I am glad that Drs. Paris and Cassel took this opportunity to remind readers of the evidence on repairing AAA in elderly patients. When I first encountered Dr. S, in 1988, there were fewer published articles on the natural history of AAA and on operative outcomes, and less-invasive treatments were not yet available. At that time, I told Dr. S that the risk for rupture and likely death was about 50% over 5 years (recent references estimate the risk for rupture at 5% per year, higher when growth exceeds 0.5 cm per year [1]). I also told him that the mortality rate from an operative repair was usually about 5%, that our surgeons claimed a lower mortality rate (near 1%), and that the risk for serious, nonfatal complications was about 10%.

Drs. Paris and Cassel provide an average life expectancy for Dr. S; approximately 50% of 87-year-old men will live an additional 5 years or longer (the percent survival actually may be lower because the distribution of years survived after age 87 is probably skewed and the median survival is probably less than the average survival) [2]. Achieving a surgical cure of the aneurysm might preserve this life expectancy, but the perioperative risk for death should be subtracted, resulting in an estimated survival of 40% to 50% at 5 years. A choice of watchful waiting, with a risk for rupture of approximately 50% and a rupture-associated mortality rate of 80% to 90%, also results in an estimated survival rate of 40% to 50% in 5 years. Dr. S was otherwise healthy, and his predicted life expectancy may have been a bit higher and his surgical risk a bit lower, but this was clearly a close decision. The laconic comment of the gerontologist I talked with was perhaps too dismissive, but it spoke to the difficulty and angst of choosing whether to have surgery.