To the Editor:

Pol and colleagues kindly commented on the results of our meta-analysis on the value of open repair of ruptured abdominal aortic aneurysm (RAAA) in patients ≥80 years old [1]. This meta-analysis provided evidence on the benefits of open repair in terms of immediate and intermediate survival in these very high-risk patients. The authors correctly suggested that endovascular repair (EVAR) could even improve these unexpectedly good results, and we shared the same opinion in the Discussion section of our article. Indeed, EVAR seems to be superior to open repair in the elective treatment of patients ≥80 years old [2], but we do not have enough data to state the same in the emergency setting. The lack of specific data on EVAR for RAAA in the very elderly simply prevented us from performing meta-analysis on this issue. However, the dramatic increase of open repair for RAAA in octogenarians and nonagenarians observed during the last 5 years in a recent Finnish multicenter study [3] suggests the need for more widespread use of EVAR in this increasing high-risk patient population.

Pol and colleagues stated that their previous research on this topic was left unnoticed in our meta-analysis. The first of their studies [4] was a report of two nonagenarians with symptomatic, unruptured (no detail on the status of the aneurysm was reported for one of them) who died within 30 days after repair. We did not include this study in our analysis as we excluded studies reporting on symptomatic, unruptured aneurysm as well as reports with fewer than 10 RAAA. The second of their studies [5] was published after we completed our meta-analysis. However, had the study been available to us, we would not have been able to extract the data from their report because it did not include the immediate and late outcome of octogenarians after EVAR versus open repair.

The satisfactory outcome after open repair of RAAA in octogenarians and nonagenarians documented by the present meta-analysis indicates that, when feasible, EVAR may further improve the results of emergency repair in the very elderly. Further research is needed to document the same benefits of EVAR observed in the elective treatment of abdominal aortic aneurysm in patients ≥80 years old.