: I715). In the JROAD-DPC database, aortic dissections
and non-ruptured aortic aneurysms are clearly distin-
guished from ruptured aortic aneurysms. Diagnosis and
comorbidities were primarily defined based on the ICD-10
codes, but they were also checked by the physicians to
examine whether they matched the treatments performed
for each patient and to determine whether these were
compatible with the code data.14 Additionally, the diagnosis
written in Japanese in the DPC database was used to in-
crease the accuracy of the diagnosis.17 Patients admitted to
hospitals that did not perform any cardiovascular
Tetsuo Yamaguchi et al.
procedures including EVAR, during this period were
excluded, because patients transferred to such hospitals
might be dead on arrival or unable to undergo surgical
treatment. In addition, patients admitted to non-teaching
hospitals were excluded to standardise the quality of
treatment and data because response rates of teaching
hospitals in the JROAD survey were 100%.15 Patients who
underwent both EVAR and open surgery were excluded
because it could not be determined whether these were
intra-operative conversions or planned staged procedures.
The cut off age (80 years) was determined by referencing
previous studies4e6 and ESVS guidelines.12
The following clinical data were extracted from the
database: patient background characteristics; comorbid-
ities; hospital information including bed number, number of
aortic procedures per year, and number of cardiovascular
surgeons; treatments including operations, drugs, and
additional treatments, such as transfusions and vasopres-
sors; in hospital death; consciousness level both on
admission and discharge according to the Japan Coma
Scale;18,19 and Barthel index (BI) at discharge. Disturbance
of consciousness (DOC) was defined as a Japan Coma Scale
score of 100e300, as described in a previous report.18 A
BI
75 was considered to be a favourable functional status
at discharge, according to a previous report.20 Emergency
operation was defined as open surgery and/or EVAR per-
formed within one day of admission.
Ethical consideration
This research plan was designed by the authors and
approved by the Institutional Review Board of the Japanese
Red Cross Musashino Hospital (approval number: 367). The
requirement for informed consent was waived because of
the anonymised data. All participants were notified through
homepages or posters at each hospital and were told that
they were free to opt out of participation at any time. The
study complied with the Declaration of Helsinki and Japa-
nese Ethical Guideline for Medical and Health Research
involving Human Subjects.
Statistical analyses
Data were expressed as the mean and standard deviation
for normally distributed variables and as median with the
interquartile range for non-normally distributed data.
Continuous variables were compared by Student’s t test or
the ManneWhitney U test as appropriate. Categorical data
were expressed as numbers and percentages and compared
by the chi-square test or Fisher’s exact test. Multilevel
mixed effect logistic regression analyses using institutional
codes as random intercepts were performed to calculate
the odds ratios (ORs) and 95% confidence intervals (CIs) for
the in hospital death of the elderly patient group compared
with the younger patients, adjusted for gender, history of
heart failure, chronic obstructive pulmonary disease, dia-
betes mellitus, cerebrovascular disease, renal failure on
admission, DOC on admission, the need for vasopressor
EVAR for Elderly Japanese rAAA Patients
administration in the emergency department, hospital bed
number, and number of cardiovascular surgeons. These
variables were selected according to their clinical impor-
tance based on previous studies.8,21e25 Discrimination of
the selected variables was confirmed by a receiver operator
characteristics (ROC) analysis. Furthermore, as sensitivity
analyses, additional logistic regression analyses were per-
formed using another cut off age made by the ROC analysis
for in hospital death. Statistical analyses were performed by
a physician (Yamaguchi T) and a statistician (Nakai M) using
the Stata software program, ver. 14.2 (StataCorp, College
Station, TX, USA). A two sided p value < .05 was considered
statistically significant.
RESULTS
Patient characteristics
A total of 8 032 patients (aged
20 years) admitted with a
primary diagnosis of ruptured aortic aneurysm from April 1,
2012, to March 31, 2015, were extracted from the database.
The patient selection flowchart is shown in Fig. 1. A total of
7 086 patients from 564 hospitals were identified and 3 991
had rAAA. After excluding non-eligible patients, 1 982 pa-
tients (49.9%) were elderly (aged
80 years). The baseline
characteristics of the patients stratified by age group are
shown in Table 1. Female patients were dominant in the
elderly group compared with the young group (41.8% vs.
17.0%, p < .001). The elderly showed a statistically signifi-
cantly lower body mass index (21.2 vs. 23.3, p < .001) and a
Patients with ruptured aortic aneurysms (n=8 302)
Patients asmitted to hospitals not performing any cardiovascular operations (n=1 026)
Patients admitted to non-teaching hospitals (n=190)
Patients from 564 hospitals (n = 7 086)
Abdominal aneurysm (n=3 991)
Patients who underwent both EVAR and open surgery (n=20)
Study population (n=3 969)
Octogenarians (n=1 982) Younger group (n=1 987)
Figure 1. Study flow chart. EVAR ¼ endovascular aneurysm repair.
221
higher prevalence of DOC on admission than younger pa-
tients (28.6% vs. 20.7%, p < .001). Elderly patients were
transferred to hospitals with fewer cardiovascular surgeons
and annual aortic procedures than younger patients. The
baseline characteristics of the patients stratified by age
group and treatments performed are shown in Table S1.
Overall, patients who were managed medically were older
with a lower body mass index and markedly higher preva-
lence of DOC on arrival, and they were transferred to
hospitals with fewer cardiovascular surgeons and annual
aortic procedures in both groups.
Clinical outcomes
Fig. 2 shows the key outcomes of this study, and Table 2
shows the treatments and outcomes comparing the
elderly and younger patients. A small number of patients
(elderly: 2.5% [49/1 982], younger: 3.5% [69/1 987]) received
delayed (more than one day after arrival) operative treat-
ment. Elderly patients were less likely to undergo emer-
gency operation (42.8% vs. 68.0%, p < .001) and open
surgical repair (31.6% vs. 56.7%, p < .001) than younger
patients. However, EVAR was performed at a similar rate in
both groups (13.7% vs. 14.8%, p ¼ .33), and the ratio of
EVAR to open surgery was much higher in the elderly pa-
tients than in the younger patients (43.5% vs. 26.1%,
p < .001). The unadjusted in hospital mortality rate of
elderly patients was statistically significantly worse than
that in the younger patients (61.8% vs. 37.6%, p < .001).
Thoracic aneurysm (n=2 700)
Thoraco-abdominal aneurysm (n=395)
Missing data for age (n=2)
222 Tetsuo Yamaguchi et al.

2.87; p < .001). This trend was similar when analyses were
Table 1. Baseline characteristics of 3 969 Japanese patients
with ruptured abdominal aortic aneurysm, stratified by age
performed for the patients receiving open surgery and
group medical management. However, only for patients who un-
derwent EVAR, was old age not statistically significant
Parameter Octogenarians Younger p (OR 1.13; 95% CI 0.77e1.66; p ¼ .53). Similar results
(n [ 1982) patients were confirmed when analyses were performed at another
(n [ 1987)
cut off age (76 years) determined by the ROC analysis
Age e y 86.2  4.3 69.7  7.3 <.001 (Table 3).
Female gender 829 (41.8) 337 (17.0) <.001
Body mass index e kg/m2 21.2  4.6 23.3  4.7 <.001
Medical history DISCUSSION
Heart failure 181 (9.1) 227 (11.4) .017
Myocardial infarction 55 (2.8) 63 (3.2) .46 This is the largest population based study to compare the
Cerebrovascular disease 145 (7.3) 133 (6.7) .44 characteristics, management, and outcomes of elderly Jap-
COPD 69 (3.5) 69 (3.5) .99 anese patients with rAAA with those of younger patients.
Diabetes mellitus 133 (6.7) 202 (10.2) <.001
Renal failure on 156 (7.9) 167 (8.4) .54
The main finding was that although elderly patients had a
admission worse overall mortality rate and functional status at
Need for additional treatment discharge than younger patients, those who received EVAR
Transfusion 1080 (54.5) 1492 (75.1) <.001 showed a comparable outcome to younger patients.
Vasopressor 982 (49.5) 1373 (69.1) <.001 Previous studies have shown a low rate of emergency
Disturbance of 567 (28.6) 412 (20.7) <.001
consciousness on
surgery (25e29%) for rAAA in elderly patients.4e6 A similar
arrival trend was noted in the present study, where statistically
Institutional parameters significantly fewer elderly patients with rAAA underwent
Number of beds .88 emergency operations than younger patients (42.8% vs.
(missing n ¼ 1) 68.0%, p < .001). This may be because of their older age and
20e100 beds 20 (1.0) 18 (0.9)
100e200 beds 39 (2.0) 44 (2.2)
more severe clinical presentation, such as a higher rate of
200e300 beds 114 (5.8) 125 (6.3) DOC on arrival, than in younger patients. Older age can be
300e450 beds 439 (22.1) 417 (21.0) related to delayed or missed diagnosis of aortic aneurysms,
450e750 beds 993 (50.1) 991 (49.9) which can result in a more severe clinical presentation.
> 750 beds 377 (19.0) 391 (19.7) Previous studies have shown that although elderly patients
Number of 5.0 (3.0e7.0) 5.0 (3.0e8.0) <.001
cardiovascular
have a significantly higher risk of post-operative death
surgeons compared with younger patients, open surgical repair has
Number of certified 6.0 (4.0e10.0) 7.0 (4.0e11.0) .002 been life saving in 33% of elderly patients,26 and the mor-
cardiologists tality rate of 59% in the pooled analysis of 36 studies was
Annual aortic 116.2  89.2 124.3  89.7 .005 deemed acceptable.27 In the present study, the mortality rate
procedures
Annual endovascular 34.1  33.3 37.6  34.0 <.001
of elderly patients receiving open surgery was also accept-
aneurysm repair able at 28.8%, which was similar to the 30 day mortality of
Data are expressed as numbers (%), means  standard deviations, or 26.7% from a tertiary referral centre.28 In addition, the in-
medians (interquartile range). A disturbance of consciousness was termediate survival rates (at one, two and three years after
defined as a Japan Coma Scale of from 100 to 300. surgery) of elderly patients with rAAA are also reported to be
COPD ¼ chronic obstructive pulmonary disease. acceptable (82%, 76%, and 69%, respectively).29 For these
reasons, the ESVS guideline recommends that advanced age
Similarly, patients who were discharged with a favourable alone should not prevent surgery for rAAA.
functional status (BI
75) were statistically significantly less Because elderly patients have more comorbidities than
frequent among elderly patients than among younger pa- younger patients, EVAR may be more beneficial for the
tients (55.3% vs. 85.0%, p < .001). Table S2 shows the former population because of its low invasiveness. In the
outcomes by each treatment comparing the elderly and the present study, the ratio of EVAR to open surgery was much
young. Unadjusted mortality was higher in the elderly pa- higher in the elderly patients than in the younger ones
tients for all types of management than in younger patients. (43.5% vs. 26.1%, p < .001). Furthermore, a multivariable
The mortality rate with conservative therapy in this data- analysis showed that elderly patients receiving EVAR
base was 89.9% in the elderly patients and 82.2% in the enjoyed comparable outcomes to younger patients. Similar
young patients. results were reported in a previous study,30 showing that
Table 3 shows the results of multilevel mixed effect lo- the peri-operative mortality in elderly patients was higher
gistic regression analyses for in hospital death. In the than that in younger patients, although not to a statistically
multivariable analyses, the area under the curve (AUC) of significant degree when only EVAR was performed. Previous
the selected variables in the ROC curve was 0.85 (95% CI studies have shown that, with the advancements in
0.84e0.86). Old age (cut off: 80 years) was detected as an endografts, nearly 80% of patients can be treated by
independent predictor of in hospital death in the overall EVAR,31 and three quarters of patients with rAAA can be
cohort after adjusting for covariates (OR 2.43; 95% CI 2.06e considered for EVAR, regardless of their haemodynamic
EVAR for Elderly Japanese rAAA Patients 223

status.32 For these reasons, EVAR for rAAA, especially in

Proportion of favourable in hospital outcome – %

p <.001 elderly patients, can be performed widely in Japan if the

100

85.0 anatomy is suitable.

p < .001
80 There are several limitations with the present study.
p < .001
First, because this study was a retrospective analysis of
61.8
60 56.7 55.3 claim based data, there may be risks of systemic or non-
systemic coding errors or insufficient data collection.
40 37.6 However, the validity of the DPC database is generally
31.6 p = .33
high, especially for primary diagnoses and procedure re-
20 13.7 14.8 cords.33 In addition, because these coding errors are likely
to affect all comparison groups equally, comparative
0 studies may be useful. Although attempts were made to
Open surgical Endovascular In-hospital Favourable functional
repair repair death status at discharge adjust for confounders as much as possible using clinically
Octogenarians Younger important predictors and the discrimination power of the
Figure 2. A comparison of key in hospital outcomes between selected variables was relatively high (AUC: 0.85), unad-
octogenarians and younger patients. A favourable functional sta- justed confounding factors may have existed. Second, the
tus at discharge was defined as a Barthel index
75. Results DPC database does not include detailed data on the aortic
from a population based analysis of 3 969 Japanese patients with
ruptured abdominal aortic aneurysm.
anatomy, such as aneurysm neck length, Fitzgerald classi-
fication, type of stent graft implanted, duration from onset
to arrival, or blood pressure at arrival, blood pressure
management, and pre-operative volume resuscitation.

Table 2. Treatments and clinical outcomes of 3969 Japanese patients with ruptured abdominal aortic aneurysm, stratified by age
group

Parameter Octogenarians Younger patients p

(n [ 1982) (n [ 1987)
Management
Medical management 1084 (54.7) 567 (28.5) <.001
Emergency repair < 24 h 849 (42.8) 1351 (68.0) <.001
Delayed repair 49 (2.5) 69 (3.5) .064
Open surgical repair 626 (31.6) 1126 (56.7) <.001
Endovascular repair 272 (13.7) 294 (14.8) .33
Endovascular repair/open surgical repair 272/626 (43.4) 294/1126 (26.1) <.001
Clinical outcomes
In hospital death 1225 (61.8) 748 (37.6) <.001
Barthel index at discharge 73.0 (30.5) 91.8 (19.6) <.001
Favourable functional status at discharge 419/757 (55.4) 1053/1239 (85.0) <.001
Other outcomes
Length of hospitalisation e d 24 (16e37) 22 (15e34) .011
Data are expressed as numbers (%), or medians (interquartile range). Emergency operation was defined as open surgery and/or endovascular
aneurysm repair performed within one day of admission. A favourable functional status was defined as a Barthel index at discharge
75.

Table 3. Multivariable logistic regression analyses for risk of in hospital death stratified by management approach

Age group Overall in hospital In hospital mortality after In hospital mortality In hospital mortality after
mortality* open surgical repair* after endovascular medical treatment*
repair*
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p
Younger 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Octogenarians 2.43 2.06e2.87 <.001 1.88 1.45e2.44 <.001 1.13 0.77e1.66 .53 2.53 1.71e3.72 <.001
Elderly (cut off: 76) 2.40 2.03e2.85 <.001 1.93 1.49e2.49 <.001 1.26 0.84e1.89 .26 2.72 1.79e4.13 <.001
Results from a population based analysis of 3969 Japanese patients with ruptured abdominal aortic aneurysm. OR ¼ odds ratio; CI ¼ confidence
interval.
*
Adjusted for gender, history of heart failure, chronic obstructive pulmonary disease, diabetes mellitus, cerebrovascular disease, renal failure on
admission, disturbance of consciousness on admission, the need for vasopressor administration in the emergency department, hospital bed
number, and number of cardiovascular surgeons.
224
However, renal failure at admission, DOC at admission, and
the need for vasopressor administration in the emergency
department in the multivariable analyses were used as
surrogates for unstable haemodynamics and a low blood
pressure on admission. Third, it was not possible to
determine indications for treatment, so the possibility of
selection bias cannot be ruled out. However, claim based
databases have strengths of including treatments per-
formed by large numbers of healthcare providers and
medical specialties, no selection bias by physicians, and
high external validity, as no reimbursement is received
without the submission of data to the funder.34 Fourth, the
non-surgery rate was very high in this study. Because some
of the hospitals participating in this study are not the large
operating centres, patients managed medically may
include those who arrived at the hospital almost dead, and
those who could not undergo surgery because of severe
complications. A previous meta-analysis35 showed that the
non-surgery rate for rAAA was nearly 40%, which was
similar to that noted in the present study. Considering
publication bias, the non-surgery rate of non-referral
centres may be higher than 40%. Therefore, it is consid-
ered that this high non-surgery rate reflects the real world
situation in Japan. The mortality rates of patients who
were managed medically in the same meta-analysis35
range between 75% and 90%, which was also similar to
the present results. Finally, it was only possible to evaluate
the in hospital outcomes and not the longer term
outcomes.
CONCLUSIONS
The present analysis of a nationwide administrative data-
base demonstrated that elderly patients with rAAA had
worse in hospital mortality and functional status at
discharge than young patients. Elderly patients with rAAA
were less likely to be offered open surgical repair, and the
mortality among those who received surgery was high.
However, the small subgroup of elderly patients currently
selected for EVAR showed a favourable outcome. Further
implementation of EVAR for rAAA in Japan, especially for
elderly patients with suitable anatomy, may be justified.
CONFLICT OF INTEREST
None.
FUNDING
None.
APPENDIX A. SUPPLEMENTARY DATA
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ejvs.2019.07.016.
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