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Møller ELR, Hauge MG, Pham MHC, Damm P, Kofoed KF, Fuchs A, Kühl JT, Sigvardsen PE, Ersbøll AS, Johansen M, Nordestgaard BG, Køber LV, Gustafsson F, Linde JJ. Aortic dimensions in women with previous pre-eclampsia. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00343-5. [PMID: 38866633 DOI: 10.1016/j.jcct.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Pre-eclampsia is a pregnancy related disorder associated with hypertension and vascular inflammation, factors that are also involved in the pathological pathway of aortic dilatation and aneurysm development. It is, however, unknown if younger women with previous pre-eclampsia have increased aortic dimensions. We tested the hypothesis that previous pre-eclampsia is associated with increased aortic dimensions in younger women. METHODS The study was a cross-sectional cohort study of women with previous pre-eclampsia, aged 40-55, from the PRECIOUS population matched by age and parity with women from the general population. Using contrast-enhanced CT, aortic diameters were measured in the aortic root, ascending aorta, descending aorta, at the level of the diaphragm, suprarenal aorta, and infrarenal aorta. RESULTS 1355 women (684 with previous pre-eclampsia and 671 from the general population), with a mean (standard deviation) age of 46.9 (4.4) were included. The pre-eclampsia group had larger mean (standard deviation) aortic diameters (mm) in all measured segments from the ascending to the infrarenal aorta (ascending: 33.4 (4.0) vs. 31.4 (3.7), descending: 23.9 (2.1) vs. 23.3 (2.0), diaphragm: 20.8 (1.8) vs. 20.4 (1.8), suprarenal: 22.9 (1.9) vs. 22.0 (2.0), infrarenal: 19.3 (1.6) vs. 18.6 (1.7), p < 0.001 for all, also after adjustment for age, height, parity, menopause, dyslipidemia, smoking and chronic hypertension. Guideline-defined ascending aortic aneurysms were found in 8 vs 2 women (p = 0.12). CONCLUSIONS Women with previous pre-eclampsia have larger aortic dimensions compared with women from the general population. Pre-eclampsia was found to be an independent risk factor associated with a larger aortic diameter.
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Affiliation(s)
- Emma L R Møller
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maria G Hauge
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael H C Pham
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Damm
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, The Diagnostic Center, Rigshospitalet, Copenhagen, University Hospital, Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørgen T Kühl
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Per E Sigvardsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne S Ersbøll
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Johansen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Biochemistry, Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Lars V Køber
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper J Linde
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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2
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Ke ZX, Chen GZ, Hu K, Zhang S, Zhou P, Chen DX, Li YQ, Li Q, Yang C. Safety and Efficacy of Endovascular Aortic Repair for Abdominal Aortic Aneurysms with a Hostile Neck Anatomy. Curr Med Sci 2023; 43:1221-1228. [PMID: 38153630 DOI: 10.1007/s11596-023-2822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/14/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE This study aimed to investigate the safety and efficacy of endovascular aortic repair (EVAR) for the treatment of an abdominal aortic aneurysm (AAA) with a hostile neck anatomy (HNA). METHODS From January 1, 2015 to December 31, 2019, a total of 259 patients diagnosed with an AAA who underwent EVAR were recruited into this study. Based on the morphological characteristics of the proximal neck anatomy, the patients were divided into the HNA group and the friendly neck anatomy (FNA) group. The patients were followed up for up to 4 years. RESULTS The average follow-up time was 1056.1±535.5 days. Type I endoleak occurred in 4 patients in the HNA group, and 2 patients in the FNA group. Neither death nor intraoperative switch to open repair occurred in either group. The time of the operation was significantly longer in the HNA group (FNA vs. HNA, 99.2±51.1 min vs. 117.5±63.8 min, P=0.011). There were no significant differences in short-term clinical success rate (P=0.228) or midterm clinical success rate (P=0.889) between the two groups. The overall mortality rate was 10.4%, and Kaplan-Meier survival analysis indicated that the two groups had similar cumulative survival rates at the end of the follow-up period (P=0.889). CONCLUSION EVAR was feasible and safe in patients with an AAA with a proximal HNA. The early and midterm results were promising; however, further studies are needed to verify the long-term effectiveness of EVAR.
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Affiliation(s)
- Zun-Xiang Ke
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ge-Zheng Chen
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ke Hu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shan Zhang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Peng Zhou
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Dian-Xi Chen
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yi-Qing Li
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Qin Li
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Chao Yang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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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: 28] [Impact Index Per Article: 14.0] [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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4
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Hultgren R, Elfström KM, Öhman D, Linné A. Long-Term Follow-Up of Men Invited to Participate in a Population-Based Abdominal Aortic Aneurysm Screening Program. Angiology 2020; 71:641-649. [PMID: 32351123 DOI: 10.1177/0003319720921741] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A screening program for abdominal aortic aneurysm (AAA), inviting 65-year-old men, was started in Stockholm in 2010 (2.3 million inhabitants). The aim was to present a long-term follow-up of men participating in screening, as well as AAA repair and ruptures among nonparticipants. Demographics were collected for men with screening detected with AAA 2010 to 2016 (n = 672) and a control group with normal aortas at screening (controls, n = 237). Medical charts and regional Swedvasc (Swedish Vascular registry) data were analyzed for aortic repair for men born 1945 to 1951. Ultrasound maximum aortic diameter (AD) as well as Aortic Size Index (ASI) was recorded. Participation was 78% and prevalence of AAA was 1.2% (n = 672). Aortic repair rates correlated with high ASI and AD. During the study period, 22% of the AAA patients were treated with the elective repair; 35 men in surveillance died (5.2%), non-AAA-related causes (82.9%) dominated, followed by unknown causes among 4 (11.4%), and 2 (5.7%) possibly AAA-related deaths. Abdominal aortic aneurysm rupture rate was higher among nonparticipants (0.096% vs 0.0036%, P < .001). The low dropout rate confirms acceptability of follow-up after screening. The efficacy is shown by the much higher rupture rate among the nonparticipating men.
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Affiliation(s)
- Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | | | - Daniel Öhman
- Regional Cancer Center Stockholm-Gotland, Stockholm, Sweden
| | - Anneli Linné
- Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden.,Department of Surgery, Section of Vascular Surgery, Södersjukhuset, Stockholm, Sweden
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5
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Hultgren R, Linné A, Svensjö S. Cost-effectiveness of targeted screening for abdominal aortic aneurysm in siblings. Br J Surg 2019; 106:206-216. [PMID: 30702746 DOI: 10.1002/bjs.11047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/21/2018] [Accepted: 10/10/2018] [Indexed: 12/29/2022]
Abstract
Background Population screening for abdominal aortic aneurysm (AAA) in 65‐year‐old men has been shown to be cost‐effective. A risk group with higher prevalence is siblings of patients with an AAA. This health economic model‐based study evaluated the potential cost‐effectiveness of targeted AAA screening of siblings. Methods A Markov model validated against other screening programmes was used. Two methods of identifying siblings were analysed: direct questioning of patients with an AAA (method A), and employing a national multigeneration register (method B). The prevalence was based on observed ultrasound data on AAAs in siblings. Additional parameters were extracted from RCTs, vascular registers, literature and ongoing screening. The outcome was cost‐effectiveness, probability of cost‐effectiveness at different willingness‐to‐pay (WTP) thresholds, reduction in AAA death, quality‐adjusted life‐years (QALYs) gained and total costs on a national scale. Results Methods A and B were estimated to reduce mortality from AAA, at incremental cost‐effectiveness ratios of €7800 (95 per cent c.i. 4627 to 12 982) and €7666 (5000 to 13 373) per QALY respectively. The probability of cost‐effectiveness was 99 per cent at a WTP of €23 000. The absolute risk reduction in AAA deaths was five per 1000 invited. QALYs gained were 27 per 1000 invited. In a population of ten million, methods A and B were estimated to prevent 12 and 17 AAA deaths, among 2418 and 3572 siblings identified annually, at total costs of €499 500 and €728 700 respectively. Conclusion The analysis indicates that aneurysm‐related mortality could be decreased cost‐effectively by applying a targeted screening method for siblings of patients with an AAA.
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Affiliation(s)
- R Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - A Linné
- Section of Vascular Surgery, Department of Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden
| | - S Svensjö
- Department of Vascular Surgery, Falun County Hospital, Falun, Sweden.,Centre for Clinical Research, Falun, Sweden.,Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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6
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Sakalihasan N, Michel JB, Katsargyris A, Kuivaniemi H, Defraigne JO, Nchimi A, Powell JT, Yoshimura K, Hultgren R. Abdominal aortic aneurysms. Nat Rev Dis Primers 2018; 4:34. [PMID: 30337540 DOI: 10.1038/s41572-018-0030-7] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.
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Affiliation(s)
- Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium. .,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.
| | - Jean-Baptiste Michel
- UMR 1148, INSERM Paris 7, Denis Diderot University, Xavier Bichat Hospital, Paris, France
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium.,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.,Department of Medical Imaging, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Koichi Yoshimura
- Graduate School of Health and Welfare, Yamaguchi Prefectural University, Yamaguchi, Japan.,Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - 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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7
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Stoberock K, Kölbel T, Atlihan G, Debus ES, Tsilimparis N, Larena-Avellaneda A, Behrendt CA, Wipper S. Gender differences in abdominal aortic aneurysm therapy - a systematic review. VASA 2018; 47:267-271. [PMID: 29733253 DOI: 10.1024/0301-1526/a000703] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This article analyses if and to what extent gender differences exist in abdominal aortic aneurysm (AAA) therapy. For this purpose Medline (PubMed) was searched from January 1999 to January 2018. Keywords were: "abdominal aortic aneurysm", "gender", "prevalence", "EVAR", and "open surgery of abdominal aortic aneurysm". Regardless of open or endovascular treatment of abdominal aortic aneurysms, women have a higher rate of complications and longer hospitalizations compared to men. The majority of studies showed that women have a lower survival rate for surgical and endovascular treatment of abdominal aneurysms after both elective and emergency interventions. Women receive less surgical/interventional and protective medical treatment. Women seem to have a higher risk of rupture, a lower survival rate in AAA, and a higher rate of complications, regardless of endovascular or open treatment. The gender differences may be due to a higher age of women at diagnosis and therapy associated with higher comorbidity, but also because of genetic, hormonal, anatomical, biological, and socio-cultural differences. Strategies for treatment in female patients must be further defined to optimize outcome.
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Affiliation(s)
- Konstanze Stoberock
- 1 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- 1 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
| | - Gülsen Atlihan
- 1 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
| | - Eike Sebastian Debus
- 1 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
| | - Nikolaos Tsilimparis
- 1 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
| | | | | | - Sabine Wipper
- 1 Department of Vascular Medicine, University Heart Center Hamburg, Hamburg, Germany
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Patel R, Powell JT, Sweeting MJ, Epstein DM, Barrett JK, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-132. [PMID: 29384470 PMCID: PMC5817412 DOI: 10.3310/hta22050] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Short-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years. OBJECTIVE To assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention. DESIGN Two national, multicentre randomised controlled trials: EVAR-1 and EVAR-2. SETTING Patients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004. PARTICIPANTS Men and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding. INTERVENTIONS EVAR, OR or no intervention. MAIN OUTCOME MEASURES The primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness. RESULTS In EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27; p = 0.14]. At 0-6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality; p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56, p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65, p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient's lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality. LIMITATIONS Devices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009. CONCLUSIONS EVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign. FUTURE WORK To find easier ways to monitor sac expansion to trigger timely reintervention. TRIAL REGISTRATION Current Controlled Trials ISRCTN55703451. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full in Health Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rajesh Patel
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - David M Epstein
- Centre for Health Economics, University of York, York, UK.,Department of Applied Economics, University of Granada, Granada, Spain
| | - Jessica K Barrett
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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9
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Stoberock K, Rieß HC, Debus ES, Schwaneberg T, Kölbel T, Behrendt CA. Gender differences in abdominal aortic aneurysms in Germany using health insurance claims data. VASA 2018; 47:36-42. [DOI: 10.1024/0301-1526/a000665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Abstract. Background: Endovascular aortic repair (EVAR) has emerged as standard of care for abdominal aortic aneurysm (AAA). Real-world evidence is limited to compare this technology to open repair (OAR). Major gaps exist related to short-term and long-term outcomes, particularly in respect of gender differences. Materials and methods: Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, was used to investigate invasive in-hospital treatment of intact (iAAA) and ruptured AAA (rAAA). Patients operated between October 2008 and April 2015 were included in the study. Results: A total of 5,509 patients (4,966 iAAA and 543 rAAA) underwent EVAR or OAR with a median follow-up of 2.44 years. Baseline demographics, comorbidities, and clinical characteristics of DAK-G patients were assessed. In total, 84.6 % of the iAAA and 79.9 % of the rAAA were male. Concerning iAAA repair, the median age (74 vs. 73 years, p < .001) compared to men was higher in females, but their EVAR-rate (66.8 % vs. 71.1 %, p = .018) was lower. Besides higher age of female patients (80 vs. 75 years, p < .001), no further statistically significant differences were seen following rAAA repair. In-hospital mortality was slightly lower in males compared to females following iAAA (2.3 % vs. 3.1 %, p = .159) and rAAA (37.3 % vs. 43.1 %, p = .273) repair. Concerning iAAA repair, a higher rate of female patients was transferred to another hospital (3.7 % vs. 2.0 %, p = 0.008) or discharged to rehabilitation (6.0 % vs. 2.7 %, p < .001) compared to male patients. Conclusions: In this large German claims data cohort, women are generally older and more often transferred to another hospital or discharged to rehab following iAAA repair. Nonetheless, no significantly increased risk of in-hospital or late death appeared for women in multivariate analyses. Further studies are necessary to evaluate the impact of recent gender-specific treatment strategies on overall outcome under real-world settings.
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Affiliation(s)
- Konstanze Stoberock
- These authors contributed equally to this work
- Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Christian Rieß
- These authors contributed equally to this work
- Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thea Schwaneberg
- Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- These authors contributed equally to this work
- Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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A Majority of Admitted Patients With Ruptured Abdominal Aortic Aneurysm Undergo and Survive Corrective Treatment: A Population-Based Retrospective Cohort Study. World J Surg 2017; 40:3080-3087. [PMID: 27549597 PMCID: PMC5104803 DOI: 10.1007/s00268-016-3705-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Abdominal aortic aneurysm (AAA) is an asymptomatic, potentially lethal condition predominantly found in elderly. The mortality is 100 % if rupture occurs and left untreated, but even in treated patients the mortality is substantial. Female sex and treatment with open repair rather than endovascular aortic repair (EVAR) have been reported to negatively affect outcome. The objective was to describe the contemporary care and outcome of all treated and untreated patients with ruptured AAA (rAAA) admitted to hospital. Method Population-based retrospective investigation, including all patients admitted to the emergency departments within Stockholm County diagnosed with rAAA 2009–2013. All identified patients’ charts (n = 297) were analyzed; the study cohort includes 283 verified patients. Results Men were in majority [214 (76 %), 69 (24 %) women] and were younger than women (78 vs 82 years, p < 0.001). A majority of patients were treated (212/283, 75 %), a similar proportion of women and men. Untreated patients had a higher mean age (84 vs 77 years, p < 0.001). The proportion treated with EVAR was 27 %, and they were older than OR treated (79 vs 76 years, p = 0.043). Forty-seven percentage of patients admitted with rAAA survived 30 days, and 62 % of treated patients survived 30 days. The 30-day mortality for women and men was similar. Conclusions Our results and other contemporary series show a shift toward a higher rate of treated patients with rAAA, and improving outcomes, similar for women and men. The increased use of EVAR contributes to this improvement in short-term outcome. High age influences the willingness to treat patients with rAAA.
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Söderberg P, Wanhainen A, Svensjö S. Five Year Natural History of Screening Detected Sub-Aneurysms and Abdominal Aortic Aneurysms in 70 Year Old Women and Systematic Review of Repair Rate in Women. Eur J Vasc Endovasc Surg 2017; 53:802-809. [DOI: 10.1016/j.ejvs.2017.02.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/21/2017] [Indexed: 11/30/2022]
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12
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Evaluation for abdominal aortic aneurysms is justified in patients with thoracic aortic aneurysms. Int J Cardiovasc Imaging 2015; 32:647-53. [PMID: 26602411 DOI: 10.1007/s10554-015-0807-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
Abstract
Aortic aneurysms are a significant cause of mortality, and the presence of multiple aneurysms may affect treatment plans. The purpose of this study was to determine the frequency of abdominal aortic aneurysms (AAAs) in patients with thoracic aortic aneurysms (TAAs) and to establish whether patient specific factors, such as gender and comorbidities, influenced the frequency of AAAs, thereby indicating if and when abdominal aortic evaluation is justified. Electronic medical records were reviewed from 1000 patients with a computed tomography (CT) angiogram of the chest and abdomen and a clinical diagnosis of TAA from Cardiac Surgery clinic between 2008 and 2013. 538 patients with history of aortic intervention, dissection, rupture or trauma were excluded. The frequency of AAAs among the 462 remaining patients was established, and statistical analysis was used to elucidate differences in frequency based on age, gender, comorbidities, and TAA location. Overall, 104 of 462 (22.5 %) patients with a TAA also had an AAA. There were significant differences in the frequency of AAA based on TAA location, age, and comorbidities. The following comorbidities showed positive associations with AAA using logistic regression analysis: age ≥65 (P < 0.0001; OR 30.1; CI 7.14-126.61), smoking history (P < 0.0001; OR 4.1; 2.35-7.30), and hypertension (P = 0.024; OR 2.1; CI 1.11-4.16). Aneurysms in the proximal/mid descending (P < 0.0001; OR 4.96; CI 2.32-10.61) and diaphragm level (P < 0.0001; OR 38.4; CI 14.71-100.15) of the aorta also showed a positive association with AAAs when adjusted for age and gender. AAA screening in patients with TAA is a reasonable, evidence-based option regardless of the TAA location, with the strongest support in patients >age 55, with systemic hypertension, a smoking history and/or a TAA in the descending thoracic aorta.
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Gray C, Goodman P, Cullen P, Badger SA, O'Malley K, O'Donohoe MK, McDonnell CO. Screening for Peripheral Arterial Disease and Carotid Artery Disease in Patients With Abdominal Aortic Aneurysm. Angiology 2015; 67:346-9. [DOI: 10.1177/0003319715590299] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Screening for concomitant atherosclerotic disease is important in cardiovascular risk reduction. This study assessed the prevalence of carotid artery disease (CAD) and peripheral arterial disease (PAD) in patients with known abdominal aortic aneurysms (AAAs). All patients with AAA attending the vascular laboratory between the January 1, 2007, and December 31, 2009, were eligible for a carotid ultrasound and measurement of ankle brachial indices. A total of 389 (305 males) patients were identified on the AAA surveillance program with a mean (±standard deviation) age of 76 (±8) years. The mean age of the males was 75.4 (±7.8) years, and the mean age of the females was 77 (±11) years. A total of 332 patients were assessed for CAD, and 101 (30.4%) of those were found to have significant disease. A total of 289 patients were assessed for PAD of which 131 (45.3%) were found to have PAD at rest, and 289 patients were assessed for both and 59 (20.4%) patients had significant CAD + PAD. Patients with AAAs are at high risk of other atherosclerotic disorders, and, therefore, they should receive intensive medical optimization.
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Affiliation(s)
- Cleona Gray
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Patrick Goodman
- School of Physics, Dublin Institute of Technology, Dublin, Ireland
| | - Paul Cullen
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stephen A. Badger
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kevin O'Malley
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin K. O'Donohoe
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciaran O. McDonnell
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Part Two: Against the Motion. Evidence Does Not Support Reducing the Threshold Diameter to 5 cm for Elective Interventions in Women with Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2014; 48:614-8. [DOI: 10.1016/j.ejvs.2014.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Vavra AK, Kibbe MR, Bown MJ, Powell JT. Debate: Whether evidence supports reducing the threshold diameter to 5 cm for elective interventions in women with abdominal aortic aneurysms. J Vasc Surg 2014; 60:1695-701. [DOI: 10.1016/j.jvs.2014.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Svensjö S, Mani K, Björck M, Lundkvist J, Wanhainen A. Screening for Abdominal Aortic Aneurysm in 65-Year-old Men Remains Cost-effective with Contemporary Epidemiology and Management. Eur J Vasc Endovasc Surg 2014; 47:357-65. [DOI: 10.1016/j.ejvs.2013.12.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
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17
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Starr JE, Halpern V. Abdominal aortic aneurysms in women. J Vasc Surg 2013; 57:3S-10S. [DOI: 10.1016/j.jvs.2012.08.125] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 08/03/2012] [Accepted: 08/25/2012] [Indexed: 10/27/2022]
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18
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Santo AH, Puech-Leão P, Krutman M. Trends in aortic aneurysm- and dissection-related mortality in the state of São Paulo, Brazil, 1985-2009: multiple-cause-of-death analysis. BMC Public Health 2012; 12:859. [PMID: 23046791 PMCID: PMC3527140 DOI: 10.1186/1471-2458-12-859] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 10/03/2012] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Aortic aneurysm and dissection are important causes of death in older people. Ruptured aneurysms show catastrophic fatality rates reaching near 80%. Few population-based mortality studies have been published in the world and none in Brazil. The objective of the present study was to use multiple-cause-of-death methodology in the analysis of mortality trends related to aortic aneurysm and dissection in the state of Sao Paulo, between 1985 and 2009. METHODS We analyzed mortality data from the Sao Paulo State Data Analysis System, selecting all death certificates on which aortic aneurysm and dissection were listed as a cause-of-death. The variables sex, age, season of the year, and underlying, associated or total mentions of causes of death were studied using standardized mortality rates, proportions and historical trends. Statistical analyses were performed by chi-square goodness-of-fit and H Kruskal-Wallis tests, and variance analysis. The joinpoint regression model was used to evaluate changes in age-standardized rates trends. A p value less than 0.05 was regarded as significant. RESULTS Over a 25-year period, there were 42,615 deaths related to aortic aneurysm and dissection, of which 36,088 (84.7%) were identified as underlying cause and 6,527 (15.3%) as an associated cause-of-death. Dissection and ruptured aneurysms were considered as an underlying cause of death in 93% of the deaths. For the entire period, a significant increased trend of age-standardized death rates was observed in men and women, while certain non-significant decreases occurred from 1996/2004 until 2009. Abdominal aortic aneurysms and aortic dissections prevailed among men and aortic dissections and aortic aneurysms of unspecified site among women. In 1985 and 2009 death rates ratios of men to women were respectively 2.86 and 2.19, corresponding to a difference decrease between rates of 23.4%. For aortic dissection, ruptured and non-ruptured aneurysms, the overall mean ages at death were, respectively, 63.2, 68.4 and 71.6 years; while, as the underlying cause, the main associated causes of death were as follows: hemorrhages (in 43.8%/40.5%/13.9%); hypertensive diseases (in 49.2%/22.43%/24.5%) and atherosclerosis (in 14.8%/25.5%/15.3%); and, as associated causes, their principal overall underlying causes of death were diseases of the circulatory (55.7%), and respiratory (13.8%) systems and neoplasms (7.8%). A significant seasonal variation, with highest frequency in winter, occurred in deaths identified as underlying cause for aortic dissection, ruptured and non-ruptured aneurysms. CONCLUSIONS This study introduces the methodology of multiple-causes-of-death to enhance epidemiologic knowledge of aortic aneurysm and dissection in São Paulo, Brazil. The results presented confer light to the importance of mortality statistics and the need for epidemiologic studies to understand unique trends in our own population.
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Affiliation(s)
- Augusto Hasiak Santo
- Departamento de Epidemiologia, Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, Brazil
| | - Pedro Puech-Leão
- Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mariana Krutman
- Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Female and Elderly Abdominal Aortic Aneurysm Patients More Commonly Have Concurrent Thoracic Aortic Aneurysm. Ann Vasc Surg 2012; 26:918-23. [DOI: 10.1016/j.avsg.2012.01.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 01/15/2012] [Accepted: 01/28/2012] [Indexed: 11/19/2022]
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20
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Oszajca K, Wroński K, Janiszewska G, Bieńkiewicz M, Panek M, Bartkowiak J, Szemraj J. Association analysis of genetic polymorphisms of factor V, factor VII and fibrinogen β chain genes with human abdominal aortic aneurysm. Exp Ther Med 2012. [PMID: 23181128 PMCID: PMC3503697 DOI: 10.3892/etm.2012.608] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Increased activity of the coagulation system is associated with the increased risk of many arterial thrombotic diseases and atherosclerosis. The purpose of this study was to evaluate the influence of selected polymorphisms in genes coding for coagulation factor V (1691 G/A, the so-called Leiden mutation), factor VII (−323 0/10 bp insertion/deletion) and fibrinogen β chain (−455 G/A) on the risk of abdominal aortic aneurysm, a particular form of atherothrombosis. We conducted a case-control study of 153 Polish patients hospitalized due to abdominal aortic aneurysm (AAA) and compared the results to those obtained from matched healthy control subjects. The polymorphisms were ascertained through genotyping by polymerase chain reaction and restriction digestion of amplified fragments. The study revealed that individuals carrying heterozygous genotype GA for the fibrinogen β chain −455 G/A mutation had at least a 2-fold greater likelihood of AAA development compared to control subjects (OR=3.01; 95% CI 1.83–4.96). The cases possessing homozygous mutant genotype (AA) had no significant risk of developing AAA compared to the control subjects (OR=1.12; 95% CI 0.33–2.44; p=0.83). Concerning factor V 1691 G/A and factor VII −323 0/10 bp mutations, we did not find any statistically significant correlation between them and AAA occurrence. In conclusion, we suggest that the −455G/A polymorphism of the fibrinogen β chain gene is a potential genetic marker to identify the risk of AAA.
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Affiliation(s)
- Katarzyna Oszajca
- Department of Medical Biochemistry, Medical University of Lodz, Lodz 90-419
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21
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Jackson BM, Woo EY, Bavaria JE, Fairman RM. Gender analysis of the pivotal results of the Medtronic Talent Thoracic Stent Graft System (VALOR) trial. J Vasc Surg 2011; 54:358-63, 363.e1. [DOI: 10.1016/j.jvs.2010.12.064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 12/06/2010] [Accepted: 12/18/2010] [Indexed: 11/27/2022]
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22
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Villard C, Swedenborg J, Eriksson P, Hultgren R. Reproductive history in women with abdominal aortic aneurysms. J Vasc Surg 2011; 54:341-5, 345.e1-2. [PMID: 21620618 DOI: 10.1016/j.jvs.2010.12.069] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 12/10/2010] [Accepted: 12/30/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of abdominal aortic aneurysms (AAAs) differs considerably between the sexes, illustrated by the male/female ratio 4-6:1. Women are also reported to have a higher risk of rupture, and a poorer outcome compared with men. The primary aim of this study was to investigate if women with AAA have a different reproductive history compared with other women. The secondary aim was to study if women with a larger AAA differ in their reproductive history from women with a smaller AAA. METHOD This case-control study was performed in October 2009 and included 140 consecutively monitored women with AAA and 140 with peripheral arterial disease (PAD) at the Department of Vascular Surgery at Karolinska University Hospital, Stockholm. AAA was defined as AAA diameter >3 cm, and women with AAA were subdivided into groups with AAA diameter ≥5 cm and diameter <5 cm. A validated questionnaire was used to obtain information about participants' reproductive history and general health. The response rate was 70% (n = 196). RESULTS Women with AAA were smokers to a greater extent than women with PAD (previous, 52% vs 46%; current, 46% vs 34%, P = .001). Diabetes mellitus was more prevalent in women with PAD (28%) than in women with AAA (15%, P = .034). Angina pectoris occurred more often in women with AAA (26%) than in women with PAD (11%, P = .026). No significant difference was found between PAD and AAA women regarding statin use, treatment for hypertension, prior myocardial infarction, and body mass index (BMI). The 54 women with AAA ≥5 cm and the 44 women with AAA <5 cm were similar in age (76 vs 76 years, P = .908) and BMI (25.7 vs 24.0 kg/m(2), P = .66). No difference was noted in the occurrence of other risk factors between women with AAA ≥5 cm and women with AAA <5 cm. Mean age at menopause was lower in women with AAA ≥5 cm than in women with AAA <5 cm and in women with PAD (47.7 vs 49.9 vs 49.7 years, P = .011). Apart from menopausal age, the groups had a similar reproductive history, including hormone replacement therapy, parity, use of contraceptives, prior gynecological surgery, and breast cancer. CONCLUSION These findings suggest that women with larger AAA reach menopausal age earlier, and this could influence an earlier onset of aneurysmatic disease or an increase in aneurysm growth. The true role of endogenous estrogen in aneurysm development and expansion is yet to be investigated.
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Affiliation(s)
- Christina Villard
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
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23
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Michel JB, Martin-Ventura JL, Egido J, Sakalihasan N, Treska V, Lindholt J, Allaire E, Thorsteinsdottir U, Cockerill G, Swedenborg J. Novel aspects of the pathogenesis of aneurysms of the abdominal aorta in humans. Cardiovasc Res 2011; 90:18-27. [PMID: 21037321 PMCID: PMC3058728 DOI: 10.1093/cvr/cvq337] [Citation(s) in RCA: 239] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 10/04/2010] [Accepted: 10/20/2010] [Indexed: 01/22/2023] Open
Abstract
Aneurysm of the abdominal aorta (AAA) is a particular, specifically localized form of atherothrombosis, providing a unique human model of this disease. The pathogenesis of AAA is characterized by a breakdown of the extracellular matrix due to an excessive proteolytic activity, leading to potential arterial wall rupture. The roles of matrix metalloproteinases and plasmin generation in progression of AAA have been demonstrated both in animal models and in clinical studies. In the present review, we highlight recent studies addressing the role of the haemoglobin-rich, intraluminal thrombus and the adventitial response in the development of human AAA. The intraluminal thrombus exerts its pathogenic effect through platelet activation, fibrin formation, binding of plasminogen and its activators, and trapping of erythrocytes and neutrophils, leading to oxidative and proteolytic injury of the arterial wall. These events occur mainly at the intraluminal thrombus-circulating blood interface, and pathological mediators are conveyed outwards, where they promote matrix degradation of the arterial wall. In response, neo-angiogenesis, phagocytosis by mononuclear cells, and a shift from innate to adaptive immunity in the adventitia are observed. Abdominal aortic aneurysm thus represents an accessible spatiotemporal model of human atherothrombotic progression towards clinical events, the study of which should allow further understanding of its pathogenesis and the translation of pathogenic biological activities into diagnostic and therapeutic applications.
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Affiliation(s)
- Jean-Baptiste Michel
- Inserm Unit 698, Cardiovascular Remodelling, Denis Diderot University, Hôpital X. Bichat, Paris, France.
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Abstract
OBJECTIVE To investigate the prevalence of thoracic aortic aneurysms (TAA) in patients with abdominal aortic aneurysms (AAA). BACKGROUND Different disease profiles between men and women treated for AAA have been reported. Reports regarding causes of death for treated AAA patients have shown an increased risk of death because of other aneurysms for women, possibly TAA. The prevalence of TAA in AAA patients is not well known. METHODS Data for AAA patients attending the outpatient clinic at a university hospital were analyzed (N = 1055). Patients who had undergone abdominal and thoracic computed tomography were included (n = 354). The diameter of the aorta was measured in the ascending, descending, and infrerenal aorta. Comorbid conditions were analyzed. RESULTS Mean age was 74 years, 23% were women. The presence of comorbid conditions did not differ between men and women except for a higher proportion of female smokers (P = 0.003). When sex-specific criteria were used, 100 patients (28%) had a TAA, 38 (48%) of the women compared with 62 (23%) of the men (P < 0.0001). Odds ratio for women compared with those of men to have a concurrent TAA was 3.09 (95% confidence interval, 1.84-5.22). CONCLUSIONS More than one fourth of patients with AAA attending a regular outpatient clinic have a concomitant TAA, and women are particularly affected. During the last decades, the therapeutic options for TAA patients have changed considerably. Physicians need to increase the efforts to investigate also the thoracic aorta in AAA patients.
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25
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Systematic review and meta-analysis of sex differences in outcome after intervention for abdominal aortic aneurysm. Br J Surg 2010; 97:1169-79. [DOI: 10.1002/bjs.7134] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Background
The aim of this study was to assess possible differences in mortality between men and women with an abdominal aortic aneurysm (AAA) treated either by elective repair or following aneurysm rupture.
Methods
A systematic literature search was performed using the MEDLINE, Cochrane and Embase databases. Data were analysed by means of bivariate random-effects meta-analysis. Data were pooled and odds ratios (ORs) calculated for women compared with men.
Results
Sixty-one studies (516 118 patients) met the predetermined inclusion criteria. Twenty-six reported on elective open AAA repair, 21 on elective endovascular repair, 25 on open repair for ruptured AAA and one study on endovascular repair for ruptured AAA. Mortality rates for women compared with men were 7·6 versus 5·1 per cent (OR 1·28, 95 per cent confidence interval (c.i.) 1·09 to 1·49) for elective open repair, 2·9 versus 1·5 per cent (OR 2·41, 95 per cent c.i. 1·14 to 5·15) for elective endovascular repair, and 61·8 versus 42·2 per cent (OR 1·16, 95 per cent c.i. 0·97 to 1·37) in the group that had open repair for rupture. The group that had endovascular repair for ruptured AAA was too small for meaningful analysis.
Conclusion
Women with an AAA had a higher mortality rate following elective open and endovascular repair.
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Mani K, Björck M, Lundkvist J, Wanhainen A. Improved Long-Term Survival After Abdominal Aortic Aneurysm Repair. Circulation 2009; 120:201-11. [DOI: 10.1161/circulationaha.108.832774] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Treatment of abdominal aortic aneurysm (AAA) has changed significantly over the past 2 decades. In this perspective, time trends in long-term survival were studied.
Methods and Results—
We identified 8663 primary intact and 4171 ruptured AAA repairs in the Swedish Vascular Registry from 1987 to 2005. Mortality was obtained from the national population registry. Crude survival was analyzed, including all mortality. To analyze the long-term outcome among those surviving the AAA repair, relative survival, which denotes the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, was calculated, excluding 90-day mortality. In a comparison of AAA repairs from 1987 to 1999 and 2000 to 2005, age (71.4 versus 72.5 years;
P
<0.001), patients with comorbidities (65.0% versus 68.5%;
P
<0.001), and endovascular repair (1.6% versus 17.0%;
P
<0.001) increased. After intact AAA repair, crude 5-year survival was 69.0% (99% confidence interval [CI], 67.7 to 70.4), and relative 5-year survival excluding 90-day mortality was 90.3% (99% CI, 88.6 to 92.0). Relative 5-year survival was better for those operated on from 2000 to 2005 compared with 1987 to 1999 (difference, 4.7%; 99% CI, 1.3 to 8.1), for men versus women (4.6%; 99% CI, 0.4 to 8.8), and for octogenarians versus patients <80 years of age (10.2%; 99% CI, 1.5 to 18.8); no difference was observed between open and endovascular repair (6.0%; 99% CI, −1.5 to 13.4). After ruptured AAA repair, crude 5-year survival was 41.7% (99% CI, 39.6 to 43.7) and relative 5-year survival was 87.1% (99% CI, 83.9 to 90.3). No significant differences in relative 5-year survival were observed between time periods, sex, or age groups.
Conclusions—
Long-term survival improved over time after intact AAA repair despite a change in case mix toward older patients with more comorbidities. Long-term survival was stable after ruptured AAA repair.
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Affiliation(s)
- Kevin Mani
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
| | - Martin Björck
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
| | - Jonas Lundkvist
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
| | - Anders Wanhainen
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
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Larsson E, Granath F, Swedenborg J, Hultgren R. More patients are treated for nonruptured abdominal aortic aneurysms, but the proportion of women remains unchanged. J Vasc Surg 2008; 48:802-7. [PMID: 18639419 DOI: 10.1016/j.jvs.2008.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Revised: 04/25/2008] [Accepted: 05/04/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Large variations in the intervention rates for ruptured and nonruptured abdominal aortic aneurysm (AAA) over time have been reported, both decreasing and increasing numbers. Women have been reported to constitute an increasing proportion of patients treated for several manifestations of cardiovascular disease; whether a similar trend is true for AAA is not well understood. This study investigated recent temporal trends in a complete national register regarding the number and type of procedure performed for AAA, and outcome, with special emphasis on gender differences. METHODS Data for all individuals treated for nonruptured or ruptured AAA in Sweden (1990 to 2005) were obtained from the Swedish National Board of Health and Welfare (NBHW). A total of 14369 individuals were identified; 2327 (16%) were women. Date and type of intervention, date and cause of death, age, and sex were included in the statistical model. RESULTS There was a relative annual increase in interventions for nonruptured AAA; 4% for women (P < .0001) and 2% for men (P < .0001). No significant trends were observed for interventions for rupture during the observation period. No significant increase in the proportion of women was recorded for nonrupture (17%) or rupture (15%). Women had higher crude 30-day mortality rate than men after treatment for both nonruptured (5.7% vs 4.9%) and ruptured (41.9% vs 36.8%) AAA. In a logistic regression model, survival improved over time after intervention for nonrupture (P < .0001) and rupture (P < .0001). Increasing age (P < .0001 for both nonrupture and rupture) but not sex (P = .49 for non rupture and P = .42 for rupture) had a negative influence on mortality. CONCLUSION Interventions for nonruptured but not for ruptured AAA increased over time, with an expected rapid increase of endovascular repair in the nonruptured group. The unchanged fraction of women over time possibly reflects the true distribution of AAA between the sexes. The outcome after treatment for both nonruptured and ruptured AAA improved, as anticipated, over time. No increase in mortality among women was recorded after adjustment for age.
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Affiliation(s)
- Emma Larsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Abstract
The risk of rupture for aneurysms 5-5.5 cm in diameter has not been specifically studied. Two large randomised trials, the United Kingdom Small Aneurysm Trial and the Aneurysm Detection And Management Study Trial concluded that immediate surgical repair did not offer any benefit compared to surveillance and surgical repair if the aneurysm reached 5.5 cm or became symptomatic. Despite these findings many indications today suggest that a lower threshold should be used in patients with higher risk for rupture e.g. women or low risk of mortality in connection with AAA repair such as patients in the lower range of ages.
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Affiliation(s)
- J Swedenborg
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
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Abstract
Although abdominal aortic aneurysm (AAA) is 4 to 6 times more common in men than in women, more than a third of all AAA deaths occur in women. In several reports from the UK Small Aneurysm Trial group, the rupture rate for women was 3–4 times that seen in men. A joint council of several vascular societies responded to these observations with the recommendation that AAA should be repaired earlier in women, at 4.5 cm to 5.0 cm rather than the 5.5 cm established in randomized trials for men. However, this recommendation does not appear to reflect a full consideration of the evidence. For example, population-based studies have reported mortality following AAA repair to be 40–60% higher in women than in men. Also, in the UK Small Aneurysm Trial itself, there was no trend toward a benefit from early repair in women. The totality of evidence available at present provides no good reason to alter for women the 5.5 cm threshold for elective repair established for men by the small AAA trials.
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Affiliation(s)
- F. A. Lederle
- Center for Epidemiological and Clinical Research, VA Medical Center, Minneapolis, MN, U.S.A
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Böckler D, Burger U, Klemm K, Hyhlik-Dürr A. Geschlechtsverteilung aortaler Gefäßerkrankungen. GEFASSCHIRURGIE 2007. [DOI: 10.1007/s00772-007-0561-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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