Long-term survival outcomes following fenestrated endovascular aortic repair: applying population-based life expectancies to contextualize postoperative survival.

BACKGROUND: With demographic changes and the increasing suitability of even older and frail patients for complex aortic aneurysm repair, clinical decision-making has become increasingly complex. A critical factor in deciding whether to proceed with surgery is the estimated life expectancy, a prediction that is inherently challenging. Understanding survival outcomes, contextualized within a population-based framework, is therefore critical. METHODS: This retrospective study analysed patients undergoing fenestrated endovascular aortic repair (FEVAR) between 2013 and 2023. Patient and mortality data were sourced from medical records and the Austrian National Death Registry. Estimated life expectancy was calculated using national life tables, fitted with spline functions to provide age- and sex-specific estimates. Observed survival was illustrated using Kaplan-Meier curves, and adjusted analyses were performed using Cox regression models. Observed survival was then contextualized based on the estimated life expectancy, and two potential survival scenarios were investigated. RESULTS: Of 293 included patients, 127 (43.3%) died, predominantly from cardiovascular events. The observed median age of survival was 83.6 years versus a population-based expectancy of 86.5 years. Patients aged < 75 years had higher post-procedural survival than patients aged > 75 years, although the confidence intervals overlapped for the first 1700 days, indicating no significant differences in mid-term survival. Women experienced higher early mortality than men (14.3% versus 6.4% at 150 days), with no significant long-term sex differences. Potential survival scenarios demonstrated close alignment between observed survival and a favourable scenario, where censored patients were assumed to live to their estimated life expectancy. Adjusted analyses identified age and American Society of Anesthesiologists grade as significant predictors of mortality. CONCLUSION: Survival outcomes aligning with population-based life expectancy estimates can be achieved in patients undergoing FEVAR when cases are well selected. However, cardiovascular mortality remains a significant burden. Population estimates can provide some guidance but are of limited usefulness for individual patient predictions, especially for younger patients, where the overall prognosis may be worse than anticipated based on age alone.