Methods

We investigated whether survival differences existed between immediate open repair and surveillance depending on age in patients with small AAAs, overall and then by gender, using the original patient data from the United Kingdom Small Aneurysm Trial (UKSAT) and the Aneurysm Detection and Management (ADAM) trial.

UKSAT and ADAM assigned patients to the immediate open repair and surveillance arms in a 1:1 ratio, stratified by medical center. Patients randomly assigned to the immediate open repair group in either trial received standard open repair no later than 6 weeks after randomization. Likewise, patients assigned to surveillance were followed at similar intervals (at minimum, once every 6 months), and the same criteria for selective repair were applied—(1) the aneurysm reached 5.5 cm, (2) the aneurysm enlarged by a minimum of 0.7 cm in 6 months or 1.0 cm in 1 year, or (3) the aneurysm became symptomatic—and those selective repairs were performed <6 weeks after any of those criteria were met.

All men and women enrolled and randomized to either immediate open surgery or ultrasound surveillance and selective surgery in either ADAM (August 1, 1992, to July 31, 2000) or UKSAT (September 1, 1991, to July 31, 1998) were included in this study, for a combined study cohort of 2,226 ( Table 1 ). We excluded 88 patients from the adjusted analysis because data on ≥1 of the covariates listed below (and in Table 1 ) were missing. The final study cohort, therefore, included 2,138 patients. ADAM and UKSAT applied comparable inclusion and exclusion criteria. The 2 trials enrolled patients with small (4.0 to 5.4 cm), nontender asymptomatic AAAs distal to the renal arteries considered fit for immediate open repair, and excluded patients who were considered unfit for immediate open repair, had symptoms associated with the aneurysms, were unable to attend the follow-up visit, or were unable to give informed consent. The ADAM trial also excluded patients who had undergone major surgical procedures or angioplasty ≤3 months before enrollment, had myocardial infarctions ≤6 months before enrollment, or were expected to survive <5 years because of invasive cancer or other life-threatening disease. Age inclusion criteria differed between the trials (50 to 79 years for ADAM, 60 to 76 years for UKSAT) ; however, most ADAM participants (88%) fell within the same age range as those of UKSAT. More than 92% of the combined study cohort were 60 to 76 years of age.

Table 1

Characteristics of the study cohort: 2,226 patients randomized to either immediate open repair or surveillance in the Aneurysm Detection and Management (ADAM) and United Kingdom Small Aneurysm Trial (UKSAT)

Variable	Surveillance n = 1094						Open Repair n = 1132
	ADAM (n = 567)			UKSAT (n = 527)			ADAM (n = 569)			UKSAT (n = 563)
	Median	IQR	%	Median	IQR	%	Median	IQR	%	Median	IQR	%
Characteristic
White	—	—	93.5%	—	—	NR	—	—	94.5%	—	—	NR
Black	—	—	4.4%	—	—	NR	—	—	2.3%	—	—	NR
Other/Unknown	—	—	2.1%	—	—	NR	—	—	3.2%	—	—	NR
Male	—	—	99.6%	—	—	82.3%	—	—	98.8%	—	—	83.1%
Female	—	—	0.4%	—	—	17.7%	—	—	1.2%	—	—	16.9%
Age (years)	68.0	63, 72	—	69.4	66, 73	—	69.0	64, 73	—	69.7	66, 73	—
Height (cm)	177.8	173, 183	—	172.0	165, 177	—	177.8	170, 182	—	172.0	167, 177	—
Weight (kg)	86.2	76, 96	—	73.0	65, 82	—	85.7	77, 96	—	73.9	65, 80	—
BSA (Dubois Method) (m 2 )	2.0	1.9, 2.2	—	1.8	1.7, 2.0	—	2.0	1.9, 2.1	—	1.9	1.8, 2.0	—
Family History of AAA	—	—	11.6%	—	—	6.0%	—	—	14.2%	—	—	5.3%
Smoker	—	—		—	—		—	—		—	—
Never	—	—	5.6%	—	—	5.9%	—	—	5.3%	—	—	5.7%
Previous	—	—	59.3%	—	—	59.6%	—	—	55.4%	—	—	54.7%
Current	—	—	35.1%	—	—	34.5%	—	—	39.4%	—	—	39.4%
Hypertension	—	—	54.9%	—	—	39.7%	—	—	57.8%	—	—	39.0%
Chronic lung disease	—	—	21.2%	—	—	10.3%	—	—	23.0%	—	—	9.0%
Stroke	—	—	12.7%	—	—	2.1%	—	—	12.0%	—	—	4.3%
Diabetes mellitus	—	—	9.9%	—	—	3.0%	—	—	9.7%	—	—	2.5%
Embolism	—	—	1.8%	—	—	0.8%	—	—	0.9%	—	—	0.7%
Ischemic Heart Disease	—	—	50.3%	—	—	29.8%	—	—	52.7%	—	—	29.5%
History of MI	—	—	26.9%	—	—	19.9%	—	—	30.4%	—	—	16.0%
History of Cancer	—	—	17.1%	—	—	5.7%	—	—	15.3%	—	—	6.6%
DVT	—	—	6.4%	—	—	—	—	—	5.6%	—	—	—
AAA diameter (cm)	4.7	4.3, 5.0	—	4.5	4.3, 4.9	—	4.7	4.3, 5.1	—	4.6	4.3, 5.0	—
Cholesterol (mg/dL)
Total	212.0	185, 235	—	235.5	208, 266	—	212.0	183, 236	—	235.5	204, 262	—
HDL	37.0	32, 45	—	41.9	33, 57	—	36.0	31, 45	—	40.5	34, 49	—
LDL	136.0	115, 160	—	154.9	127, 185	—	136.0	115, 163	—	151.5	126, 180	—
Creatinine (mg/dL)	1.1	1.0, 1.3	—	1.2	1.0, 1.3	—	1.1	1.0, 1.3	—	1.2	1.0, 1.3	—
Forced expiratory volume in one second (L)	2.6	2.1, 2.9	—	2.1	1.6, 2.6	—	2.5	2.1, 2.9	—	2.2	1.7, 2.7	—
Previous CABG/PCI	—	—	24.3%	—	—	5.9%	—	—	24.8%	—	—	5.2%
Aspirin	—	—	48.7%	—	—	28.8%	—	—	47.8%	—	—	13.0%
Beta-blocker	—	—	14.8%	—	—	15.6%	—	—	16.9%	—	—	14.7%
Anti-arrhythmic	—	—	12.5%	—	—	0.4%	—	—	12.1%	—	—	0.5%
Cholesterol lowering	—	—	21.0%	—	—	2.5%	—	—	20.8%	—	—	3.4%
Hypertension lowering	—	—	52.9%	—	—	45.4%	—	—	59.9%	—	—	42.1%
Had AAA Repair	—	—	61.6%	—		62.4%	—	—	92.6%	—	—	92.4%
AAA rupture	—	—	2.1%	—		3.6%	—	—	0.4%	—	—	1.1%
Time until surgery – if had surgery (Days)	819	439, 1252	—	588	322, 1032	—	31	21, 41	—	52	33, 90	—
Outcome
Survival status
Alive	—	—	78.5%	—	—	71.4%	—	—	74.9%	—	—	71.8%
Dead	—	—	21.5%	—	—	28.6%	—	—	25.1%	—	—	28.2%
AAA related death Total Pop	—	—	3.4%	—	—	6.6%	—	—	3.3%	—	—	5.7%
Death within 30 days of surgery	—	—	1.1%	—	—	7.0%	—	—	1.9%	—	—	5.6%
Time to death or censoring (Days surviving)	1805	1362, 2316	—	1373	1156, 1813	—	1754	1347, 2281	—	1544	1172, 1981	—

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