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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: 49] [Impact Index Per Article: 49.0] [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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Gellatly C, Sweeting M, Emin A, Katsogridakis E, Finch S, Saratzis A, Bown MJ. Influence of cardiometabolic medications on abdominal aortic aneurysm growth in the UK Aneurysm Growth Study: metformin and angiotensin-converting enzyme inhibitors associated with slower aneurysm growth. Br J Surg 2024; 111:znad375. [PMID: 38055889 PMCID: PMC10763526 DOI: 10.1093/bjs/znad375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/14/2023] [Accepted: 10/21/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND There is a clinical need for treatments that can slow or prevent the growth of an abdominal aortic aneurysm, not only to reduce the need for surgery, but to provide a means to treat those who cannot undergo surgery. METHODS Analysis of the UK Aneurysm Growth Study (UKAGS) prospective cohort was conducted to test for an association between cardiometabolic medications and the growth of an abdominal aortic aneurysm above 30 mm in diameter, using linear mixed-effect models. RESULTS A total of 3670 male participants with data available on abdominal aortic aneurysm growth, smoking status, co-morbidities, and medication history were included. The mean age at recruitment was 69.5 years, the median number of surveillance scans was 6, and the mean(s.e.) unadjusted abdominal aortic aneurysm growth rate was 1.75(0.03) mm/year. In a multivariate linear mixed-effect model, smoking (mean(s.e.) +0.305(0.07) mm/year, P = 0.00003) and antiplatelet use (mean(s.e.) +0.235(0.06) mm/year, P = 0.00018) were found to be associated with more rapid abdominal aortic aneurysm growth, whilst metformin was strongly associated with slower abdominal aortic aneurysm growth (mean(s.e.) -0.38(0.1) mm/year, P = 0.00019), as were angiotensin-converting enzyme inhibitors (mean(s.e.) -0.243(0.07) mm/year, P = 0.0004), angiotensin II receptor antagonists (mean(s.e.) -0.253(0.08) mm/year, P = 0.00255), and thiazides/related diuretics (mean(s.e.) -0.307(0.09) mm/year, P = 0.00078). CONCLUSION The strong association of metformin with slower abdominal aortic aneurysm growth highlights the importance of the ongoing clinical trials assessing the effectiveness of metformin with regard to the prevention of abdominal aortic aneurysm growth and/or rupture. The association of angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, and diuretics with slower abdominal aortic aneurysm growth points to the possibility that optimization of cardiovascular risk management as part of abdominal aortic aneurysm surveillance may have the secondary benefit of also reducing abdominal aortic aneurysm growth rates.
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Affiliation(s)
- Corry Gellatly
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield General Hospital, Leicester, UK
| | - Michael Sweeting
- Department of Population Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
- Statistical Innovation, Oncology Biometrics, AstraZeneca, Cambridge, UK
| | - Atilla Emin
- Trauma & Orthopaedics, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Emmanuel Katsogridakis
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield General Hospital, Leicester, UK
| | - Sarah Finch
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield General Hospital, Leicester, UK
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield General Hospital, Leicester, UK
| | - Matthew J Bown
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield General Hospital, Leicester, UK
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Lecouturier J, Stansby G, Thomson RG. Information provision and decision-making in the treatment of abdominal aortic aneurysm: A qualitative study of patient experience. PLoS One 2023; 18:e0293354. [PMID: 37871042 PMCID: PMC10593210 DOI: 10.1371/journal.pone.0293354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/11/2023] [Indexed: 10/25/2023] Open
Abstract
INTRODUCTION Shared decision making (SDM) refers to patients and health care professionals working together to reach a decision about treatment/care. In abdominal aortic aneurysm (AAA) treatment options are influenced by patients' clinical characteristics, their preferences, and potential trade-offs between alternative interventions. This is a prime example of where SDM is essential to ensure the right decision is made for the right patient, yet we have little understanding of what happens in practice. This study explored patient experiences to understand SDM practice in AAA surgery. METHODS We used a qualitative approach to describe, and identify improvements to, current treatment decision making in abdominal aortic aneurysm (AAA) surgery. Two groups of patients were interviewed: those at the point of discussing treatment options (with corresponding digitally recorded consultation data) and following surgical intervention from one hospital. Framework analysis was used. RESULTS Fifteen patients were interviewed, seven at the point of discussing treatment options and eight following surgical intervention. Timing, format and sources of information, verbal framing of interventions and level of patient engagement were key themes. Four areas for improvement were identified: earlier provision and more detailed written information along with signposting to quality on-line information; both intervention options, risks, benefits, and consequences, were not always discussed; some clinicians were somewhat directive in the decision-making process; and patients' treatment values/preferences were not explored-the only example was in one of the eight recorded consultations. Patients could feel overwhelmed by the information and decision and fearful of the impending surgery. CONCLUSIONS More emphasis should be placed on the provision of full information and the exploration of patient values and preferences for treatment. Clinician training and support for patients, including decision aids, could facilitate the decision-making process. Providing written information earlier and guidance on reliable on-line resources would benefits patients and their families.
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Affiliation(s)
- Jan Lecouturier
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gerry Stansby
- Northern Vascular Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- School of Surgical and Reproductive Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard G. Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Hanna L, Borsky K, Abdullah AA, Sounderajah V, Marshall DC, Salciccioli JD, Shalhoub J, Gibbs RGJ. Trends in Hospital Admissions, Operative Approaches, and Mortality Related to Abdominal Aortic Aneurysms in England Between 1998 and 2020. Eur J Vasc Endovasc Surg 2023; 66:68-76. [PMID: 36934837 DOI: 10.1016/j.ejvs.2023.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/26/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE To assess trends in abdominal aortic aneurysm (AAA) hospital admissions, interventions, and aneurysm related mortality in England, and to examine the impact of endovascular repair on mortality for the years 1998 - 2020. METHODS Hospital admission and operative approach (endovascular aortic aneurysm repair, or open surgical repair [OSR]) using Hospital Episodes Statistics (HES), and aneurysm related mortality data from the Office for National Statistics for England standardised to the 2013 European Standard Population, were analysed using linear regression and Joinpoint regression analyses. Aneurysm related mortality was compared between the pre-endovascular era (1998 - 2010) and the endovascular era (2011 - 2019). RESULTS A declining trend in hospital admission incidence was observed, mainly due to a decline in ruptured admissions from 34.6 per 100 000 (95% confidence interval [CI] 33.5 - 35.6) to 13.5 per 100 000 (95% CI 12.9 - 14.2; βi = -1.04, r2 = .97, p < .001). Operative interventions have been declining over the last 23 years mainly due to the statistically significant decline in open procedures (41.2 per 100 000 in 2000 [95% CI 40 - 42.3] to 9.6 per 100 000 [95% CI 9.1 - 10.1]; βi = -1.92, r2 = .95; p < .001). There was an increasing trend toward endovascular procedures (5.8 per 100 000 [95% CI 5.3 - 6.2] in 2006 to 16.9 per 100 000 [95% CI 16.2 - 17.5] in 2020; βi = .82, r2 = .30, p = .040). Reductions in aneurysm related mortality due to AAAs were observed for males and females, irrespective of age and rupture status. CONCLUSION A significant decrease in hospital admissions for AAAs was observed over the last 23 years in England, paralleled by a shift toward endovascular repair and a decline in OSR. Declines in aneurysm related mortality were observed overall, and in the endovascular era irrespective of age, sex, and rupture status.
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Affiliation(s)
- Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK.
| | - Kim Borsky
- Medical Data Research Collaborative, London, UK; Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Ammar A Abdullah
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Viknesh Sounderajah
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Institute of Global Health Innovation, Imperial College London, London, UK
| | - Dominic C Marshall
- Medical Data Research Collaborative, London, UK; Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Justin D Salciccioli
- Medical Data Research Collaborative, London, UK; Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Joseph Shalhoub
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Medical Data Research Collaborative, London, UK
| | - Richard G J Gibbs
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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Veličković VM, Carradice D, Boyle JR, Hamady M, Cleveland T, Neequaye S, Ignjatović A, Bogdanović D, Savovic J, Siebert U. Umbrella review and meta-analysis of reconstructed individual patient data of mortality following conventional endovascular and open surgical repair of infrarenal abdominal aortic aneurysm. Expert Rev Cardiovasc Ther 2023; 21:347-356. [PMID: 37128666 DOI: 10.1080/14779072.2023.2207009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES This umbrella review aims to quality assess published meta-analyses, conduct a de-novo meta-analysis of the available randomized control trials (RCTs), and test the hypothesis that there is a long-term difference in mortality between OSR and EVAR. METHODS A systematic search was conducted in MEDLINE and EMBASE's bibliographic databases (June 2022). Data were extracted using standardized extraction forms. The methodological quality of publications was assessed using the ROBIS tool. Data were analyzed with 'one-stage' and 'two-stage' approaches. RESULTS According to two-stage analysis, EVAR has significantly favorable mortality for up to four years (increasing evidence). Subsequently, until the longest available time period, there is no difference between EVAR and OSR; all the results are statistically non-significant.In one stage analysis, the Cox model demonstrated a non-significant (weak evidence) hazard ratio of 1.03 (95% confidence interval [CI]: 0.94-1.12) in favor of OSR. The best-fitting parametric model (generalized gamma), leads to an hazard ratio of 0.97 (95% CI: 0.93-1.01) in favor of EVAR, with the results approaching significance (weak evidence). CONCLUSION The results of this umbrella systematic review and meta-analysis failed to demonstrate any difference in long-term mortality following planned EVAR, compared with OSR of infrarenal AAA.
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Affiliation(s)
- Vladica M Veličković
- Evidence Synthesis Department, Biomath Models, London, UK
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL, University for Health Sciences and Technology, Hall i.T, Austria
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School & Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, UK
| | - Mohamad Hamady
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Neequaye
- Department of Interventional Radiology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Aleksandra Ignjatović
- Evidence Synthesis Department, Biomath Models, London, UK
- Faculty of Medicine, University of Niš, Niš, Serbia
| | | | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- and Weston NHS Foundation Trust, NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol, Bristol, UK
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL, University for Health Sciences and Technology, Hall i.T, Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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The NICE Guidelines for Aortic Aneurysm Repair: A View from the Vascular Society of Great Britain and Ireland. Eur J Vasc Endovasc Surg 2021; 62:847-848. [PMID: 34785125 DOI: 10.1016/j.ejvs.2021.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 01/31/2023]
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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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