1
|
Mansoor SM, Jørgensen JJ, Hisdal J, Rabben T. Thirty-nine percent of patients with a ruptured abdominal aortic aneurysm (AAA) have an incidentally detected AAA prior to rupture. Ann Vasc Surg 2024:S0890-5096(24)00293-0. [PMID: 38942371 DOI: 10.1016/j.avsg.2024.04.017] [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: 01/31/2024] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred in individuals who are not eligible for screening. The primary aim of this study was to describe the group of patients admitted to Oslo University Hospital with a ruptured AAA after the implementation of the local AAA screening project. The following parameters were investigated: AAA detection prior to rupture, surveillance status, eligibility for screening and comorbidities. We also sought to compare outcomes (repair rates and 30-day mortality) between patients with and without an AAA detected prior to rupture. METHODS This cohort study included patients admitted acutely to Oslo University Hospital due to a symptomatic or ruptured AAA in the period January 2011 to December 2022. Data on demographics, prior AAA detection, surveillance status, treatment and mortality were collected retrospectively through electronic medical records. RESULTS We identified 200 patients with a symptomatic or ruptured AAA, among which 79 (40%) had an AAA detected prior to rupture - one (1%) through screening and 78 (39%) incidentally. Up to 30% of the incidentally detected AAAs were not under any surveillance. Six patients were found eligible for screening: one had attended, three were non-attenders and two had not been invited. Patients with an incidentally detected AAA prior to rupture had a more advanced age and a significantly higher degree of comorbidities than patients without a previously detected AAA, and the repair rates in these groups were 56% and 84% respectively (p < 0.001). Adjusted for comorbidities and risk factors, the odds ratio for repair among patients with incidentally detected AAA was 0.56 (p = 0.292). The 30-day mortality was not significantly different between the two groups (p = 0.097). CONCLUSION Most patients with a ruptured AAA were not eligible for screening, but 39% of the patients had an incidentally detected AAA prior to rupture. Standardized reporting and follow-up of incidentally detected AAAs is thus identified as an additional measure to organized screening in the effort to reduce AAA-related mortality.
Collapse
Affiliation(s)
- Saira Mauland Mansoor
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Jørgen Joakim Jørgensen
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Traumatology, Oslo University Hospital, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Toril Rabben
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Vikan KK, Seternes A, Nilsen LH, Pettersen EM, Altreuther M. Peri-Operative Mortality and Survival After Repair of Abdominal Aortic Aneurysm in Advanced Age Patients: A National Study from the Norwegian Registry for Vascular Surgery Focused on Nonagenarians. Eur J Vasc Endovasc Surg 2024; 67:427-433. [PMID: 37778499 DOI: 10.1016/j.ejvs.2023.09.038] [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: 02/28/2023] [Revised: 09/08/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Treatment of abdominal aortic aneurysm (AAA) in nonagenarians has become more frequent. This national observational cohort study aimed to investigate peri-operative mortality and survival after AAA surgery in nonagenarians in Norway. METHODS All AAA repairs registered in the Norwegian Registry for Vascular Surgery from 2015 to 2021 were identified and stratified into nonagenarians > 90 years old (n = 77), octogenarians 80 - 89 years old (n = 1 362), and patients < 80 years old (n = 4 590). The patient characteristics and comorbidities were recorded, and the 30 and 90 day mortality rates were calculated. Kaplan-Meier analysis was performed to obtain the estimated median survival and survival curves. RESULTS In the nonagenarians, the 30 day mortality rates were 2.5% in asymptomatic patients, 33.3% in symptomatic patients, and 59.1% in the patients with a ruptured AAA (rAAA). The estimated median survival (years) were 3.3 (95% confidence interval [CI] 1.95 - 4.59) for asymptomatic AAA, 2.9 (interquartile range [IQR] 2.82, 5.80) for symptomatic AAA, and 0.1 for rAAA (IQR 0.01, 3.04). For nonagenarians surviving the first 90 days, the estimated median survival (years) were 4.2 (95% CI 2.56 - 5.88) for asymptomatic AAA, 3.4 (IQR 2.86, 5.80) for symptomatic AAA, and 3.8 (IQR 1.49, 4.85) for rAAA. The 90 day mortality rates were 100.0%, 80.0%, and 62.5% for asymptomatic, symptomatic, and rAAA, respectively, after open surgical repair (OSR), and 5.1%, 10.0%, and 50.0%, respectively, after endovascular aortic repair (EVAR). CONCLUSION Peri-operative mortality and survival results after AAA surgery in nonagenarians support treatment of selected asymptomatic patients. The 90 day survivors had an expected survival of more than three years, enabling balanced decision making regarding surgical vs. conservative treatment options in this challenging cohort. EVAR is the treatment method of choice for AAA in nonagenarians because most of them would probably live longer untreated than if treated by OSR.
Collapse
Affiliation(s)
- Kristin K Vikan
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway.
| | - Arne Seternes
- Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Linn Hege Nilsen
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway
| | - Erik Mulder Pettersen
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Surgery, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | - Martin Altreuther
- The Norwegian Registry for Vascular Surgery (NORKAR), Department of Medical Quality Registries, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
3
|
Hafeez MS, Habib SG, Semaan DB, Abdul-Malak O, Liang NL, Madigan MC, Siracuse JJ, Eslami MH. Outcomes of octogenarians receiving aortic repair. J Vasc Surg 2024; 79:34-43.e3. [PMID: 37714501 DOI: 10.1016/j.jvs.2023.09.005] [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: 04/26/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm in men and 5 cm in women. Because AAA is more common among the elderly, we sought to evaluate contemporary practices of elective AAA repair and 2-year postoperative outcomes in octogenarians. METHODS We identified octogenarians undergoing elective AAA repair in the Vascular Quality Initiative from 2012 to 2019. We included patients undergoing endovascular (EVAR) and open (OAR) aortic repair. Demographics and comorbid conditions were compared between patient groups. Frailty was calculated using previously published methods. Patients with frailty scores above the 75th percentile of the operative cohort were considered high frailty. The primary outcome was 1- and 2-year mortality. Secondary outcomes included postoperative complications. Standard statistical methods were utilized. Cox proportional hazard models were used to identify factors that affect mortality. RESULTS The frequency of AAA repair in octogenarians has remained stable. Of all aortic operations, 21.4% were performed on octogenarians; 9735 (23.3% of 41,712) EVAR and 755 (10.3% of 7325) OARs. Among octogenarian patients, 42.0% of EVARs were under size thresholds: 48.3% males ≤5.5 cm diameter and 21.5% females ≤5.0 cm diameter compared with 18.8% OARs: 23.4% males and 10.7% females. Additionally, 25.6% had high frailty scores. Among octogenarians, 1- and 2-year mortality was 9.3% ± 0.3% and 14.8% ± 0.4% for EVAR and 15.2% ± 1.3% and 18.9% ± 1.5% for OAR patients, respectively (P < .01). In-hospital mortality rate was higher after OAR (0.87% EVAR vs 7.55% OAR; P < .01) and differed with frailty (EVAR, low frailty 0.2% vs high frailty 1.7%; OAR, low frailty 2.3% vs high frailty 15.6%). For EVAR, patient factors associated with mortality included heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.06-1.25; P = .001) and dialysis (HR, 1.71; 95% CI, 1.13-2.59; P = .012). For OAR, coronary artery disease (HR, 1.55; 95% CI, 0.98-2.44; P = .062) was associated with mortality. Statin use was protective of mortality for all patients (EVAR: HR, 0.68; 95% CI, 0.60-0.78; P < .01): OAR: HR, 0.58; 95% CI, 0.37-0.92; P = .020). Among octogenarians, high frailty was independently associated with 2-year mortality (EVAR: HR, 3.36; 95% CI, 2.62-4.31; P < .01 and OAR: HR, 2.35; 95% CI, 1.09-5.10; P = .030). CONCLUSIONS Nationally, a large portion of elective AAA repair in octogenarians is performed below recommended size thresholds, one-quarter of whom are frail with poor long-term 2-year mortality rates. High 2-year mortality following AAA repair in this age group exceeds the published risk of rupture for 5- to 5.5-cm AAA, suggesting that increase in the size threshold of elective repair among octogenarians should be explored.
Collapse
Affiliation(s)
| | - Salim G Habib
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Dana B Semaan
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael C Madigan
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV.
| |
Collapse
|
4
|
Kindon AJ, McCombie AM, Frampton C, Khashram M, Clarke G, Roake J. Early Relative Growth Rate of Abdominal Aortic Aneurysms and Future Risk of Rupture or Repair. Eur J Vasc Endovasc Surg 2023; 66:797-803. [PMID: 37567340 DOI: 10.1016/j.ejvs.2023.08.006] [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: 11/14/2022] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE This study aimed to test whether the relative growth rate of subthreshold abdominal aortic aneurysms (AAAs) in the first 24 months of surveillance predicts the risk of future rupture or repair. METHODS This was a single centre retrospective observational analysis of all small (< 45 mm diameter) and medium (45 - 54 mm in men, 45 - 50 mm in women) AAAs entered into ultrasound surveillance between January 2002 and December 2019, which received ≥ 24 months of surveillance. Relative growth rates were calculated from measurements taken in the first 24 months of surveillance. The Kaplan-Meier method was used to estimate intervention and rupture free proportions five years following diagnosis for AAAs growing by < 5% and by ≥ 5% in the first 24 months of surveillance. Multivariable Cox regression analysis was used to further analyse this relationship by adjusting for factors found to be significantly associated with outcome in univariable analysis. RESULTS A total of 556 patients with AAAs (409 men, 147 women) were followed for ≥ 24 months. This included 431 small AAAs. Of these, 109 (25.3%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.98 ± 0.05 at five years compared with 0.78 ± 0.05 for the ≥ 5% growth group (p < .001). Of 125 medium AAAs, 26 (20.8%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.73 ± 0.11 at five years compared with 0.29 ± 0.13 for the ≥ 5% growth group (p = .024). Baseline diameter and early relative growth rate were strongly and independently predictive of future intervention or rupture with hazard ratios of 9.16 (95% CI 5.98 - 14.03, p < .001) and 4.46 (95% CI 2.45 - 8.14, p < .001), respectively. CONCLUSION The results suggest that slow expansion of small (< 45 mm) AAAs observed over an isolated 24 month period is indicative of a very low risk of rupture or repair in the medium term. Isolated growth rates may be a useful tool with which to triage low risk AAAs and prevent unnecessary surveillance.
Collapse
Affiliation(s)
- Andrew J Kindon
- Geo-Health Laboratory, University of Canterbury, New Zealand; Department of Radiology, Christchurch Public Hospital, Canterbury District Health Board, New Zealand; Christchurch Vascular Group, Christchurch, New Zealand.
| | | | | | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, New Zealand; Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Glynnis Clarke
- Department of Vascular, Endovascular & Transplant Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| | - Justin Roake
- Christchurch Vascular Group, Christchurch, New Zealand; Department of Surgery, University of Otago, New Zealand; Department of Vascular, Endovascular & Transplant Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| |
Collapse
|
5
|
Maryosh S, Gwilym B, Lewis P, McLain AD, Lewis D, Bosanquet DC. Small Abdominal Aortic Aneurysms in the Over 85s: Do We Need to Survey Them All? Eur J Vasc Endovasc Surg 2023; 65:911-912. [PMID: 36958478 DOI: 10.1016/j.ejvs.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/15/2023] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Affiliation(s)
- Sally Maryosh
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport.
| | - Brenig Gwilym
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport
| | - Peter Lewis
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport
| | - Alexander D McLain
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport
| | - David Lewis
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport
| | - David C Bosanquet
- South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport
| |
Collapse
|
6
|
Singh AA, Boyle JR. Small Aneurysm Surveillance Over 80: Is it Worthwhile? Eur J Vasc Endovasc Surg 2021; 62:54. [PMID: 33896726 DOI: 10.1016/j.ejvs.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Aminder A Singh
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK.
| |
Collapse
|