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Ozawa H, Takahashi A, Bessho R, Hoshina K, Shukuzawa K, Ohki T. Saccular and Fusiform Abdominal Aortic Aneurysms Treated With Endovascular Repair Differ in Presentation and Treatment Threshold: Analyses Using a National Clinical Database in Japan. J Am Heart Assoc 2024; 13:e032715. [PMID: 38780177 PMCID: PMC11255613 DOI: 10.1161/jaha.123.032715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/13/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Saccular abdominal aortic aneurysms (AAAs) are considered to be at higher risk of rupture than fusiform AAAs, but not much is known about the extent of this risk. Therefore, this study aimed to compare the rupture presentation between fusiform and saccular AAAs. METHODS AND RESULTS This is a retrospective cohort study on 27 290 patients who underwent primary endovascular repair for a degenerative AAA between 2016 and 2019, and who were registered in the National Clinical Database in Japan. At operation for nonruptured case, the aneurysm diameter was significantly smaller in saccular AAAs than in fusiform AAAs (median, 44.0 versus 51.0 mm; P<0.001). Similarly, aneurysm diameter at rupture was significantly smaller in saccular AAAs than in fusiform AAAs (median, 55.6 versus 68.0 mm; P<0.001). The likelihood of repair for rupture was significantly higher in saccular AAAs than in fusiform AAAs in the 40- to 54-mm diameter range, in which saccular morphology was found to be an independent risk factor for rupture against fusiform morphology by adjusting for sex and aneurysm diameter (odds ratio, 2.54 [95% CI, 1.75-3.69]). In addition, receiver-operating characteristic curve analysis revealed that the cutoff diameter to predict rupture was smaller in saccular AAAs than in fusiform AAAs (50.5 and 59.5 mm, respectively) based on the Youden index. CONCLUSIONS Saccular AAAs presented at smaller diameters than fusiform AAAs in patients with ruptured AAAs treated with endovascular aortic repair, which supports the idea that saccular AAAs should be treated at smaller diameters.
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Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of SurgeryThe Jikei University School of MedicineTokyoJapan
- Japanese Society for Vascular SurgeryTokyoJapan
| | - Arata Takahashi
- Department of Health Policy and Management, School of MedicineKeio UniversityTokyoJapan
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Ryuzo Bessho
- Department of Cardiovascular SurgeryNippon Medical School, Chiba Hokusoh HospitalChibaJapan
| | - Katsuyuki Hoshina
- Department of Vascular Surgery, Graduate School of MedicineThe University of TokyoTokyoJapan
- Japanese Committee for Stentgraft ManagementTokyoJapan
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Takao Ohki
- Division of Vascular Surgery, Department of SurgeryThe Jikei University School of MedicineTokyoJapan
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Rastogi V, Guetter CR, Patel PB, Anjorin AC, Marcaccio CL, Yadavalli SD, Scali ST, Beck AW, Verhagen HJM, Schermerhorn ML. Clinical presentation, outcomes, and threshold for repair by sex in degenerative saccular vs fusiform aneurysms in the descending thoracic aorta. J Vasc Surg 2023; 78:1392-1401.e1. [PMID: 37652142 PMCID: PMC10841204 DOI: 10.1016/j.jvs.2023.06.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE Saccular-shaped thoracic aortic aneurysms (TAAs) are often treated at smaller diameters compared with fusiform TAAs, despite a lack of strong clinical evidence to support this practice. The aim of this study was to examine differences in presentation, treatment, and outcomes between saccular TAAs and fusiform TAAs in the descending thoracic aorta. We also examined the need for sex-specific treatment thresholds for TAAs. METHODS All Vascular Quality Initiative (VQI) patients undergoing thoracic endovascular aneurysm repair (TEVAR) for degenerative TAAs in the descending thoracic aorta from 2012 through 2022 were reviewed. Patients were stratified by urgency: emergent/urgent vs elective repairs (ruptured/symptomatic). Demographics, comorbidities, anatomical/procedural characteristics, and outcomes for fusiform TAAs and saccular TAAs were compared. Cumulative distribution curves were used to plot the proportion of patients who underwent emergent/urgent repair according to sex-stratified aortic diameter. RESULTS Among 655 emergent/urgent TEVARs, 37% were performed for saccular TAAs, whereas among 1352 elective TEVARs, 35% had saccular TAA morphology. Compared with fusiform TAAs, saccular TAAs more frequently underwent emergent/urgent (ruptured/symptomatic) TEVAR below the repair threshold in both females (<50 mm: 38% vs 10%; relative risk, 3.39; 95% confidence interval [CI], 2.04-5.70; P < .001), and males (<55 mm: 47% vs 21%; relative risk, 2.26; 95% CI, 1.60-3.18; P < .001). Moreover, among patients with emergent/urgent fusiform TAAs, females presented at smaller diameters compared with males, whereas there was no difference in preoperative aneurysm diameter among patients with saccular TAAs. Regarding outcomes, emergent/urgent treated saccular TAAs had similar postoperative outcomes and 5-year mortality compared with fusiform TAAs. Nevertheless, in the elective cohort, patients with saccular TAAs had similar postoperative mortality compared with those with fusiform TAAs, but a lower rate of postoperative spinal cord ischemia (0.7% vs 3.2%; P = .010). Furthermore, patients with saccular TAAs had a higher rate of 5-year mortality compared with their fusiform counterparts (23% vs 17%; hazard ratio, 1.53; 95% CI, 1.12-2.10; P = .010). CONCLUSIONS Patients with saccular TAAs underwent emergent/urgent TEVAR at smaller diameters than those with fusiform TAAs, supporting current clinical practice guideline recommendations that saccular TAAs warrant treatment at smaller diameters. Furthermore, these data support a sex-specific treatment threshold for patients with fusiform TAAs, but not for those with saccular TAAs. Although there were no differences in outcomes following TEVAR between morphologies in the emergent/urgent cohort, patients with saccular TAAs who were treated electively were associated with higher 5-year mortality compared with those with fusiform TAAs.
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Affiliation(s)
- Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Camila R Guetter
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of General Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Aderike C Anjorin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Kessler V, Klopf J, Eilenberg W, Neumayer C, Brostjan C. AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis. Biomedicines 2022; 10:94. [PMID: 35052774 PMCID: PMC8773452 DOI: 10.3390/biomedicines10010094] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.
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Affiliation(s)
| | | | | | | | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria; (V.K.); (J.K.); (W.E.); (C.N.)
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Broda M, Rouet L, Zielinski A, Sillesen H, Eiberg J, Ghulam Q. Profiling abdominal aortic aneurysm growth with three-dimensional ultrasound. INT ANGIOL 2021; 41:33-40. [PMID: 34672485 DOI: 10.23736/s0392-9590.21.04724-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND "Profiling" is a new method based on three-dimensional ultrasound (3D-US) allowing for direct comparison of baseline and follow-up diameters along the AAA length. This study aimed to evaluate the feasibility of profiling to visualize AAA changes at sub-maximum diameters, and to categorize the growth profiles. METHODS Retrospective analysis of prospectively and consecutively included patients under AAA surveillance at a tertiary referral centre. 3D-US images of AAAs at baseline and at one-year follow-up were segmented, generating a centerline and a mesh of the aneurysm geometry. The mesh was processed to illustrate diameter changes of a given AAA. Three growth profiles were identified: A) Peak Growth: the largest, significant (≥3.6 mm) diameter difference occurred within a 10 mm margin to either side of the maximum baseline diameter; B) Edge Growth: at least one significant diameter difference and the criteria for Peak Growth did not apply; C) No Growth: all diameter differences were nonsignificant. A centerline length of ≥60 mm was assumed to capture a comparable segment of the wall geometry at baseline and follow-up. Cohen's kappa and Kaplan Meier analysis were used to analyze data. RESULTS In total, 186 patients had growth profiles generated. Of these, 28 (15%) were discarded, mainly based on inadequate centerline lengths (n= 21, 11.3%). The remaining patients were categorized into Edge Growth (n=83, 52%), No Growth (n=47, 30%), and Peak Growth (n=28, 18%). CONCLUSIONS Profiling interprets AAA growth at sub-maximum diameters. Half of the cohort had Edge Growth. These AAAs risk being classified as stable.
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Affiliation(s)
- Magdalena Broda
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark - .,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark -
| | | | - Alexander Zielinski
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Academy of Medical Education and Simulation (CAMES), Copenhagen, Denmark
| | - Qasam Ghulam
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
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Akkoyun E, Gharahi H, Kwon ST, Zambrano BA, Rao A, Acar AC, Lee W, Baek S. Defining a master curve of abdominal aortic aneurysm growth and its potential utility of clinical management. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106256. [PMID: 34242864 PMCID: PMC8364512 DOI: 10.1016/j.cmpb.2021.106256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The maximum diameter measurement of an abdominal aortic aneurysm (AAA), which depends on orthogonal and axial cross-sections or maximally inscribed spheres within the AAA, plays a significant role in the clinical decision making process. This study aims to build a total of 21 morphological parameters from longitudinal CT scans and analyze their correlations. Furthermore, this work explores the existence of a "master curve" of AAA growth, and tests which parameters serve to enhance its predictability for clinical use. METHODS 106 CT scan images from 25 Korean AAA patients were retrospectively obtained. We subsequently computed morphological parameters, growth rates, and pair-wise correlations, and attempted to enhance the predictability of the growth for high-risk aneurysms using non-linear curve fitting and least-square minimization. RESULTS An exponential AAA growth model was fitted to the maximum spherical diameter, as the best representative of the growth among all parameters (r-square: 0.94) and correctly predicted to 15 of 16 validation scans based on a 95% confidence interval. AAA volume expansion rates were highly correlated (r=0.75) with thrombus accumulation rates. CONCLUSIONS The exponential growth model using spherical diameter provides useful information about progression of aneurysm size and enables AAA growth rate extrapolation during a given surveillance period.
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Affiliation(s)
- Emrah Akkoyun
- Department of Health Informatics, Graduate School of Informatics, Middle East Technical University, Dumlupinar Bulvari #1, 06800 Cankaya, Ankara, Turkey
| | - Hamidreza Gharahi
- Department of Mechanical Engineering, Michigan State University, 2457 Engineering Building, East Lansing, MI 48824, USA
| | - Sebastian T Kwon
- Department of Anesthesiology and Perioperative Medicine, UCLA David Geffen School of Medicine, 757 Westwood Blvd., Los Angeles, CA 90095, USA
| | - Byron A Zambrano
- Department of Mechanical Engineering, Michigan State University, 2457 Engineering Building, East Lansing, MI 48824, USA
| | - Akshay Rao
- Department of Mechanical Engineering, Michigan State University, 2457 Engineering Building, East Lansing, MI 48824, USA
| | - Aybar C Acar
- Department of Health Informatics, Graduate School of Informatics, Middle East Technical University, Dumlupinar Bulvari #1, 06800 Cankaya, Ankara, Turkey
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, Republic of Korea
| | - Seungik Baek
- Department of Mechanical Engineering, Michigan State University, 2457 Engineering Building, East Lansing, MI 48824, USA.
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Bellamkonda KS, Nassiri N, Sadeghi MM, Zhang Y, Guzman RJ, Ochoa Chaar CI. Characteristics and outcomes of small abdominal aortic aneurysm rupture in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2021; 74:729-737. [PMID: 33617982 DOI: 10.1016/j.jvs.2021.01.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The current guidelines recommend elective abdominal aortic aneurysm (AAA) repair at 5.5 cm for men and 5.0 cm for women. However, rupture can occur in patients with an aneurysm smaller than these size thresholds. In the present study, we investigated the proportion of AAAs that rupture at sizes less than elective operative thresholds and compared the outcomes of repair with those of aneurysms that had ruptured at a larger size. Our hypothesis was that the rupture of small AAAs carries mortality similar to that of rupture at larger sizes. METHODS The American College of Surgeons National Surgical Quality Improvement Program targeted vascular files for open AAA repair and endovascular aneurysm repair (EVAR) were reviewed for all cases of ruptured AAAs (rAAAs) from 2011 to 2018. The patients were divided into two groups: those with small AAAs that had ruptured at a size less than the current size guidelines for elective repair and those with large AAAs that had ruptured at a size that had met the criteria for elective repair. Univariate analyses were conducted to compare the comorbidities and perioperative outcomes of infrarenal rAAA repair between the groups. Multivariable logistic regression was performed to examine the differences in mortality between small and large rAAAs after controlling for confounding variables. RESULTS Of the 1612 rAAA repairs, 167 (10.4%) were small rAAAs. The proportion of small rAAAs did not significantly change during the study period (P = .15). The large rAAA group was more likely to have juxtarenal or suprarenal aneurysms compared with the small rAAA group (27% vs 16%; P = .001). A comparison of infrarenal rAAAs only demonstrated that the mean small rAAA (n = 141) diameter was 4.1 cm in the women and 4.5 cm in the men compared with the large rAAAs (n = 1051), with a mean diameter of 7.1 cm in women and 8.3 cm in men (P < .01 for the women; P < .01 for the men). The patients in the small rAAA group had had a significantly lower body mass index but were more likely to be African American and to have hypertension. The small rAAA group was more likely to present without hypotension and to have undergone EVAR. The repair of small rAAAs was associated with lower bleeding and mortality and a shorter mean operative time but with more readmissions. Multivariable regression analysis demonstrated that size was not associated with outcome after adjusting for other variables. CONCLUSIONS Of all AAA repairs classified as treating rupture, 10% were for patients with small AAAs. Patients with small rAAA were less likely to present with hypotension and were more likely to have undergone EVAR. Further research into sac morphology and more sensitive imaging modalities might help identify small rAAAs at high risk of rupture that would benefit from elective repair.
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Affiliation(s)
- Kirthi S Bellamkonda
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Mehran M Sadeghi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Yawei Zhang
- Yale School of Public Health, New Haven, Conn
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, Conn.
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Small abdominal aortic aneurysms: Has anything changed so far? Trends Cardiovasc Med 2020; 30:500-504. [DOI: 10.1016/j.tcm.2019.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/27/2019] [Accepted: 11/16/2019] [Indexed: 10/25/2022]
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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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Variation in Surgical Treatment of Abdominal Aortic Aneurysms With Small Aortic Diameters in the Netherlands. Ann Surg 2020; 271:781-789. [PMID: 30216222 DOI: 10.1097/sla.0000000000003050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. BACKGROUND Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. METHODS All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of <55 mm for men and <50 mm for women were considered guideline deviations. National deviation and hospital variation in deviation were evaluated over time. Questionnaires were distributed among all Dutch VSUs, inquiring for acceptable reasons for guideline deviation. VSUs were asked to estimate the guideline deviation percentage in their hospital which was then compared with their DSAA percentage. RESULTS In all, 9039 patients were included. In 15%, we found guideline deviation, varying from 2% to 40% between VSUs. Over time, 21 VSUs were identified with a lower percentage of deviation than the national mean each year and 8 VSUs with a higher percentage. 44/60 VSUs completed the questionnaire. Most commonly reported reasons to deviate were concomitant large iliac diameter (91%) and saccular aneurysm (82%). The majority of the VSUs (77%) estimated their guideline deviation to be <5%. Eleven VSUs (25%) estimated their deviation concordant with their DSAA percentage, but 75% of VSUs underestimated their deviation. CONCLUSIONS Dutch VSUs regularly deviate from the guidelines regarding aneurysm diameter, with variation between VSUs. Consensus exists amongst VSUs on acceptable reasons for guideline deviations; however, the majority underestimates their actual deviation percentage.
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12
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Davis FM, Jerzal E, Albright J, Kazmers A, Monsour A, Bove P, Henke PK. Variation in the elective management of small abdominal aortic aneurysms and physician practice patterns. J Vasc Surg 2019; 70:1089-1098. [DOI: 10.1016/j.jvs.2018.12.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 12/13/2018] [Indexed: 12/20/2022]
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Siika A, Lindquist Liljeqvist M, Zommorodi S, Nilsson O, Andersson P, Gasser TC, Roy J, Hultgren R. A large proportion of patients with small ruptured abdominal aortic aneurysms are women and have chronic obstructive pulmonary disease. PLoS One 2019; 14:e0216558. [PMID: 31136570 PMCID: PMC6538142 DOI: 10.1371/journal.pone.0216558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/23/2019] [Indexed: 12/19/2022] Open
Abstract
Objective In a population-based cohort of ruptured abdominal aortic aneurysms (rAAAs), our aim was to investigate clinical, morphological and biomechanical features in patients with small rAAAs. Methods All patients admitted to an emergency department in Stockholm and Gotland, a region with a population of 2.1 million, between 2009–2013 with a CT-verified rupture (n = 192) were included, and morphological measurements were performed. Patients with small rAAAs, maximal diameter (Dmax) ≤ 60 mm were selected (n = 27), and matched 2:1 by Dmax, sex and age to intact AAA (iAAAs). For these patients, morphology including volume and finite element analysis-derived biomechanics were assessed. Results The mean Dmax for all rAAAs was 80.8 mm (SD = 18.9 mm), women had smaller Dmax at rupture (73.4 ± 18.4 mm vs 83.1 ± 18.5 mm, p = 0.003), and smaller neck and iliac diameters compared to men. Aortic size index (ASI) was similar between men and women (4.1 ± 3.1 cm/m2 vs 3.8 ± 1.0 cm/m2). Fourteen percent of all patients ruptured at Dmax ≤ 60 mm, and a higher proportion of women compared to men ruptured at Dmax ≤ 60 mm: 27% (12/45) vs. 10% (15/147), p = 0.005. Also, a higher proportion of patients with a chronic obstructive pulmonary disease ruptured at Dmax ≤ 60 mm (34.6% vs 14.6%, p = 0.026). Supra-renal aortic size index (14.0, IQR 13.3–15.3 vs 12.8, IQR = 11.4–14.0) and peak wall rupture index (PWRI, 0.35 ± 0.08 vs 0.43 ± 0.11, p = 0.016) were higher for small rAAAs compared to matched iAAAs. Aortic size index, peak wall stress and aneurysm volume did not differ. Conclusion More than one tenth of ruptures occur at smaller diameters, women continuously suffer an even higher risk of presenting with smaller diameters, and this must be considered in surveillance programs. The increased supra-renal aortic size index and PWRI are potential markers for rupture risk, and patients under surveillance with these markers may benefit from increased attention, and potentially from timely repair.
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Affiliation(s)
- Antti Siika
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | | | - Sayid Zommorodi
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Olga Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Patricia Andersson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - T. Christian Gasser
- Department of Solid Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, 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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14
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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ACR Appropriateness Criteria ® Pulsatile Abdominal Mass Suspected Abdominal Aortic Aneurysm. J Am Coll Radiol 2017; 14:S258-S265. [DOI: 10.1016/j.jacr.2017.01.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/20/2022]
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16
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Georgakarakos E, Schoretsanitis N, Koufopoulos G, Paulou K, Lazarides MK. Abdominal Pain in the Presence of Small Abdominal Aortic Aneurysms: If in Doubt, Cut It Out! Ann Vasc Surg 2017; 40:300.e17-300.e21. [PMID: 28163182 DOI: 10.1016/j.avsg.2016.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/29/2016] [Accepted: 08/29/2016] [Indexed: 10/20/2022]
Abstract
Although small (<5 cm) abdominal aortic aneurysms (AAA) have been associated with symptoms and indication for intervention scarcely, the clinicians should never exclude such potential association especially in the absence of other overt pathological findings. In such cases, a surgical exploration with consequent intervention, if feasible, should be justified to prevent a detrimental evolution in a dubious scenario. In this article, we present 2 cases of patients with small AAA presenting with severe abdominal pain. In the absence of other solid clinical and radiological pathological findings, both patients underwent laparotomy where an inflammatory small AAA was identified and subjected either to resection and restoration with a tube graft or secondary endovascular repair because the periaortic fibrosis precluded the open repair. The characteristics and rationale of treatment modalities are exemplified and discussed.
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Affiliation(s)
- Efstratios Georgakarakos
- Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
| | - Nikolaos Schoretsanitis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - Konstantinos Paulou
- Department of General Surgery, Sismanogleion General Hospital of Komotini, Komotini, Greece
| | - Miltos K Lazarides
- Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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