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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: 119] [Impact Index Per Article: 119.0] [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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Leone N, Broda MA, Eiberg JP, Resch TA. Systematic Review and Meta-Analysis of the Incidence of Rupture, Repair, and Death of Small and Large Abdominal Aortic Aneurysms under Surveillance. J Clin Med 2023; 12:6837. [PMID: 37959301 PMCID: PMC10648148 DOI: 10.3390/jcm12216837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture risk, and recently, large AAAs just above the threshold (5.5-6.0 cm) seem to be at low risk of rupture as well. The present review aims to investigate the outcomes of AAAs under surveillance through a comprehensive systematic review and meta-analysis. METHODS PubMed, Embase, and the Cochrane Central Register were searched (22 March 2022; PROSPERO; #CRD42022316094). The Cochrane and PRISMA statements were respected. Blinded systematic screening of the literature, data extraction, and quality assessment were performed by two authors. Conflicts were resolved by a third author. The meta-analysis of prevalence provided estimated proportions, 95% confidence intervals, and measures of heterogeneity (I2). Based on I2, the heterogeneity might be negligible (0-40%), moderate (30-60%), substantial (50-90%), and considerable (75-100%). The primary outcome was the incidence of AAA rupture. Secondary outcomes included the rate of small AAAs reaching the threshold for repair, aortic-related mortality, and all-cause mortality. RESULTS Fourteen publications (25,040 patients) were included in the analysis. The outcome rates of the small AAA group (<55 mm) were 0.3% (95% CI 0.0-1.0; I2 = 76.4%) of rupture, 0.6% (95% CI 0.0-1.9; I2 = 87.2%) of aortic-related mortality, and 9.6% (95% CI 2.2-21.1; I2 = 99.0%) of all-cause mortality. During surveillance, 21.4% (95% CI 9.0-37.2; I2 = 99.0%) of the initially small AAAs reached the threshold for repair. The outcome rates of the large AAA group (>55 mm) were 25.7% (95% CI 18.0-34.3; I2 = 72.0%) of rupture, 22.1% (95% CI 16.5-28.3; I2 = 25.0%) of aortic-related mortality, and 61.8% (95% CI 47.0-75.6; I2 = 89.1%) of all-cause mortality. The sensitivity analysis demonstrated a higher rupture rate in studies including <662 subjects, patients with a mean age > 72 years, >17% of female patients, and >44% of current smokers. CONCLUSION The rarity of rupture and aortic-related mortality in small AAAs supports the current conservative management of small AAAs. Surveillance seems indicated, as one-fifth reached the threshold for repair. Large aneurysms had a high incidence of rupture and aortic-related mortality. However, these data seem biased by the sparse and heterogeneous literature overrepresented by patients unfit for surgery. Specific rupture risk stratified by age, gender, and fit-for-surgery patients with large AAAs needs to be further investigated.
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Affiliation(s)
- Nicola Leone
- Department of Vascular Surgery, Rigshospitalet, 2200 Copenhagen, Denmark; (M.A.B.); (J.P.E.); (T.A.R.)
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Magdalena Anna Broda
- Department of Vascular Surgery, Rigshospitalet, 2200 Copenhagen, Denmark; (M.A.B.); (J.P.E.); (T.A.R.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 1172 København, Denmark
| | - Jonas Peter Eiberg
- Department of Vascular Surgery, Rigshospitalet, 2200 Copenhagen, Denmark; (M.A.B.); (J.P.E.); (T.A.R.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 1172 København, Denmark
- Copenhagen Academy of Medical Education and Simulation (CAMES), 2100 København, Denmark
| | - Timothy Andrew Resch
- Department of Vascular Surgery, Rigshospitalet, 2200 Copenhagen, Denmark; (M.A.B.); (J.P.E.); (T.A.R.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 1172 København, Denmark
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Talvitie M, Åldstedt-Nyrønning L, Stenman M, Roy J, Cohnert T, Hultgren R. Women with large intact abdominal aortic aneurysms remain untreated. J Vasc Surg 2023; 78:657-667.e5. [PMID: 37211143 DOI: 10.1016/j.jvs.2023.05.025] [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: 03/03/2023] [Revised: 04/20/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE A lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. METHODS This was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of "truly untreated" (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. RESULTS Women and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). CONCLUSIONS Surgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Linn Åldstedt-Nyrønning
- Department of Surgery, Vascular Surgery, St Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tina Cohnert
- Department of Vascular Surgery, Medical University of Graz, Graz, Austria
| | - 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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Shahin Y, Dixon S, Kerr K, Cleveland T, Goode SD. Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair. J Vasc Surg 2023; 77:386-395.e3. [PMID: 36152982 DOI: 10.1016/j.jvs.2022.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.
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Affiliation(s)
- Yousef Shahin
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; SAMRC/WITS Centre for Health Economics and Decision Science-PRICELESS, Johannesburg, South Africa
| | - Karen Kerr
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK
| | - Stephen D Goode
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK.
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Titarenko V, Beer A, Schonefeld-Siepmann E, Muschal F, Beyer JK. Giant Symptomatic Unruptured Juxtarenal Abdominal Aortic Aneurysm. Vasc Specialist Int 2022; 38:23. [PMID: 36097707 PMCID: PMC9468660 DOI: 10.5758/vsi.220019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Herein, we present the case of an 84-year-old male with a 13-cm, symptomatic, unruptured juxtarenal abdominal aortic aneurysm. This aneurysm was successfully treated with open surgical repair, which was deemed satisfactory at the 3-year follow-up. Despite a paradigm shift towards endovascular techniques in aortic repair, postgraduate training with a focused exposure to open aortic surgery at high-volume centers is essential for future vascular surgeons to safely perform complex aortic repairs with acceptable mortality and morbidity rates.
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Affiliation(s)
- Valentin Titarenko
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Anita Beer
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Eva Schonefeld-Siepmann
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Felix Muschal
- Departments of Interventional, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Jochen Karsten Beyer
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
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Lancaster EM, Gologorsky R, Hull MM, Okuhn S, Solomon MD, Avins AL, Adams JL, Chang RW. The natural history of large abdominal aortic aneurysms in patients without timely repair. J Vasc Surg 2021; 75:109-117. [PMID: 34324972 DOI: 10.1016/j.jvs.2021.07.125] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Contemporary data on the natural history of large abdominal aortic aneurysms (AAAs) in patients undergoing delayed or no repair are lacking. In this study, we examine the impact of large AAA size on the incidence of rupture and mortality. METHODS From a prospectively maintained aneurysm surveillance registry, patients with an unrepaired, large AAA (≥5.5 cm in men and ≥5.0 cm in women) at baseline (ie, index imaging) or who progressed to a large size from 2003 to 2017 were included, with follow-up through March 2020. Outcomes of interest obtained by manual chart review included rupture (confirmed by imaging/autopsy), probable rupture (timing/findings consistent with rupture without more likely cause of death), repair, reasons for either no or delayed (>1 year after diagnosis of large AAA) repair and total mortality. Cumulative incidence of rupture was calculated using a nonparametric cumulative incidence function, accounting for the competing events of death and aneurysm repair and was stratified by patient sex. RESULTS Of the 3248 eligible patients (mean age, 83.6 ± 9.1 years; 71.2% male; 78.1% white; and 32.0% current smokers), 1423 (43.8%) had large AAAs at index imaging, and 1825 progressed to large AAAs during the follow-up period, with a mean time to qualifying size of 4.3 ± 3.4 years. In total, 2215 (68%) patients underwent repair, of which 332 were delayed >1 year; 1033 (32%) did not undergo repair. The most common reasons for delayed repair were discrepancy in AAA measurement between surgeon and radiologist (34%) and comorbidity (20%), whereas the most common reasons for no repair were patient preference (48%) and comorbidity (30%). Among patients with delayed repair (mean time to repair, 2.6 ± 1.8 years), nine (2.7%) developed symptomatic aneurysms, and an additional 11 (3.3%) ruptured. Of patients with no repair, 94 (9.1%) ruptured. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 3-year cumulative incidence of rupture of 12.8% (95% confidence interval, 7.5%-19.6%) compared with 4.5% (95% confidence interval, 3.0%-6.5%) in men (P = .002). CONCLUSIONS In this large cohort of AAA registry patients over 17 years, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. Further analyses are ongoing to identify those at increased risk for aneurysm rupture and may provide targeted surveillance regimens and improve patient counseling.
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Affiliation(s)
| | - Rebecca Gologorsky
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, Calif
| | - Michaela M Hull
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
| | - Steven Okuhn
- Division of Vascular Surgery, Department of Surgery, VA San Francisco Healthcare System, San Francisco, Calif
| | - Matthew D Solomon
- Department of Cardiology, The Permanente Medical Group, Oakland, Calif; Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif; Departments of Medicine, Epidemiology, and Biostatistics, University of California, San Francisco, Calif
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
| | - Robert W Chang
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif; Department of Vascular Surgery, Permanente Medical Group, South San Francisco, Calif.
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7
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Gravesteijn B, Krijkamp E, Busschbach J, Geleijnse G, Helmrich IR, Bruinsma S, van Lint C, van Veen E, Steyerberg E, Verhoef K, van Saase J, Lingsma H, Baatenburg de Jong R. Minimizing Population Health Loss in Times of Scarce Surgical Capacity During the Coronavirus Disease 2019 Crisis and Beyond: A Modeling Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:648-657. [PMID: 33933233 PMCID: PMC7933792 DOI: 10.1016/j.jval.2020.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/29/2020] [Accepted: 12/13/2020] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Coronavirus disease 2019 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model to estimate the impact of postponing semielective surgical procedures on health, to support prioritization of care from a utilitarian perspective. METHODS A cohort state-transition model was developed and applied to 43 semielective nonpediatric surgical procedures commonly performed in academic hospitals. Scenarios of delaying surgery from 2 weeks were compared with delaying up to 1 year and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization Global Burden of Disease study. For each surgical procedure, the model estimated the average expected disability-adjusted life-years (DALYs) per month of delay. RESULTS Given the best available evidence, the 2 surgical procedures associated with most DALYs owing to delay were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 DALY/month, 95% confidence interval [CI]: 0.13-0.36) and transaortic valve implantation (0.15 DALY/month, 95% CI: 0.09-0.24). The 2 surgical procedures with the least DALYs were placing a shunt for dialysis (0.01, 95% CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95% CI: 0.01-0.02). CONCLUSION Expected health loss owing to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgical procedures to minimize population health loss in times of scarcity. The model results should be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.
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Affiliation(s)
- Benjamin Gravesteijn
- Department of Otorhinolaryngology (ENT), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline Krijkamp
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Jan Busschbach
- Department of Medical Psychology, Erasmus University Medical Center, Rotterdam, The Netherlands; Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Geert Geleijnse
- Department of Otorhinolaryngology (ENT), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabel Retel Helmrich
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sophie Bruinsma
- Department of Quality and Patient Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Céline van Lint
- Department of Quality and Patient Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ernest van Veen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kees Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan van Saase
- Department of Internal Medicine - Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hester Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rob Baatenburg de Jong
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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8
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Talvitie M, Stenman M, Roy J, Leander K, Hultgren R. Sex Differences in Rupture Risk and Mortality in Untreated Patients With Intact Abdominal Aortic Aneurysms. J Am Heart Assoc 2021; 10:e019592. [PMID: 33619974 PMCID: PMC8174277 DOI: 10.1161/jaha.120.019592] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Studies on intact abdominal aortic aneurysms mainly focus on treated patients, and data on untreated patients are sparse. The objective was to investigate sex differences among untreated patients regarding rupture and mortality rates and to determine predictors for these events. Sex‐specific causes of death were evaluated. Methods and Results All patients ≥40 years diagnosed from 2001 to 2015 (n=32 393) with intact abdominal aortic aneurysms were identified in national registries; 60% (n=19 569) were untreated. Comorbid loads, crude rupture, and mortality rates were assessed. Predictors of 5‐year rupture and mortality were analyzed in Cox models (sex, age, comorbidities, income, and marital status). The proportion of men and women with multiple comorbidities was similar. Within 5 years, 798 ruptures occurred (9.7% women versus 6.9% men, P<0.001). Ruptures were independently predicted by female sex (hazard ratio [HR], 1.23; 95% CI, 1.07–1.42; P=0.004), chronic obstructive pulmonary disease (HR, 1.36; 95% CI, 1.15–1.62; P<0.001), age (HR, 11.49; 95% CI, 5.68–23.25 for ≥80 years; P<0.001), and income (HR, 0.63; 95% CI, 0.53–0.75 for highest tertile; P<0.001). After 5 years, 56.5% women and 50.4% men were deceased. Mortality was not independently predicted by female sex. Rupture was the third most common cause of death (11.9% women versus 8.7% men; P<0.001). The median time‐to‐events was 2.8 years. Conclusions A considerable proportion of patients with intact abdominal aortic aneurysms in surveillance remain untreated. Despite surveillance algorithms, the healthcare system fails to prevent a high number of ruptures, especially among women. The time‐to‐event data highlight the urgency to develop more individualized surveillance.
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Perioperative Medicine and Intensive Care Function Karolinska University Hospital Stockholm Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
| | - Karin Leander
- Institute of Environmental Medicine, Karolinska Institutet Stockholm Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
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9
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Mani K. Turning Down Those Who Turn up for AAA Screening. Eur J Vasc Endovasc Surg 2020; 61:200. [PMID: 32792291 DOI: 10.1016/j.ejvs.2020.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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10
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Grima MJ, Behrendt CA, Vidal-Diez A, Altreuther M, Björck M, Boyle JR, Eldrup N, Karthikesalingam A, Khashram M, Loftus I, Schermerhorn M, Setacci C, Szeberin Z, Debus S, Venermo M, Holt P, Mani K. Editor's Choice - Assessment of Correlation Between Mean Size of Infrarenal Abdominal Aortic Aneurysm at Time of Intact Repair Against Repair and Rupture Rate in Nine Countries. Eur J Vasc Endovasc Surg 2020; 59:890-897. [PMID: 32217115 DOI: 10.1016/j.ejvs.2020.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 12/16/2019] [Accepted: 01/17/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study aimed to analyse the mean abdominal aortic aneurysm (AAA) diameter for repair in nine countries, and to determine variation in mean AAA diameter for elective AAA repair and its relationship to rupture AAA repair rates and aneurysm related mortality in corresponding populations. METHODS Data on intact (iAAA) and ruptured infrarenal AAA (rAAA) repair for the years 2010-2012 were collected from Denmark, England, Finland, Germany, Hungary, New Zealand, Norway, Sweden, and the USA. The rate of iAAA repair and rAAA per 100 000 inhabitants above 59 years old, mean AAA diameter for iAAA repair and rAAA repair, and the national rates of rAAA were assessed. National cause of death statistics were used to estimate aneurysm related mortality. Direct standardisation methods were applied to the national mortality data. Logistic regression and analysis of variance model adjustments were made for age groups, sex, and year. RESULTS There was a variation in the mean diameter of iAAA repair (n = 34 566; range Germany = 57 mm, Denmark = 68 mm). The standardised iAAA repair rate per 100000 inhabitants varied from 10.4 (Hungary) to 66.5 (Norway), p<.01, and the standardised rAAA repair rate per 100 000 from 5.8 (USA) to 16.9 (England), p<.01. Overall, there was no significant correlation between mean diameter of iAAA repair and standardised iAAA rate (r2 = 0.04, p = .3). There was no significant correlation between rAAA repair rate (n = 12 628) with mean diameter of iAAA repair (r2 = 0.2, p = .1). CONCLUSION Despite recommendations from learned society guidelines, data indicate variations in mean diameter for AAA repair. There was no significant correlation between mean diameter of AAA repair and rates of iAAA repair and rAAA repair. These analyses are subject to differences in disease prevalence, uncertainties in rupture rates, validations of vascular registries, causes of death and registrations.
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Affiliation(s)
- Matthew J Grima
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, UK.
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Alberto Vidal-Diez
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jonathan R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Alan Karthikesalingam
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Manar Khashram
- Department of Surgery, The University of Auckland, Waikato, New Zealand
| | - Ian Loftus
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Carlo Setacci
- Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - Zoltán Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Sebastian Debus
- Department of Vascular Medicine, Research Group GermanVasc, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Peter Holt
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
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Jetty P, Husereau D, Kansal V, Zhang T, Nagpal S. Variability in aneurysm sac regression after endovascular aneurysm repair based on a comprehensive registry of patients in Eastern Ontario. J Vasc Surg 2019; 70:1469-1478. [DOI: 10.1016/j.jvs.2019.01.091] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/22/2019] [Indexed: 12/01/2022]
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Endovascular Aneurysm Repair May Provide a Survival Advantage in Patients Deemed Physiologically Ineligible for Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2019; 61:334-340. [PMID: 31394243 DOI: 10.1016/j.avsg.2019.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity and fitness. It can be used to guide decision making prior to major vascular surgery. The EVAR-2 trial suggested that endovascular aneurysm repair (EVAR) in patients unfit for open repair failed to provide a significant survival advantage over nonsurgical management. The aim of this study is to assess contemporary survival differences between patients with poor CPET measures who underwent EVAR or were not offered surgical intervention. METHODS A prospectively maintained database of CPET results of patients considered for elective infrarenal aortic aneurysm repair were interrogated. Anaerobic threshold (AT) of <11 mL/min/kg was used to indicate poor physical fitness. Hospital electronic records were then reviewed for perioperative, reintervention, and long-term outcomes. RESULTS Between November 2007 and October 2017, 532 aortic aneurysm repairs were undertaken, of which 376 underwent preoperative CPET. Seventy patients were identified as having an AT <11 mL/min/kg. Thirty-seven patients underwent EVAR and 33 were managed nonsurgically. All-cause survival at 1, 3, and 5 years for those patients who underwent EVAR was 97%, 92%, and 81%, respectively. For those not offered surgical intervention survival at the same points was 72%, 48%, and 24% [hazard ratio, HR = 5.13 (1.67-15.82), P = 0.004]. Aneurysm-specific survival at 1, 3, and 5 years for those patients who underwent EVAR was 97%, 94%, and 94%, respectively. Survival at the same time points for those not offered surgical intervention was 90%, 69%, and 39%, respectively [HR = 7.48 (1.37-40.82), P = 0.02]. CONCLUSIONS In this small, retrospective, single-center, nonrandomized cohort, EVAR may provide a survival advantage in patients with poor physical fitness identified via CPET. Randomized studies with current generation EVAR are required to validate the results shown here.
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13
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Chan WC, Papaconstantinou D, Winnard D, Jackson G. Retrospective review of abdominal aortic aneurysm deaths in New Zealand: what proportion of deaths is potentially preventable by a screening programme in the contemporary setting? BMJ Open 2019; 9:e027291. [PMID: 31366645 PMCID: PMC6677995 DOI: 10.1136/bmjopen-2018-027291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To describe the proportions of people dying from abdominal aortic aneurysm (AAA) who might have benefited from a formal screening programme for AAA. DESIGN Retrospective cross-sectional review of deaths. SETTING AND STUDY POPULATIONS All AAA deaths registered in New Zealand from 2010 to 2014 in the absence of a national AAA screening programme. MAIN OUTCOME MEASURES Known history of AAA prior to the acute event leading to AAA death, prognosis limiting comorbidities, history of prior abdominal imaging and a validated multimorbidity measure (M3-index scores). RESULTS 1094 AAA deaths were registered in the 5 years between 2010 and 2014 in New Zealand. Prior to the acute AAA event resulting in death, 31.3% of the cohort had a known AAA diagnosis, and 10.9% had a previous AAA procedure. On average, the AAA diagnosis was known 3.7 years prior to death. At least 77% of the people dying from AAA also had one or more other prognosis limiting diagnosis. The hazard of 1-year mortality associated with the non-AAA related comorbidities for the AAA cohort aged 65 or above were 1.5-2.6 times higher than to the age matched general population based on M3-index scores. In 2014, overall AAA deaths accounted for only 0.7% of total deaths, and 1.0% of deaths among men aged 65 or above in New Zealand. At most, 20% of people dying from AAA in New Zealand between 2010 and 2014 might have had the potential to derive full benefit from a screening programme. About 51% of cases would have derived no or very limited benefit from a screening programme. CONCLUSION Falling AAA mortality, and high prevalence of competing comorbidities and/or prior AAA diagnosis and procedure raises the question about the likely value of a national AAA screening programme in a country such as New Zealand.
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Affiliation(s)
- Wing Cheuk Chan
- Population Health, Counties Manukau District Health Board, Auckland, New Zealand
| | | | - Doone Winnard
- Population Health, Counties Manukau District Health Board, Auckland, New Zealand
| | - Gary Jackson
- Population Health, Counties Manukau District Health Board, Auckland, New Zealand
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14
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Thompson SG, Bown MJ, Glover MJ, Jones E, Masconi KL, Michaels JA, Powell JT, Ulug P, Sweeting MJ. Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation. Health Technol Assess 2019; 22:1-142. [PMID: 30132754 DOI: 10.3310/hta22430] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain. OBJECTIVE To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options. DESIGN A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses. SETTING Population screening in the UK. PARTICIPANTS Women aged ≥ 65 years, followed up to the age of 95 years. INTERVENTIONS Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs. MAIN OUTCOME MEASURES Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting. DATA SOURCES AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP). REVIEW METHODS Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters. RESULTS The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was -£12.03 (95% uncertainty interval -£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination. LIMITATIONS The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women. CONCLUSION The accepted criteria for a population-based AAA screening programme in women are not currently met. FUTURE WORK A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020444 and CRD42016043227. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Simon G Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew J Bown
- Department of Cardiovascular Sciences and National Institute of Health Research (NIHR) Leicester Biomedical Research Unit, University of Leicester, Leicester, UK
| | - Matthew J Glover
- Health Economics Research Group, Brunel University London, London, UK
| | - Edmund Jones
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katya L Masconi
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jonathan A Michaels
- Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Pinar Ulug
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Michael J Sweeting
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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15
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Paraskevas KI, Eckstein HH, Schermerhorn ML. Guideline Recommendations for the Management of Abdominal Aortic Aneurysms. Angiology 2019; 70:688-689. [DOI: 10.1177/0003319719825518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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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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17
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Paraskevas KI. Reconsidering the Rupture Risk Potential of Abdominal Aortic Aneurysms in High Risk Patients. Eur J Vasc Endovasc Surg 2018; 55:290. [PMID: 29292206 DOI: 10.1016/j.ejvs.2017.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular and Endovascular Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK.
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18
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Endovascular Repair of Abdominal Aortic Aneurysm in Patients Physically Ineligible for Open Repair. Ann Surg 2017; 266:713-719. [DOI: 10.1097/sla.0000000000002392] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Johansson M, Harris RP. Thresholds in women with abdominal aortic aneurysm. Lancet 2017; 389:2446-2448. [PMID: 28455147 DOI: 10.1016/s0140-6736(17)31110-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Minna Johansson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Research Unit and Section for General Practice, FoUU-centrum Fyrbodal, 46235 Vänersborg, Sweden.
| | - Russell P Harris
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
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20
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Ulug P, Sweeting MJ, von Allmen RS, Thompson SG, Powell JT. Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. Lancet 2017; 389:2482-2491. [PMID: 28455148 PMCID: PMC5483509 DOI: 10.1016/s0140-6736(17)30639-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prognosis for women with abdominal aortic aneurysm might be worse than the prognosis for men. We aimed to systematically quantify the differences in outcomes between men and women being assessed for repair of intact abdominal aortic aneurysm using data from study periods after the year 2000. METHODS In these systematic reviews and meta-analysis, we identified studies (randomised, cohort, or cross-sectional) by searching MEDLINE, Embase, CENTRAL, and grey literature published between Jan 1, 2005, and Sept 2, 2016, for two systematic reviews and Jan 1, 2009, and Sept 2, 2016, for one systematic review. Studies were included if they were of both men and women, with data presented for each sex separately, with abdominal aortic aneurysms being assessed for aneurysm repair by either endovascular repair (EVAR) or open repair. We conducted three reviews based on whether studies reported the proportion morphologically suitable (within manufacturers' instructions for use) for EVAR (EVAR suitability review), non-intervention rates (non-intervention review), and 30-day mortality (operative mortality review) after intact aneurysm repair. Studies had to include at least 20 women (for the EVAR suitability review), 20 women (for the non-intervention review), and 50 women (for the operative mortality review). Studies were excluded if they were review articles, editorials, letters, or case reports. For the operative review, studies were also excluded if they only provided hazard ratios or only reported in-hospital mortality. We assessed the quality of the studies using the Newcastle-Ottawa scoring system, and contacted authors for the provision of additional data if needed. We combined results across studies by random-effects meta-analysis. This study is registered with PROSPERO, number CRD42016043227. FINDINGS Five studies assessed the morphological eligibility for EVAR (1507 men, 400 women). The overall pooled proportion of women eligible (34%) for EVAR was lower than it was in men (54%; odds ratio [OR] 0·44, 95% CI 0·32-0·62). Four single-centre studies reported non-intervention rates (1365 men, 247 women). The overall pooled non-intervention rates were higher in women (34%) than men (19%; OR 2·27, 95% CI 1·21-4·23). The review of 30-day mortality included nine studies (52 018 men, 11 076 women). The overall pooled estimate for EVAR was higher in women (2·3%) than in men (1·4%; OR 1·67, 95% CI 1·38-2·04). The overall estimate for open repair also was higher in women (5·4%) than in men (2·8%; OR 1·76, 95% CI 1·35-2·30). INTERPRETATION Compared with men, a smaller proportion of women are eligible for EVAR, a higher proportion of women are not offered intervention, and operative mortality is much higher in women for both EVAR and open repair. The management of abdominal aortic aneurysm in women needs improvement. FUNDING National Institute for Health Research (UK).
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Affiliation(s)
- Pinar Ulug
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Regula S von Allmen
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK; Clinic for Vascular Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Simon G Thompson
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK.
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Virgilio F, Maurel B, Davis M, Hamilton G, Mastracci TM. Vertebral Tortuosity Index in Patients with Non-Connective Tissue Disorder-Related Aneurysm Disease. Eur J Vasc Endovasc Surg 2017; 53:425-430. [PMID: 28065612 DOI: 10.1016/j.ejvs.2016.11.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/30/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The vertebral tortuosity index (VTI) predicts increased risk of acute aortic events in patients with known genetic aortopathies. This study describes the VTI in a cohort of patients with non-connective tissue disorder-related large aneurysms. METHODS Hospital imaging records from July 2012 to March 2016 were interrogated to identify patients with aneurysmal disease who had undergone computed tomographic angiography that included imaging of vertebral arteries. A control group of consecutive patients undergoing carotid and vertebral imaging was also assessed. VTI was calculated using the formula: [(centre-line distance) / (straight-line distance)-1] ×100 for all patients, and statistical analysis undertaken to determine whether measured VTI was statistically different in patients of younger age, with larger aneurysms, or an acute presentation. Comparison was made with patients who had no aneurysm disease. RESULTS Sixty-five patients were identified with adequate imaging to assess the entire aorta, including vertebral arteries. The majority of patients were male (71%, 46/65) and mean age at the time of the CT scan was 71 years (SD 11.1 years). There were 11 patients under the age of 60 years in this cohort. The mean VTI was 33.17 (SD 20.43). There was no statistically significant difference between different territories of presentation (proximal vs. distal aneurysm, p=.94), age of patient (>60 years vs. <60 years, p=.2), or size of aneurysm (>6 cm vs. <6 cm, p=.09). Acuity of presentation was not predicted by a higher VTI (p=.69). The VTI in patients with aneurysms was higher than in patients without aneurysm disease (VTI = 16.1, p<.005) CONCLUSIONS: An elevated VTI is consistently present in patients with degenerative aneurysms and has potential as a universally available predictive measurement. However, the increased VTI in the older cohort without connective tissue disease may not carry the same predictive value for acute presentations as has been demonstrated in younger patients with a known genetic basis for their aortopathy.
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Affiliation(s)
| | | | - M Davis
- Royal Free London, London, UK
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22
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Management of AAA and Concomitant Intra-Abdominal Malignancy: the Jury is Still Out. Eur J Vasc Endovasc Surg 2016; 52:757. [PMID: 27756529 DOI: 10.1016/j.ejvs.2016.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/13/2016] [Indexed: 11/22/2022]
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Commentary on ‘Late Survival in Non-operated Patients With Infra-renal Abdominal Aortic Aneurysm’. Eur J Vasc Endovasc Surg 2016; 52:450. [DOI: 10.1016/j.ejvs.2016.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/13/2016] [Indexed: 11/22/2022]
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