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Svidlova Y, Epple J, Lingwal N, Schmitz-Rixen T, Böckler D, Grundmann RT. [Long-term Results after Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysm - a Propensity Score Matched Analysis]. Zentralbl Chir 2024; 149:398-407. [PMID: 36977467 DOI: 10.1055/a-2044-0780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND This retrospective propensity score matched study presents the perioperative mortality and long-term survival up to 9 years after endovascular (EVAR) and open (OAR) repair of patients with ruptured abdominal aortic aneurysm (rAAA) in Germany using health insurance data. MATERIALS AND METHODS 2170 patients treated between January 1st, 2010 and December 31st, 2016, for rAAA within 24 hours of hospital admission and receiving blood transfusions were enrolled in the study and tracked until December 31st, 2018. For better comparability of EVAR and OAR, a 1:1 propensity score matching with 624 pairs according to patient age, sex and comorbidities was carried out using the R program (Foundation for Statistical Computing, Vienna, Austria). RESULTS In the unadjusted groups, 29.1% (631/2170) of the patients were treated with EVAR and 70.9% (1539/2170) with OAR. EVAR patients had a significantly higher overall rate of comorbidities. After adjustment, EVAR patients showed significantly better perioperative survival (EVAR 35.7%, OAR 51.0%, p = 0.000). Perioperative complications occurred in 80.4% of EVAR patients and 80.3% of OAR patients (p = 1.000). At the end of follow-up, Kaplan-Meier estimated that 15.2% of patients survived after EVAR vs. 19.5% after OAR (p = 0.027). In the multivariate Cox regression analysis, OAR, age ≥ 80 years, diabetes mellitus type 2 and renal failure stages 3 to 5 had a negative impact on overall survival. Patients treated on weekdays had a significantly lower perioperative mortality than patients treated during the weekend (perioperative mortality on weekdays 40.6% vs. 53.4% during the weekend; p = 0.000) and a better overall survival as estimated by Kaplan-Meier. CONCLUSION Significantly better perioperative and overall survival was observed with EVAR than with OAR in patients with rAAA. The perioperative survival benefit of EVAR was also found in patients older than 80 years. Female gender had no significant influence on perioperative mortality and overall survival. Patients treated on weekends had a significantly poorer perioperative survival than patients treated on weekdays, and this lasted through the end of follow-up. The extent to which this was dependent on hospital structure was unclear.
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Affiliation(s)
- Yuliya Svidlova
- Klinik für Gefäß- und Endovaskularchirurgie, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Jasmin Epple
- Klinik für Gefäß- und Endovaskularchirurgie, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Neelam Lingwal
- Institut für Biostatistik und mathematische Modellierung, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Thomas Schmitz-Rixen
- Klinik für Gefäß- und Endovaskularchirurgie, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Reinhart T Grundmann
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung (DIGG gGmbH) der DGG, Berlin, Deutschland
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Ramkumar N, Suckow BD, Columbo JA, Arya S, Sedrakyan A, Mackenzie TA, Brown JR, Goodney PP. Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:1212-1220.e5. [PMID: 37442215 DOI: 10.1016/j.jvs.2023.06.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE Although the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture. METHODS We performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention. RESULTS The mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75). CONCLUSIONS Male and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.
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Affiliation(s)
| | - Bjoern D Suckow
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Shipra Arya
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | | | - Todd A Mackenzie
- Geisel School of Medicine, Hanover, NH; Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH
| | - Jeremiah R Brown
- Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH; Department of Epidemiology, Geisel School of Medicine, Hanover, NH
| | - Philip P Goodney
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Alberga AJ, de Bruin JL, Bastos Gonçalves F, Karthaus EG, Wilschut JA, van Herwaarden JA, Wever JJ, Verhagen HJM. Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic Aneurysms. J Endovasc Ther 2023; 30:419-432. [PMID: 35311414 PMCID: PMC10209502 DOI: 10.1177/15266028221083460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
PURPOSE Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data. METHODS All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians. RESULTS The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8). CONCLUSION Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
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Affiliation(s)
- Anna J. Alberga
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jorg L. de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frederico Bastos Gonçalves
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário de Lisboa Central, NOVA Medical School, Lisboa, Portugal
| | - Eleonora G. Karthaus
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Janneke A. Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | | | - Jan J. Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hence J. M. Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Svidlova Y, Epple J, Schmitz-Rixen T, Steffen M, Böckler D, Steinbauer M, Grundmann RT. [Perioperative lethality after endovascular and open repair of ruptured abdominal aortic aneurysms: An analysis of administrative data of the AOK health insurance fund]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 173:56-63. [PMID: 35941041 DOI: 10.1016/j.zefq.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/23/2022] [Accepted: 04/14/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE In this paper we will report the perioperative outcome after endovascular (EVAR) and open (OAR) repair of ruptured abdominal aortic aneurysms (rAAA) in Germany based on data of the AOK health insurance fund. METHODS Anonymised data of all patients with rAAA (n = 3,227) who were treated from 01/01/2010 to 12/31/2016 were analysed, using SPSS 27 (IBM Deutschland GmbH, Ehningen, Germany). RESULTS 41.9% (1,353/3,227) of the patients were treated with EVAR and 58.1% (1,874/3,227) with OAR. Patients ≥80 years made up 38.4% for EVAR and 32.9% for OAR (p = 0.002). The proportion of patients undergoing surgery within 24 hours after admission was significantly higher for OAR (87.8%) than for EVAR (73.0%) (p = 0.000). The perioperative lethality rate for OAR was 42.4%, and thus almost twice as high as for EVAR with 21.3% (p = 0.000). Women had higher perioperative lethality rates for both EVAR (perioperative lethality 24.6%) and OAR (perioperative lethality 51.7%) compared to men with 20.6% (EVAR) and 40.2% (OAR), respectively. With EVAR, 35.8% of the patients showed a complication-free postoperative course, with OAR it was 17.7% (p = 0.000). Blood transfusions (whole blood, red cell concentrates, and autotransfusions) were administered in 57.6% of the patients with EVAR, but in 92.3% with OAR (p = 0.000). The highest perioperative lethality was found in EVAR and OAR patients who received both surgery within 24 hours after admission and blood transfusions (perioperative lethality EVAR 36.0%, OAR 46.0%; p = 0.000). In contrast, patients who did not require blood transfusions and were treated later than 24 hours after admission had the lowest perioperative lethality with 3.2% for EVAR vs. 5.4% for OAR (p = 0.623). CONCLUSION The data confirm the observation that the perioperative mortality of rAAA patients is lower with EVAR than with OAR. However, strict attention must be paid to the time of the intervention. The low perioperative lethality of patients who were treated later than 24 hours after hospital admission and who did not require blood transfusions indicates that cases of symptomatic AAA without rupture have also been recorded in this administrative database under the diagnosis rAAA. One point of criticism is that the decision not to adjust for the patient groups with EVAR and with OAR in order to be able to better analyse the properties of routine data includes a considerable risk of bias in the statements of this work due to confounding variables.
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Affiliation(s)
- Yuliya Svidlova
- Klinik für Gefäß- und Endovascularchirurgie, Klinikum der Goethe-Universität, Frankfurt/M, Deutschland
| | - Jasmin Epple
- Klinik für Gefäß- und Endovascularchirurgie, Klinikum der Goethe-Universität, Frankfurt/M, Deutschland
| | - Thomas Schmitz-Rixen
- Klinikum der Goethe-Universität, Frankfurt/M. und Deutsches Institut für Gefäßmedizinische Gesundheitsforschung (DIGG gGmbH), Berlin, Deutschland
| | | | - Dittmar Böckler
- Ärztlicher Direktor der Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus Steinbauer
- Chefarzt der Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Deutschland
| | - Reinhart T Grundmann
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung (DIGG gGmbH), Berlin, Deutschland.
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Harnarayan P, Budhooram S, Harnanan D, Ramdass MJ, Islam S, Naraynsingh V. Gender Influence on Abdominal Aortic Aneurysm Surgery in a Caribbean Population. Int J Angiol 2022; 32:26-33. [PMID: 36727148 PMCID: PMC9886443 DOI: 10.1055/s-0042-1750017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Female patients with abdominal aortic aneurysms (AAAs) are usually less common and older than their male counterparts. We report on AAA disease in a Caribbean nation with respect to gender and review their outcomes relative to the male population. Data were collected prospectively and analyzed retrospectively for patients with AAAs who underwent surgery from 2001 to 2018. Sixty patients were diagnosed with AAA with 44 going on to have surgical repair of which 35 were males, aged 61 to 89 (mean age 73.4 years). Nine women ages 44 to 74 years (mean age 60.8 years) had surgical intervention, three being between 40 and 49 years. The size of aneurysms in these patients ranged from 4.3 to 11.0 cm in diameter (average 6.95 cm), female patients having an average diameter of 6.7 cm. Of the 44 patients, 43 underwent open and one endovascular repair. Thirty-three were elective cases and 11 were ruptured with 32 aorto-aortic and 13 aorto-iliac repairs. There were nine fatalities, three elective and six ruptured, with only one being female. Women had similar outcomes to men in all age groups with young patients having good results. Female AAA patients are usually older, undergo less surgical procedures especially if endovascular, and have worse outcomes than their male counterparts. Our study showed that the females were younger but had similar outcomes to the male patients. The female Caribbean patients may present at much younger ages than in continental populations and this may be due to genetic, ethnic, or lifestyle factors.
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Affiliation(s)
- Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies,Address for correspondence Patrick Harnarayan, MBBS, FRCS, FACS Department of Clinical Surgical Sciences, University of the West IndiesSt. Augustine, Trinidad and TobagoWest Indies
| | - Steve Budhooram
- Department of Vascular Surgery, The Surgi-Med Clinic, San Fernando, Trinidad and Tobago, West Indies
| | - Dave Harnanan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies
| | - Michael J. Ramdass
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies
| | - Shariful Islam
- Department of Surgery, San Fernando General and Teaching Hospitals, San Fernando, Trinidad and Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6594528. [DOI: 10.1093/ejcts/ezac218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/07/2022] [Accepted: 03/21/2022] [Indexed: 11/14/2022] Open
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Pouncey AL, Powell JT. Womens lives at stake: Women Suffer Disproportionately After Abdominal Aortic Aneurysm Repair, So What Can We Do About It? Eur J Vasc Endovasc Surg 2021; 62:1-3. [PMID: 34092490 DOI: 10.1016/j.ejvs.2021.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Janet T Powell
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Smedberg C, Steuer J, Leander K, Hultgren R. Sex differences and temporal trends in aortic dissection: a population-based study of incidence, treatment strategies, and outcome in Swedish patients during 15 years. Eur Heart J 2021; 41:2430-2438. [PMID: 32558879 PMCID: PMC7340356 DOI: 10.1093/eurheartj/ehaa446] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/26/2020] [Accepted: 05/11/2020] [Indexed: 01/01/2023] Open
Abstract
Aims As large population-based studies of aortic dissection are lacking, the incidence numbers and knowledge about time-trends and sex differences are uncertain. The objective was to describe incidence, temporal trends and outcome of aortic dissection with particular emphasis on sex differences. Methods and results During the study period 2002–2016, 8057 patients in Sweden were diagnosed with aortic dissection, identified from the National Patient Register and the Cause of Death Register. A total of 5757 (71%) patients were hospitalized, whereas 2300 (29%) patients were deceased without concurrent hospital stay. The annual incidence was 7.2 per 100 000 (9.1 in men and 5.4 in women), decreasing over time in men (P = 0.005). Mean age in the hospitalized patients was 68 years (SD 13), 2080 (36%) were women. Within the first 14 days after onset, 1807 patients (32%) underwent surgical repair. The proportion of surgically treated increased from the 5-year period 2002–2006 to 2012–2016 [27% vs. 35%, odds ratio (OR) 1.61, 95% confidence interval (CI) 1.39–1.86; P < 0.001]. In hospitalized patients, 30-day mortality decreased between the same periods (26% vs. 21%, OR 0.68, 95% CI 0.59–0.80; P < 0.001). Long-term mortality decreased as well (hazard ratio 0.74, 95% CI 0.67–0.82; P < 0.001). Women had higher 30-day mortality than men after acute repair, a sex difference that remained after age adjustment (17% vs. 12%, OR 1.38, 95% CI 1.04–1.82; P = 0.006). Conclusion This population-based study detected a higher incidence of aortic dissection than prior reports, but a decreasing incidence in men. Surgical therapy was increasingly used and with more favourable outcome but was less frequently offered to elderly patients. The sustained sex differences regarding both incidence and outcome require further attention. ![]()
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Affiliation(s)
- Christian Smedberg
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, SE-11883 Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Sjukhusbacken 10, SE-11883 Stockholm, Sweden
| | - Johnny Steuer
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, SE-11883 Stockholm, Sweden.,Department of Surgery, Södersjukhuset, Sjukhusbacken 10, SE-11883 Stockholm, Sweden
| | - Karin Leander
- Institute of Environmental Medicine, Karolinska Institutet, Box 210, SE-17177 Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm S301 SE-17176, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm S301 SE-17176, Sweden
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Talvitie M, Stenman M, Roy J, Leander K, Hultgren R. Sex Differences in Rupture Risk and Mortality in Untreated Patients With Intact Abdominal Aortic Aneurysms. J Am Heart Assoc 2021; 10:e019592. [PMID: 33619974 PMCID: PMC8174277 DOI: 10.1161/jaha.120.019592] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Studies on intact abdominal aortic aneurysms mainly focus on treated patients, and data on untreated patients are sparse. The objective was to investigate sex differences among untreated patients regarding rupture and mortality rates and to determine predictors for these events. Sex‐specific causes of death were evaluated. Methods and Results All patients ≥40 years diagnosed from 2001 to 2015 (n=32 393) with intact abdominal aortic aneurysms were identified in national registries; 60% (n=19 569) were untreated. Comorbid loads, crude rupture, and mortality rates were assessed. Predictors of 5‐year rupture and mortality were analyzed in Cox models (sex, age, comorbidities, income, and marital status). The proportion of men and women with multiple comorbidities was similar. Within 5 years, 798 ruptures occurred (9.7% women versus 6.9% men, P<0.001). Ruptures were independently predicted by female sex (hazard ratio [HR], 1.23; 95% CI, 1.07–1.42; P=0.004), chronic obstructive pulmonary disease (HR, 1.36; 95% CI, 1.15–1.62; P<0.001), age (HR, 11.49; 95% CI, 5.68–23.25 for ≥80 years; P<0.001), and income (HR, 0.63; 95% CI, 0.53–0.75 for highest tertile; P<0.001). After 5 years, 56.5% women and 50.4% men were deceased. Mortality was not independently predicted by female sex. Rupture was the third most common cause of death (11.9% women versus 8.7% men; P<0.001). The median time‐to‐events was 2.8 years. Conclusions A considerable proportion of patients with intact abdominal aortic aneurysms in surveillance remain untreated. Despite surveillance algorithms, the healthcare system fails to prevent a high number of ruptures, especially among women. The time‐to‐event data highlight the urgency to develop more individualized surveillance.
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Perioperative Medicine and Intensive Care Function Karolinska University Hospital Stockholm Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
| | - Karin Leander
- Institute of Environmental Medicine, Karolinska Institutet Stockholm Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
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11
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Andersson M, Talvitie M, Benson L, Roy J, Roos H, Hultgren R. A population-based study of post-endovascular aortic repair rupture during 15 years. J Vasc Surg 2021; 74:701-710.e3. [PMID: 33617983 DOI: 10.1016/j.jvs.2021.01.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/21/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The devastating event of a ruptured abdominal aortic aneurysm (rAAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for endovascular aortic repair (EVAR) vs open surgical repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures after OSR (post-OSR ruptures) was investigated. METHODS We conducted a nationwide, population-based, retrospective cohort study using the inpatient and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was rAAA, registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry and the Cause of Death Registry. RESULTS In total, 14,859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding with a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% confidence interval [CI], 2.7-4.2)/1000 person-years. The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI, 1.4-4.1, p 0.002) and age (hazard ratio, 1.1; 95% CI, 1.0-1.1; P < .001). Freedom from post-EVAR rupture was 99%, 98%, and 96% at 3, 5, and 10 years, respectively. Total and postoperative mortality after post-EVAR rupture were 42% and 17% (30 days), 45% and 22% (90 days), and 53% and 33% (1 year). The incidence rate of post-OSR rupture was 0.9/1000 person-years (95% CI, 0.7-1.2). CONCLUSIONS Post-EVAR rupture is a rare complication that can occur at any time after the index EVAR procedure. This finding may have implications for the discussion of limited follow-up programs and for the choice of procedure in patients with an AAA with a long life expectancy. An rAAA as the indication for the index surgery and age were identified as risk factors for post-EVAR rupture. The mortality associated with post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed, but must not be neglected as a possible late complication.
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Affiliation(s)
- Mattias Andersson
- Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sunderbyn Hospital, Sunderbyn, Sweden.
| | - Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Roos
- Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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12
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Schmitz-Rixen T, Böckler D, J. Vogl T, T. Grundmann R. Endovascular and Open Repair of Abdominal Aortic Aneurysm. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:813-819. [PMID: 33568258 PMCID: PMC8005839 DOI: 10.3238/arztebl.2020.0813] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 04/28/2020] [Accepted: 07/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND This review presents the surgical indications, surgical procedures, and results in the treatment of asymptomatic and ruptured abdominal aortic aneurysms (AAA). METHODS An updated search of the literature on screening, diagnosis, treatment, and follow-up of AAA, based on the German clinical practice guideline published in 2018. RESULTS Surgery is indicated in men with an asymptomatic AAA ≥ 5.5 cm and in women, ≥ 5.0 cm. The indication in men is based on four randomized trials, while in women the data are not conclusive. The majority of patients with AAA (around 80%) meanwhile receive endovascular treatment (endovascular aortic repair, EVAR). Open surgery (open aneurysm repair, OAR) is reserved for patients with longer life expectancy and lower morbidity. The pooled 30-day mortality is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, 3.27% [2.7; 3.83] after OAR. Women have higher operative/interventional mortality than men (odds ratio 1.67%). The mortality for ruptured AAA is extremely high: around 80% of women and 70% of men die after AAA rupture. Ruptured AAA should, if possible, be treated via the endovascular approach, ideally with the patient under local anesthesia. Treatment at specialized centers guarantees the required expertise and infrastructure. Long-term periodic monitoring by mean of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and (if appropriate) treat endoleaks, to document stable diameter of the eliminated aneurysmal sac, and to determine whether reintervention is necessary (long-term reintervention rate circa 18%). CONCLUSION Vascular surgery now offers a high degree of safety in the treatment of patients with asymptomatic AAA. Endovascular intervention is preferred.
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Affiliation(s)
- Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery and the University Wound Center, Hospital of the Goethe University, Frankfurt/Main, Germany
- Institute of Diagnostic and Interventional Radiology, Hospital of the Goethe University, Frankfurt/Main, Germany
| | - Dittmar Böckler
- Department of Vascular Surgery and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas J. Vogl
- Department of Vascular and Endovascular Surgery and the University Wound Center, Hospital of the Goethe University, Frankfurt/Main, Germany
| | - Reinhart T. Grundmann
- German Institute for Vascular Health Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG), Berlin, Germany
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13
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Lindquist Liljeqvist M, Hultgren R, Bergman O, Villard C, Kronqvist M, Eriksson P, Roy J. Tunica-Specific Transcriptome of Abdominal Aortic Aneurysm and the Effect of Intraluminal Thrombus, Smoking, and Diameter Growth Rate. Arterioscler Thromb Vasc Biol 2020; 40:2700-2713. [PMID: 32907367 DOI: 10.1161/atvbaha.120.314264] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There is no medical treatment to prevent abdominal aortic aneurysm (AAA) growth and rupture, both of which are linked to smoking. Our objective was to map the tunica-specific pathophysiology of AAA with consideration of the intraluminal thrombus, age, and sex, and to subsequently identify which mechanisms were linked to smoking and diameter growth rate. Approach and Results: Microarray analyses were performed on 246 samples from 76 AAA patients and 13 controls. In media and adventitia, there were 5889 and 2701 differentially expressed genes, respectively. Gene sets related to adaptive and innate immunity were upregulated in both tunicas. Media-specific gene sets included increased matrix disassembly and angiogenesis, as well as decreased muscle cell development, contraction, and differentiation. Genes implicated in previous genome-wide association studies were dysregulated in media. The intraluminal thrombus had a pro-proteolytic and proinflammatory effect on the underlying media. Active smoking resulted in increased inflammation, oxidative stress, and angiogenesis in all tissues and enriched lipid metabolism in adventitia. Processes enriched with active smoking in control aortas overlapped to a high extent with those differentially expressed between AAAs and controls. The AAA diameter growth rate (n=24) correlated with T- and B-cell expression in media, as well as lipid-related processes in the adventitia. CONCLUSIONS This tunica-specific analysis of gene expression in a large study enabled the detection of features not previously described in AAA disease. Smoking was associated with increased expression of aneurysm-related processes, of which adaptive immunity and lipid metabolism correlated with growth rate.
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Affiliation(s)
- Moritz Lindquist Liljeqvist
- Department of Molecular Medicine and Surgery (M.L.L., R.H., C.V., M.K., J.R.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery (M.L.L., R.H., C.V., M.K., J.R.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden (R.H., J.R.)
| | - Otto Bergman
- Department of Medicine (O.B., P.E.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Villard
- Department of Molecular Medicine and Surgery (M.L.L., R.H., C.V., M.K., J.R.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Kronqvist
- Department of Molecular Medicine and Surgery (M.L.L., R.H., C.V., M.K., J.R.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Per Eriksson
- Department of Medicine (O.B., P.E.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery (M.L.L., R.H., C.V., M.K., J.R.), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden (R.H., J.R.)
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14
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Nikol S, Mathias K, Olinic DM, Blinc A, Espinola-Klein C. Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review. VASA 2020; 49:1-36. [PMID: 32856993 DOI: 10.1024/0301-1526/a000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.
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Affiliation(s)
- Sigrid Nikol
- Department of Angiology, ASKLEPIOS Klinik St. Georg, Hamburg, Germany.,University of Münster, Germany
| | - Klaus Mathias
- World Federation for Interventional Stroke Treatment (WIST), Hamburg, Germany
| | - Dan Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy and Interventional Cardiology Department, Emergency Hospital, Cluj-Napoca, Romania
| | - Aleš Blinc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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15
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Granberg Y, Lundgren KT, Lindqvist EK. Socioeconomic position is associated with surgical treatment of open fractures of the lower limb: results from a Swedish population-based study. Acta Orthop 2020; 91:439-443. [PMID: 32285734 PMCID: PMC8023872 DOI: 10.1080/17453674.2020.1751418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - High-energy trauma to the lower limbs can result in open fractures, treated by reconstructive surgery or amputation. We examined whether socioeconomic position is associated with choice of primary treatment.Patients and methods - We performed a nationwide population-based study using the Swedish National Patient Register to identify all adult patients who between 1998 and 2013 underwent reconstruction or amputation after an open fracture below the knee. Information on socioeconomic position was collected from Statistics Sweden.Results - Of 275 individuals undergoing surgery after an open fracture below the knee during the study period, the 1st surgery was reconstructive in 58% of the patients and amputation in 42%. The chance of having an initial reconstruction was lower for women than for men (OR 0.5, 95% CI 0.3-0.9), lower with age (OR 0.97, CI 0.96-0.99), and lower for individuals without employment compared with individuals in employment (OR 0.3, CI 0.2-0.5). Primary treatment was in women associated with family composition, whereas in men it was associated with level of education.Interpretation - Choice of primary treatment after open fracture in the lower limb is affected by socioeconomic position including sex, age, employment, family composition, level of education, and income.
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Affiliation(s)
- Yamin Granberg
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm; ,Correspondence:
| | - Kalle T Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm; ,Craniofacial Diseases, Karolinska University Hospital, Stockholm;
| | - Ebba K Lindqvist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm; ,Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
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