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Milch HS, Haramati LB. The science and practice of imaging-based screening: What the radiologist needs to know. Clin Imaging 2024; 114:110266. [PMID: 39216274 DOI: 10.1016/j.clinimag.2024.110266] [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: 06/20/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
Imaging-based screening is an important public health focus and a fundamental part of Diagnostic Radiology. Hence, radiologists should be familiar with the concepts that drive imaging-based screening practice including goals, risks, biases and clinical trials. This review article discusses an array of imaging-based screening exams including the key epidemiology and evidence that drive screening guidelines for abdominal aortic aneurysm, breast cancer, carotid artery disease, colorectal cancer, coronary artery disease, lung cancer, osteoporosis, and thyroid cancer. We will provide an overview on societal interests in screening, screening-related inequities, and opportunities to address them. Emerging evidence for opportunistic screening and the role of AI in imaging-based screening will be explored. In-depth knowledge and formalized training in imaging-based screening strengthens radiologists as clinician scientists and has the potential to broaden our public health leadership opportunities. SUMMARY SENTENCE: An overview of key screening concepts, the evidence that drives today's imaging-based screening practices, and the need for radiologist leadership in screening policies and evidence development.
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Affiliation(s)
- Hannah S Milch
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| | - Linda B Haramati
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
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Mazzucco S, Li L, Tuna MA, Rothwell PM. Age-specific sex-differences in cerebral blood flow velocity in relation to haemoglobin levels. Eur Stroke J 2024; 9:772-780. [PMID: 38634499 PMCID: PMC11343687 DOI: 10.1177/23969873241245631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Cerebral blood flow (CBF) declines with age and abnormalities in CBF are associated with age-related cerebrovascular disease and neurodegeneration. Women have higher CBF than men, although this sex-difference diminishes to some extent with age in healthy subjects. The physiological drivers of these age/sex differences are uncertain, but might be secondary to age and sex-differences in haemoglobin (Hb) level. Hb levels are inversely correlated with CBF, are lower in women, and decline with age in men, but the interrelations between these factors have not been explored systematically either in healthy subjects or across the full age-range in patients with vascular risk factors. We aimed to determine the age-specific interrelations between sex, Hb, and CBF velocity in a large cohort of patients with cerebrovascular disease. PATIENTS AND METHODS In patients with a recent transient ischaemic attack or minor stroke (Oxford Vascular Study) and no ipsilateral or contralateral stenosis of the carotid or intracranial arteries, we related peak-systolic velocity (PSV) and other parameters on transcranial Doppler ultrasound (TCD) of the middle cerebral artery to sex, age, Hb and vascular risk factors. RESULTS Of 958 eligible subjects (mean age/SD = 68.04/14.26, 53.2% male), younger women (age < 55 years) had higher CBF velocities than men (mean sex difference in PSV at age < 55 years = 16.31 cm/s; p < 0.001), but this difference declined with age (interaction p < 0.001), such that it was no longer significant at age 75-84 (∆PSV = 3.26 cm/s; p = 0.12) and was reversed at age ⩾ 85 (∆PSV = -7.42 cm/s; p = 0.05). These changes mirrored trends in levels of Hb, which were higher in men at age < 55 (∆Hb = 1.92 g/dL; p < 0.001), but steadily decreased with age in men but not in women (interaction p < 0.001), with no residual sex-difference at age ⩾ 85 (∆Hb = 0.12 g/dL; p = 0.70). There was an inverse correlation between Hb and PSV in both women and men (both p ⩽ 0.01), and the sex-difference in PSV at age < 55 was substantially diminished after adjustment for Hb (∆PSV = 6.92; p = 0.036; ∆PSV = 5.92, p = 0.13 with further adjustment for end-tidal CO2). In contrast, the sex difference in PSV was unaffected by adjustment for systolic and diastolic blood pressure, heart rate, and vascular risk factors (history of hypertension, diabetes, hyperlipidaemia and smoking). DISCUSSION CBF velocity is strongly correlated with Hb level at all ages, and sex-differences in CBF velocity appear to be explained in major part by age-related sex-differences in Hb.
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Affiliation(s)
- Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Maria Assuncao Tuna
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Pham MHC, Sigvardsen PE, Fuchs A, Kühl JT, Sillesen H, Afzal S, Nordestgaard BG, Køber LV, Kofoed KF. Aortic aneurysms in a general population cohort: prevalence and risk factors in men and women. Eur Heart J Cardiovasc Imaging 2024; 25:1235-1243. [PMID: 38662458 DOI: 10.1093/ehjci/jeae103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 08/18/2024] Open
Abstract
AIMS The prevalence and difference in risk factors for having thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA) in men compared with women in the general population is not well described. This study aimed to test the hypotheses that (i) cardiovascular risk factors for TAA and AAA differ and (ii) the prevalence of TAA and AAA is sex specific. METHODS AND RESULTS Aortic examination using computed tomography angiography was performed in 11 294 individuals (56% women), with a mean age of 62 (range 40-95) years participating in the Copenhagen General Population Study. TAAs were defined as an ascending aortic diameter ≥45 mm and a descending aortic diameter ≥35 mm, while AAAs were defined as an abdominal aortic diameter ≥30 mm. Demographic data were obtained from questionnaires. Overall prevalence of aortic aneurysms (AAs) in the study population included: total population 2.1%, men 4.0% and women 0.7% (P-value men vs. women P < 0.001). AAs were independently associated with male sex, increasing age, and body surface area (BSA). While TAAs were associated with hypertension, odds ratio (OR) = 2.0 [95% confidence interval (CI): 1.5-2.8], AAAs were associated with hypercholesterolaemia and smoking, OR = 2.4 (95% CI: 1.6-3.6) and 3.2 (95% CI: 1.9-5.4). CONCLUSION Subclinical AAs are four times more prevalent in men than in women. In both sexes, increasing age and BSA are risk factors for AAs of any anatomical location. Whereas arterial hypertension is a risk factor for TAAs, hypercholesterolaemia and smoking are risk factors for AAAs.
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Affiliation(s)
- Michael Huy Cuong Pham
- Department of Cardiology, The Heart Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Radiology, The Diagnostic Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
| | - Per Ejlstrup Sigvardsen
- Department of Cardiology, The Heart Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Radiology, The Diagnostic Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, The Heart Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Radiology, The Diagnostic Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
| | - Jørgen Tobias Kühl
- Department of Cardiology, Zealand University Hospital, 4000 Roskilde, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, The Heart Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
| | - Shoaib Afzal
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte Hospital, 2730 Herlev, Denmark
- Copenhagen General Population Study, Copenhagen University Hospital-Herlev and Gentofte Hospital, 2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Børge Grønne Nordestgaard
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte Hospital, 2730 Herlev, Denmark
- Copenhagen General Population Study, Copenhagen University Hospital-Herlev and Gentofte Hospital, 2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Valeur Køber
- Department of Cardiology, The Heart Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Klaus Fuglsang Kofoed
- Department of Cardiology, The Heart Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Radiology, The Diagnostic Center, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Guo X, Zhong J, Zhao Y, Fu Y, Sun LY, Yuan A, Liu J, Chen AF, Pu J. LXRα Promotes Abdominal Aortic Aneurysm Formation Through UHRF1 Epigenetic Modification of miR-26b-3p. Circulation 2024; 150:30-46. [PMID: 38557060 PMCID: PMC11219073 DOI: 10.1161/circulationaha.123.065202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) is a severe aortic disease without effective pharmacological approaches. The nuclear hormone receptor LXRα (liver X receptor α), encoded by the NR1H3 gene, serves as a critical transcriptional mediator linked to several vascular pathologies, but its role in AAA remains elusive. METHODS Through integrated analyses of human and murine AAA gene expression microarray data sets, we identified NR1H3 as a candidate gene regulating AAA formation. To investigate the role of LXRα in AAA formation, we used global Nr1h3-knockout and vascular smooth muscle cell-specific Nr1h3-knockout mice in 2 AAA mouse models induced with angiotensin II (1000 ng·kg·min; 28 days) or calcium chloride (CaCl2; 0.5 mol/L; 42 days). RESULTS Upregulated LXRα was observed in the aortas of patients with AAA and in angiotensin II- or CaCl2-treated mice. Global or vascular smooth muscle cell-specific Nr1h3 knockout inhibited AAA formation in 2 mouse models. Loss of LXRα function prevented extracellular matrix degeneration, inflammation, and vascular smooth muscle cell phenotypic switching. Uhrf1, an epigenetic master regulator, was identified as a direct target gene of LXRα by integrated analysis of transcriptome sequencing and chromatin immunoprecipitation sequencing. Susceptibility to AAA development was consistently enhanced by UHRF1 (ubiquitin-like containing PHD and RING finger domains 1) in both angiotensin II- and CaCl2-induced mouse models. We then determined the CpG methylation status and promoter accessibility of UHRF1-mediated genes using CUT&Tag (cleavage under targets and tagmentation), RRBS (reduced representation bisulfite sequencing), and ATAC-seq (assay for transposase-accessible chromatin with sequencing) in vascular smooth muscle cells, which revealed that the recruitment of UHRF1 to the promoter of miR-26b led to DNA hypermethylation accompanied by relatively closed chromatin states, and caused downregulation of miR-26b expression in AAA. Regarding clinical significance, we found that underexpression of miR-26b-3p correlated with high risk in patients with AAA. Maintaining miR-26b-3p expression prevented AAA progression and alleviated the overall pathological process. CONCLUSIONS Our study reveals a pivotal role of the LXRα/UHRF1/miR-26b-3p axis in AAA and provides potential biomarkers and therapeutic targets for AAA.
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MESH Headings
- Aortic Aneurysm, Abdominal/genetics
- Aortic Aneurysm, Abdominal/metabolism
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Abdominal/chemically induced
- Animals
- Liver X Receptors/metabolism
- Liver X Receptors/genetics
- Epigenesis, Genetic
- MicroRNAs/genetics
- MicroRNAs/metabolism
- Humans
- CCAAT-Enhancer-Binding Proteins/genetics
- CCAAT-Enhancer-Binding Proteins/metabolism
- Mice
- Mice, Knockout
- Ubiquitin-Protein Ligases/genetics
- Ubiquitin-Protein Ligases/metabolism
- Male
- Disease Models, Animal
- Mice, Inbred C57BL
- DNA Methylation
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Angiotensin II/pharmacology
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Affiliation(s)
- Xiao Guo
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianmei Zhong
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yichao Zhao
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanan Fu
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ling-yue Sun
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ancai Yuan
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junling Liu
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education (J.L.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Alex F. Chen
- Institute for Developmental and Regenerative Cardiovascular Medicine, Xinhua Hospital (A.F.C.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Pu
- Department of Cardiology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital (X.G., J.Z., Y.Z., Y.F., L.-y.S., A.Y., J.L., J.P.), Shanghai Jiao Tong University School of Medicine, Shanghai, China
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5
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Stacey BS, Cho JS, Lanéelle D, Bashir M, Williams IM, Lewis MH, Bailey DM. A prospective longitudinal study of risk factors for abdominal aortic aneurysm. Physiol Rep 2024; 12:e16130. [PMID: 38946069 PMCID: PMC11214915 DOI: 10.14814/phy2.16130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/14/2024] [Accepted: 06/23/2024] [Indexed: 07/02/2024] Open
Abstract
The aim of this study was to identify risk factors for abdominal aortic aneurysm (AAA) from the largest Welsh screening cohort to date. Patients were recruited from 1993 (to 2015) as part of the South East Wales AAA screening programme through general practitioners. Demographic data and risk factors were collected by means of a self-report questionnaire. Statistical tests were performed to determine whether associations could be observed between AAA and potential risk factors. Odds ratios (OR) were also calculated for each of the risk factors identified. A total of 6879 patients were included in the study. Two hundred and seventy-five patients (4.0%) presented with AAA, of which 16% were female and 84% were male. Patients with AAA were older than the (no AAA) control group (p < 0.0001). The following risk factors were identified for AAA: family history of AAA (p < 0.0001); history of vascular surgery (p < 0.0001), cerebrovascular accident (p < 0.0001), coronary heart disease (p < 0.0001), diabetes (p < 0.0001), medication (p = 0.0018), claudication (p < 0.0001), smoking history (p = 0.0001) and chronic obstructive pulmonary disorder (p = 0.0007). AAA is associated with classical vascular risk factors, in addition to other less-well-documented risk factors including previous vascular surgery. These findings have practical implications with the potential to improve future clinical screening of patients in order to reduce AAA mortality.
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Affiliation(s)
- Benjamin S. Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
| | - Jun Seok Cho
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
- Department of SurgeryRoyal Free HospitalLondonUK
| | - Damien Lanéelle
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
- UNICAEN, CHU Caen Normandie, Vascular Medicine Unit, INSERM, COMETECaenFrance
| | - Mohammad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
- Department of SurgeryUniversity Hospital WalesCardiffUK
| | - Ian M. Williams
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
- Department of SurgeryUniversity Hospital WalesCardiffUK
| | - Michael H. Lewis
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
| | - Damian M. Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and EducationUniversity of South WalesPontypriddUK
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Leyba K, Hanif H, Millhuff AC, Quazi MA, Sohail AH, Clark RM, Sheikh AB, Rana MA. Racial and sex disparities in inpatient outcomes of patients with ruptured abdominal aortic aneurysms in the United States. J Vasc Surg 2024; 80:115-124.e5. [PMID: 38431061 DOI: 10.1016/j.jvs.2024.02.029] [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: 12/18/2023] [Revised: 02/07/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Ruptured abdominal aortic aneurysm (AAA) is a medical emergency that requires immediate surgical intervention. The aim of this analysis was to identify the sex- and race-specific disparities that exist in outcomes of patients hospitalized with this condition in the United States using the National Inpatient Sample (NIS) to identify targets for improvement and support of specific patient populations. METHODS In this descriptive, retrospective study, we analyzed the patients admitted with a primary diagnosis of ruptured AAA between January 1, 2016, and December 31, 2020, using the NIS database. We compared demographics, comorbidities, and in-hospital outcomes in AAA patients, and compared these results between different racial groups and sexes. RESULTS A total of 22,395 patients with ruptured AAA were included for analysis. Of these, 16,125 patients (72.0%) were male, and 6270 were female (28.0%). The majority of patients (18,655 [83.3%]) identified as Caucasian, with the remaining patients identifying as African American (1555 [6.9%]), Hispanic (1095 [4.9%]), Asian or Pacific Islander (470 [2.1%]), or Native American (80 [0.5%]). Females had a higher risk of mortality than males (OR, 1.7; 95% confidence interval [CI], 1.45-1.96; P < .001) and were less likely to undergo endovascular aortic repair (OR, 0.70; 95% CI, 0.61-0.81; P < .001) or fenestrated endovascular aortic repair (OR, 0.71; 95% CI, 0.55-0.91; P = .007). Relative to Caucasian race, patients who identified as African American had a lower risk of inpatient mortality (OR, 0.50; 95% CI, 0.37-0.68; P < .001). CONCLUSIONS In this retrospective study of the NIS database from 2016 to 2020, females were less likely to undergo endovascular intervention and more likely to die during their initial hospitalization. African American patients had lower rates in-hospital mortality than Caucasian patients, despite a higher burden of comorbidities. Future studies are needed to elucidate the potential factors affecting racial and sex disparities in ruptured AAA outcomes, including screening practices, rupture risk stratification, and more personalized guidelines for both elective and emergent intervention.
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Affiliation(s)
- Katarina Leyba
- Department of Internal Medicine, University of Colorado, Aurora
| | - Hamza Hanif
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque.
| | - Alexandra C Millhuff
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Mohammed A Quazi
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque
| | - Ross M Clark
- Division of Vascular Surgery, Department of Surgery, Albuquerque
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Muhammad A Rana
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque
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Rubin MJ, Wakinekona NA, Reilly MA, Canales B, Sparapani R, Dyer M, Kibbe MR, Mansukhani NA. Reporting and analysis of sex in vascular surgery research. J Vasc Surg 2024:S0741-5214(24)01338-7. [PMID: 38901638 DOI: 10.1016/j.jvs.2024.06.021] [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: 12/31/2023] [Revised: 05/20/2024] [Accepted: 06/13/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE To examine sex in human vascular surgery research by quantifying the inclusion and analysis of sex-based data in high-impact vascular surgery journals. METHODS A bibliographic review of original articles published in the European Journal of Vascular and Endovascular Surgery, Journal of Vascular Surgery, JVS: Venous and Lymphatic Disorders, Journal of Endovascular Therapy, and Annals of Vascular Surgery from January 1, 2018, to December 31, 2020, and from January 1, 2023, to December 31, 2023, was conducted. Abstracted data included sex-based data analysis, inclusion of sex as a variable in multivariable analysis, inclusion of sex as an independent variable, and a discussion of sex-based results. RESULTS Of the 3762 articles that included human, animal, or cell subjects, 249 (6.6%) did not state sex. Of those 249 articles, 183 included human subjects, 55 included animal subjects, and 11 used cell lines as the subjects. These were removed from analysis as well as the remaining 68 articles with animal subjects. In addition, 23 researched a sex-specific pathology and were removed from analysis. Of the remaining 3422 articles included in our study, 42.3% analyzed sex, 46.9% included sex in multivariable analysis, 4.8% included sex as an independent variable, and 26.6% included a discussion of sex. There were no significant differences in all four sex variables between 2018, 2019, and 2020. Between 2018-2020 and 2023, there were significant increases in all four sex variables. Multicenter studies had significantly higher rates of independent analysis of sex over single-center studies (7.4% vs 3.3%, P < .001). There was no significant difference in independent analysis of sex between U.S.-based and non-U.S.-based studies. Only 191 articles (5.6%) had 90% or greater matching of men and women in their study. CONCLUSIONS Equitable inclusion and analysis of sex is rare in vascular surgery research. Less than 5% of articles included an independent analysis of data by sex, and few studies included males and females equally. Clinical research is the basis for evidence-based medicine; therefore, it is important to strive for equitable inclusion, analysis, and reporting of data to foster generalizability of clinical research to men and women.
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Affiliation(s)
- Micah J Rubin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Nalani A Wakinekona
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Margaret A Reilly
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bethany Canales
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Rodney Sparapani
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Mitchell Dyer
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Melina R Kibbe
- Department of Surgery and Biomedical Engineering, University of Virginia School of Medicine, Charlottesville, VA
| | - Neel A Mansukhani
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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8
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Nargesi S, Abutorabi A, Mohamadi Y, Salimi J, Tajdini M, Alipour V. Cost-effectiveness analysis of endovascular versus open repair in patients with abdominal aortic aneurysm in Iran: a cross-sectional study. Int J Surg 2024; 110:3338-3345. [PMID: 38502855 PMCID: PMC11175740 DOI: 10.1097/js9.0000000000001321] [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: 11/24/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Abdominal aortic aneurysm (AAA) is one of the most important cardiovascular diseases, especially in the elderly. People with this disease are at risk of rupture of the abdominal aorta and death. The present study was conducted with the aim of analyzing the cost-effectiveness of endovascular repair compared to open surgery in AAA patients in Iran. METHODS A Markov chain model was developed based on the use of endovascular repair and open surgery. The base-case patient was defined as a 65-year-old man presenting with AAA diameter greater than 5 cm. The determination of costs was from the perspective of the public sector provider. QALY was used to calculate the effectiveness. Incremental cost-effectiveness ratio (ICER) and TreeAge software were used for cost-effectiveness analysis. The follow-up period was 10 years and the willingness to pay (WTP) was determined as three times the Gross domestic product (GDP) per capita. RESULT At the end of year 10, the endovascular aneurysm repair (EVAR) strategy gained 1 318 313 559 Iranian Rial (IRR) (67 885.29$) in cost and 3.57 QALYs in effectiveness. In contrast, the use of the open surgery repair (OSR) strategy gained 1 186 761 858 IRR (61 111.16$) in cost and 3·32 QALYs in effectiveness. The incremental cost-effectiveness ratio, comparing EVAR versus OSR, was 53, 346, 3757 IRR (178.36$) per QALYs, which is lower than the proposed WTP, indicating that EVAR is more expensive and more effective. Based on the Monte Carlo simulation test, EVAR is the preferred strategy in 58.6% of the population. CONCLUSION Endovascular repair has a relative superiority compared to open surgery, and the probability of the effectiveness of endovascular repair compared to open surgery does not change with increasing willingness to pay.
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Affiliation(s)
- Shahin Nargesi
- Department of Health Management and Economics, Faculty of Health, Ilam University of Medical Sciences, Ilam
| | - Ali Abutorabi
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran
| | - Yousef Mohamadi
- Department of Anatomy, School of Medicine, Ilam University of Medical Sciences, Ilam
| | - Javad Salimi
- Vascular and Endovascular Surgery Department, Sina Hospital, Tehran University of Medical Sciences, Tehran
| | - Masih Tajdini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Alipour
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran
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Png CYM, Pendleton AA, Altreuther M, Budtz-Lilly JW, Gunnarsson K, Kan CD, Khashram M, Laine MT, Mani K, Pederson CC, Srivastava SD, Eagleton MJ. Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities. J Clin Med 2024; 13:2464. [PMID: 38730993 PMCID: PMC11084331 DOI: 10.3390/jcm13092464] [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: 02/02/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.
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Affiliation(s)
- C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - A Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, 7030 Trondheim, Norway
| | - Jacob W Budtz-Lilly
- Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Skejby, 8200 Aarhus, Denmark
| | - Kim Gunnarsson
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Chung-Dann Kan
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 701, Taiwan
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland 1010, New Zealand
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Christian C Pederson
- Department of Vascular Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
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10
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Jiang H, Xu H, Xu Z. Sex-related differences in outcome of thoracic aortic surgery. J Cardiothorac Surg 2024; 19:226. [PMID: 38627818 PMCID: PMC11020790 DOI: 10.1186/s13019-024-02735-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Sex-related dissimilarities' influence on outcomes following thoracic aortic surgery is poorly understood. Our aim is to examine sex-related disparities in patients undergoing thoracic aortic aneurysm (TAA). METHODS A total of 455 cases undergoing thoracic aortic aneurysm (TAA) surgery were consecutively enrolled between December 2009 and December 2015 in a Chinese hospital. Primary outcomes, including overall mortality and related risk factors, were evaluated. Cox regression is utilized to recognize the independent risk factor of these consequences. RESULTS Females, compared to males, had greater indexed aortic diameters and higher aortic transvalvular pressure differences. For the location of aortic aneurysms, females had a higher rate of aortic arch involvement, while males had a higher rate of root involvement. Females underwent less frequent complex proximal aortic operations compared with males (29.5% versus 46.9%; p < 0.001). Women and men both had a lower rate of aortic transvalvular pressure difference and LV volume index 7 days after thoracic aortic surgery. The overall mortality for the women's groups (11%) was suggestively greater compared to 4.9% for the men's groups (p = 0.026). Renal failure and aortic arch involvement were the main risk factors associated with males' survival, while maximum indexed aortic diameter and cross-clamp time were the risk factors associated with females' survival. CONCLUSIONS The outcome after TAA surgery was less favorable in women with significantly increased overall mortality. It highlights the need to focus on implementing personalized surgery strategies and gender-specific guidelines in treating female patients following TAA surgery.
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Affiliation(s)
- Hongxue Jiang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hongjie Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200168, China
| | - Zhiyun Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200168, China.
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11
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Gormley S, Mao J, Sedrakyan A, Beck AW, Mani K, Beiles B, Szeberin Z, Venermo M, Cassar K, Khashram M. The association of ruptured abdominal aortic aneurysm diameter with mortality in the International Consortium of Vascular Registries. J Vasc Surg 2024; 79:748-754.e2. [PMID: 38013041 PMCID: PMC11144387 DOI: 10.1016/j.jvs.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The mortality after ruptured abdominal aortic aneurysm (rAAA) repair is high, despite improvements in perioperative care, centralization of emergency vascular surgical services, and the introduction of endovascular aneurysm repair (EVAR). The diameter of intact AAA has been shown to be a predictor of short- and long-term survival. The aim of this study was to analyze the impact of AAA diameter on mortality for rAAA repair using contemporary data collected from the International Consortium of Vascular Registries and compare outcomes by sex and the type of repair patients received. METHODS Prospective registry data on repair of rAAA from seven countries were collected from 2010 to 2016. The primary outcome was perioperative mortality after EVAR and open surgical repair (OSR). Data were stratified by type of repair and sex. Logistic regression models were used to estimate odds ratio (OR) for the association between AAA diameter and perioperative mortality and the association between type of repair and mortality. Multivariable logistic regression models were used to adjust for differences in patient characteristics. RESULTS The study population consisted of 6428 patients with a mean age ranging from 70.2 to 75.4 years; the mean AAA diameter was 7.7 ± 1.8 cm. Females had a significantly smaller AAA diameter at presentation compared with males (6.9 ± 1.6 cm vs 7.9 ± 1.8 cm; P < .001). who underwent OSR had larger AAA diameters compared with those who underwent EVAR (P < .001). Females who underwent repair were significantly older (P < .001). Males were more likely to have cardiac disease, diabetes mellitus, and renal impairment. Overall, AAA diameter was a predictor of mortality in univariate and multivariate analysis. When analyzing EVAR and OSR separately, the impact of AAA diameter per cm increase on mortality was apparent in both males and females undergoing EVAR, but not OSR (EVAR: male OR, 1.09 [95% confidence interval, 1.03-1.16] and EVAR: female OR, 1.17 [95% confidence interval, 1.02-1.35]). The early mortality rate for males and females who underwent EVAR was 18.9% and 25.9% (P < .001), respectively. The corresponding mortality for males and females who underwent OSR was 30.2% and 38.6% (P < .001), respectively. CONCLUSIONS In these real-world international data, there is a significant association between rAAA diameters and early mortality in males and females. This association was more evident in patients undergoing EVAR, but not shown in OSR. Despite improvements in overall AAA repair outcomes, the risk of mortality after rAAA repair is consistently higher for females.
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Affiliation(s)
- Sinead Gormley
- Department of Surgery, University of Auckland, Auckland, NZ; Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, NZ
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Barry Beiles
- Australasian Vascular Audit, Australia & New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kevin Cassar
- Department of Surgery, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, NZ; Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, NZ.
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12
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Brie DA, Jianu AM, Popescu R, Cerbulescu T, Dema S, Brie DM, Borugă VM. Aortic aneurysms in patients with atherosclerotic coronary artery disease in the southwestern region of Romania - clinical and histopathological study. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2024; 65:251-256. [PMID: 39020539 PMCID: PMC11384034 DOI: 10.47162/rjme.65.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
An aneurysm is defined as a dilation of the arterial wall with a diameter exceeding 1.5 times the normal diameter of the vessel concerned. Aortic aneurysms (AAs) can develop at any level but are mostly found at the abdominal and infrarenal levels and extend to the iliac arteries. AAs are usually asymptomatic and are most often discovered incidentally during various imaging investigations for other conditions. Rupture of an AA is usually dramatic, being one of the causes of sudden cardiac death. Surgical treatment and, more recently, endovascular treatment are the only effective methods of AA repair. In this study, we screened for the diagnosis of AAs in patients with stable exertional angina who had indications for coronary angiography. The study was carried out in the period 2021-2023 in the Institute of Cardiovascular Diseases Timişoara, Romania. Of the 2458 patients with exertional angina who required coronary angiography, a number of 1844 (75%) patients had at least one stenotic atheromatous plaque, and of these 312 patients had AAs, of which 173 at the level of the abdominal aorta.
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Affiliation(s)
- Diduţa Alina Brie
- Department of Interventional Cardiology, Cardiovascular Disease Institute Timişoara, Romania;
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13
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Ren S, Guidoin R, Xu Z, Deng X, Fan Y, Chen Z, Sun A. Narrative Review of Risk Assessment of Abdominal Aortic Aneurysm Rupture Based on Biomechanics-Related Morphology. J Endovasc Ther 2024; 31:178-190. [PMID: 36052406 DOI: 10.1177/15266028221119309] [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] [Indexed: 11/15/2022]
Abstract
CLINICAL IMPACT Studies have shown that the biomechanical indicators based on multi-scale models are more effective in accurately assessing the rupture risk of AAA. To meet the need for clinical monitoring and rapid decision making, the typical morphological parameters associated with AAA rupture and their relationships with the mechanical environment have been summarized, which provide a reference for clinical preoperative risk assessment of AAA.
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Affiliation(s)
- Shuqi Ren
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Robert Guidoin
- Department of Surgery, Faculty of Medicine, Université Laval and CHU de Québec Research Centre, Quebec, QC, Canada
| | - Zaipin Xu
- College of Animal Science, Guizhou University, Guiyang, China
| | - Xiaoyan Deng
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Zengsheng Chen
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Anqiang Sun
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
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14
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Piwowarczyk M, Rubinkiewicz M, Krzywoń J, Kołodziejski M, Krzyżewski RM, Zbierska-Rubinkiewicz K. Low-profile versus standard-profile stent grafts in the treatment of abdominal aortic aneurysm: a case-matched study. Wideochir Inne Tech Maloinwazyjne 2024; 19:100-106. [PMID: 38974762 PMCID: PMC11223529 DOI: 10.5114/wiitm.2024.136248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/24/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction Endovascular aortic repair (EVAR) is nowadays a widespread method of managing abdominal aortic aneurysm (AAA). Low-profile stent grafts (LPSGs) enable treatment of patients with complex and anatomically challenging aneurysms, and facilitate a percutaneous and thus less invasive procedure. Aim To assess the outcomes of EVAR with low-profile versus standard-profile stent grafts (SPSGs). Material and methods Thirty-one patients with abdominal aortic aneurysms (AAA) were treated by endovascular aortic repair (EVAR) using LPSGs. The control group of patients treated with SPSGs was matched with MedCalc software. The clinical records and the preoperative and follow-up computed tomography angiography of patients who underwent endovascular treatment of AAA were included in this study. Results Patients in the LPSG group had significantly more often low access vessel diameter (< 6 mm) compared to the SPSG group (38.7% vs. 6.7%, p = 0.003). In 1-year follow-up, there was no rupture, no infection, no conversion to open repair and no aneurysm-related death. Five secondary interventions were necessary in the SPSG group and only 1 in the LPSG group (p = 0.09). Type of stent graft was not a risk factor of perioperative complications, presence of endoleak or reintervention (p > 0.05). Risk factors for perioperative complications were COPD and conical neck (OR = 6.3, 95% CI: 1.5-25, p = 0.01 and OR = 6.2, 95% CI: 1-39.76, p = 0.04). The risk factor for endoleak was lower maximal aneurysm diameter. The risk factor for reintervention was proximal neck diameter (OR = 0.77, 95% CI: 0.-0.97, p = 0.03). Conclusions Our study showed that use of LPSGs is a safe and viable method for patients with narrow access vessels who are not eligible for standard-profile systems.
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Affiliation(s)
- Marek Piwowarczyk
- Department of Vascular Surgery, University Hospital, Jagiellonian University, Krakow, Poland
| | | | - Jerzy Krzywoń
- Department of Vascular Surgery, University Hospital, Jagiellonian University, Krakow, Poland
| | - Marcin Kołodziejski
- Department of Vascular Surgery, University Hospital, Jagiellonian University, Krakow, Poland
| | - Roger M. Krzyżewski
- Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical College, Krakow, Poland
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15
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Crosier R, Lopez Laporte MA, Unni RR, Coutinho T. Female-Specific Considerations in Aortic Health and Disease. CJC Open 2024; 6:391-406. [PMID: 38487044 PMCID: PMC10935703 DOI: 10.1016/j.cjco.2023.09.006] [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: 07/31/2023] [Accepted: 09/06/2023] [Indexed: 03/17/2024] Open
Abstract
The aorta plays a central role in the modulation of blood flow to supply end organs and to optimize the workload of the left ventricle. The constant interaction of the arterial wall with protective and deleterious circulating factors, and the cumulative exposure to ventriculoarterial pulsatile load, with its associated intimal-medial changes, are important players in the complex process of vascular aging. Vascular aging is also modulated by biomolecular processes such as oxidative stress, genomic instability, and cellular senescence. Concomitantly with well-established cardiometabolic and sex-specific risk factors and environmental stressors, arterial stiffness is associated with cardiovascular disease, which remains the leading cause of morbidity and mortality in women worldwide. Sexual dimorphisms in aortic health and disease are increasingly recognized and explain-at least in part-some of the observable sex differences in cardiovascular disease, which will be explored in this review. Specifically, we will discuss how biological sex affects arterial health and vascular aging and the implications this has for development of certain cardiovascular diseases uniquely or predominantly affecting women. We will then expand on sex differences in thoracic and abdominal aortic aneurysms, with special considerations for aortopathies in pregnancy.
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Affiliation(s)
- Rebecca Crosier
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Rudy R. Unni
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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16
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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17
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Talvitie M, Jonsson M, Roy J, Hultgren R. Association of women-specific size threshold and mortality in elective abdominal aortic aneurysm repair. Br J Surg 2024; 111:znad376. [PMID: 37963191 PMCID: PMC10776526 DOI: 10.1093/bjs/znad376] [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: 05/24/2023] [Revised: 08/17/2023] [Accepted: 10/22/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND It is unclear whether women derive mortality benefit from early repair of abdominal aortic aneurysms (AAA). The aim of this study was to compare short- and mid-term mortality for women treated at small versus large diameters. METHOD Women receiving elective repair of AAA at small (49-54 mm) and large (≥55 mm) diameters from 2008 to 2022 were extracted from the Swedish National Registry for Vascular Surgery (n = 1642 women). The effect of diameter on 90-day, 1- and 3-year mortality was studied in logistic regression and propensity score models. Age, co-morbidities, smoking and repair modality were considered as confounders. Men (n = 9047) were analysed in parallel. RESULTS Some 1642 women were analysed, of whom 34% underwent repair at small diameters (versus 52% of men). Women with small (versus large) AAAs were younger (73 versus 75 years, P < 0.001), and 63% of women in both size groups had endovascular repairs (P = 0.120). Mortality was 3.5% (90 days), 7.1% (1 year) and 15.8% (3 years), with no differences between the size strata. There was no consistent association between AAA size and mortality in multivariable models. Sex differences in mortality were almost entirely due to mortality in younger-than-average women versus men (3-year mortality: small AAAs 11.1% versus 7.3%, P < 0.030, or large 14.4% versus 10.7%, P < 0.038). CONCLUSION Mortality in women is high and unaffected by AAA size at repair. The optimal threshold for women remains undefined. The higher rupture risk in women should not automatically translate into a lower, women-specific threshold.
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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
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, 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
| | - 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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18
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Meccanici F, Bom A, Knol W, Gökalp A, Thijssen C, Bekkers J, Geuzebroek G, Mokhles M, van Kimmenade R, Budde R, Takkenberg J, Roos-Hesselink J. Male-female differences in thoracic aortic diameters at presentation of acute type A aortic dissection. IJC HEART & VASCULATURE 2023; 49:101290. [PMID: 37942298 PMCID: PMC10628350 DOI: 10.1016/j.ijcha.2023.101290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023]
Abstract
Background Acute type A aortic dissection (ATAAD) is a highly lethal event, associated with aortic dilatation. It is not well known if patient height, weight or sex impact the thoracic aortic diameter (TAA) at ATAAD. The study aim was to identify male-female differences in TAA at ATAAD presentation. Methods This retrospective cross-sectional study analysed all adult patients who presented with ATAAD between 2007 and 2017 in two tertiary care centres and underwent contrast enhanced computed tomography (CTA) before surgery. Absolute aortic diameters were measured at the sinus of Valsalva (SoV), ascending (AA) and descending thoracic aorta (DA) using double oblique reconstruction, and indexed for body surface area (ASI) and height (AHI). Z-scores were calculated using the Campens formula. Results In total, 59 % (181/308) of ATAAD patients had CT-scans eligible for measurements, with 82 female and 99 male patients. Females were significantly older than males (65.5 ± 12.4 years versus 60.3 ± 2.3, p = 0.024). Female patients had larger absolute AA diameters than male patients (51.0 mm [47.0-57.0] versus 49.0 mm [45.0-53.0], p = 0.023), and larger ASI and AHI at all three levels. Z-scores for the SoV and AA were significantly higher for female patients (2.99 ± 1.66 versus 1.34 ± 1.77, p < 0.001 and 5.27 [4.38-6.26] versus 4.06 [3.14-5.02], p < 0.001). After adjustment for important clinical factors, female sex remained associated with greater maximal TAA (p = 0.019). Conclusion Female ATAAD patients had larger absolute ascending aortic diameters than males, implying a distinct timing in disease presentation or selection bias. Translational studies on the aortic wall and studies on growth patterns should further elucidate these sex differences.
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Affiliation(s)
- F. Meccanici
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A.W. Bom
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - W.G. Knol
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A.L. Gökalp
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - C.G.E. Thijssen
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - J.A. Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - G.S.C. Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - M.M. Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiothoracic Surgery, Utrecht University Medical Centre, Utrecht, Netherlands
| | - R.R.J. van Kimmenade
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - R.P.J. Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - J.J.M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - J.W. Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
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19
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De Freitas S, Falls G, Weis T, Bakhshi K, Korepta LM, Bechara CF, Erben Y, Arya S, Fatima J. Comprehensive framework of factors accounting for worse aortic aneurysm outcomes in females: A scoping review. Semin Vasc Surg 2023; 36:508-516. [PMID: 38030325 DOI: 10.1053/j.semvascsurg.2023.10.007] [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: 07/23/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Sex-based outcome studies have consistently documented worse results for females undergoing care for abdominal aortic aneurysms. This review explores the underlying factors that account for worse outcomes in the females sex. A scoping review of studies reporting sex-based disparities on abdominal aortic aneurysms was performed. The review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. Factors that account for worse outcomes in the females sex were identified, grouped into themes, and analyzed. Key findings of each study are reported and a comprehensive framework of these factors is presented. A total of 35 studies were identified as critical in highlighting sex-based disparities in care of patients with aortic aneurysms. We identified the following 10 interrelated themes in the chain of aneurysm care that account for differential outcomes in females: natural history, risk factors, pathobiology, biomechanics, screening, morphology, device design and adherence to instructions for use, technique, trial enrollment, and social determinants. Factors accounting for worse outcomes in the care of females with aortic aneurysms were identified and described. Some factors are immediately actionable, such as screening criteria, whereas device design improvement will require further research and development. This comprehensive framework of factors affecting care of aneurysms in females should serve as a blueprint to develop education, outreach, and future research efforts to improve outcomes in females.
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Affiliation(s)
| | | | - Tahlia Weis
- Marshfield Clinic Health System, Marshfield, WI
| | | | | | | | | | - Shipra Arya
- Stanford University School of Medicine, Stanford, CA
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20
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Gruber M, Sotir A, Klopf J, Lakowitsch S, Domenig C, Wanhainen A, Neumayer C, Busch A, Eilenberg W. Operation time and clinical outcomes for open infrarenal abdominal aortic aneurysms to remain stable in the endovascular era. Front Cardiovasc Med 2023; 10:1213401. [PMID: 38034380 PMCID: PMC10682774 DOI: 10.3389/fcvm.2023.1213401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Objective Endovascular aortic repair (EVAR) has become a routine procedure worldwide. Ultimately, the increasing number of EVAR cases entails changing conditions for open surgical repair (OSR) regarding patient selection, complexity, and surgical volume. This study aimed to assess the time trends of open abdominal aortic aneurysm (AAA) repair in a high-volume single center in Austria over a period of 20 years, focusing on the operation time and clinical outcomes. Materials and methods A retrospective analysis of all patients treated for infrarenal AAAs with OSR or EVAR between January 2000 and December 2019 was performed. Infrarenal AAA was defined as the presence of a >10-mm aortic neck. Cases with ruptured or juxtarenal AAAs were excluded from the analysis. Two cohorts of patients treated with OSR at different time periods, namely, 2000-2009 and 2010-2019, were assessed regarding demographical and procedure details and clinical outcomes. The time periods were defined based on the increasing single-center trend toward the EVAR approach from 2010 onward. Results A total of 743 OSR and 766 EVAR procedures were performed. Of OSR cases, 589 were infrarenal AAAs. Over time, the EVAR to OSR ratio was stable at around 50:50 (p = 0.488). After 2010, history of coronary arterial bypass (13.4% vs. 7.2%, p = 0.027), coronary artery disease (38.1% vs. 25.1%, p = 0.004), peripheral vascular disease (35.1% vs. 21.3%, p = 0.001), and smoking (61.6% vs. 34.3%, p < 0.001) decreased significantly. Age decreased from 68 to 66 years (p = 0.023). The operation time for OSR remained stable (215 vs. 225 min, first vs. second time period, respectively, p = 0.354). The intraoperative (5.8% vs. 7.2%, p = 0.502) and postoperative (18.3% vs. 20.8%, p = 0.479) complication rates also remained stable. The 30-day mortality rate did not change over both time periods (3.0% vs. 2.4%, p = 0.666). Conclusion Balanced EVAR to OSR ratio, similar complexity of cases, and volume over the two decades in OSR showed stable OSR time without compromise in clinical outcomes.
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Affiliation(s)
- M. Gruber
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - A. Sotir
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - J. Klopf
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - S. Lakowitsch
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - C. Domenig
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - C. Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - A. Busch
- Department of Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University Dresden, Dresden, Germany
| | - W. Eilenberg
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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21
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Nana P, Koelemay MJW, Leone N, Brodis A, van den Berg JC, de Bruin JL, Geelkerken RH, Spanos K. A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2023; 66:632-643. [PMID: 37451604 DOI: 10.1016/j.ejvs.2023.07.011] [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: 03/16/2023] [Revised: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. DATA SOURCES Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. REVIEW METHODS The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. RESULTS Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. CONCLUSION Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Mark J W Koelemay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Konstantinos Spanos
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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22
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Ramirez JL, Govsyeyev N, Sorber R, Iannuzzi JC, Schanzer AS, Hicks CW, Malas MB, Zarkowsky DS. Proximal Instructions for Use Violations in Elective Endovascular Aneurysm Repair in the Vascular Quality Initiative: Retrospective Analysis. J Am Coll Surg 2023; 237:633-643. [PMID: 37288832 PMCID: PMC10788874 DOI: 10.1097/xcs.0000000000000783] [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] [Indexed: 06/09/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is often attempted in patients with marginal anatomy. These patients' midterm outcomes are available in the Vascular Quality Initiative for analysis. STUDY DESIGN Retrospective analysis of prospectively collected data in the Vascular Quality Initiative from patients who underwent elective infrarenal EVAR between 2011 and 2018. Each EVAR was identified as either on- or off-instructions for use (IFU) based on aortic neck criteria. Multivariable logistic regression models were used to assess associations between aneurysm sac enlargement, reintervention, and type Ia endoleak with IFU status. Kaplan-Meier time-to-event models estimated reintervention, aneurysm sac enlargement, and overall survival. RESULTS We identified 5,488 patients with at least 1 follow-up recorded. Those treated off-IFU included 1,236 patients ([23%] mean follow-up 401 days) compared with 4,252 (77%) treated on-IFU (mean follow-up 406 days). There was no evidence of significant differences in crude 30-day survival (96% vs 97%; p = 0.28) or estimated 2-year survival (97% vs 97%; log-rank p = 0.28). Crude type Ia endoleak frequency was greater in patients treated off IFU (2% vs 1%; p = 0.03). Off-IFU EVAR was associated with type Ia endoleak on multivariable regression model (odds ratio 1.84 [95% CI 1.23 to 2.76]; p = 0.003). Patients treated off IFU vs on IFU experienced had increased risk of reintervention within 2 years (7% vs 5%; log-rank p = 0.02), a finding consistent with results from the Cox modeling (hazard ratio 1.38 [95% CI 1.06 to 1.81]; p = 0.02). CONCLUSIONS Patients treated off IFU were at greater risk for type Ia endoleak and reintervention, although they had similar 2-year survival compared with those treated on IFU. Patients with anatomy outside IFU should be considered for open surgery or complex endovascular repair to reduce the probability for revision.
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Affiliation(s)
- Joel L Ramirez
- From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky)
- Chan Zuckerberg Biohub, San Francisco, CA (Rmairez)
| | | | - Rebecca Sorber
- Johns Hopkins University School of Medicine, Baltimore, MD (Sorber, Hicks)
| | | | - Andres S Schanzer
- University of Massachusetts Medical School, Worcester, MA (Schanzer)
| | - Caitlin W Hicks
- Johns Hopkins University School of Medicine, Baltimore, MD (Sorber, Hicks)
| | | | - Devin S Zarkowsky
- From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky)
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23
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Nana P, Jama K, Kölbel T, Spanos K, Panuccio G, Jakimowicz T, Rohlffs F. Sex-Comparative Outcomes of the T-Branch Device for the Treatment of Complex Aortic Aneurysms. J Clin Med 2023; 12:5811. [PMID: 37762752 PMCID: PMC10531663 DOI: 10.3390/jcm12185811] [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: 07/30/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Females are at increased risk of mortality compared to males after complex endovascular aortic repair. This study aims to examine sex-related peri-operative and follow-up outcomes in patients managed with the t-Branch device. METHODS A two-center retrospective analysis of patients managed with the off-the-shelf t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) between 1 January 2014 and 30 September 2020 was performed. Primary outcomes were sex-comparative 30-day mortality, major adverse events (MAEs) and spinal cord ischemia (SCI). RESULTS A total of 542 patients were included; 28.0% were females. Urgent repair and type I-III thoracoabdominal aneurysms were more common among females (52.6% vs. 34%, p = 0.01, and 57.1% vs. 35.8%, p = 0.004). Technical success was similar (97.4% vs. 96.9%, p = 0.755), as well as early mortality (16.2% in females vs. 10.8% in males; p = 0.084). SCI rates were similar between groups (13.6% vs. 9.2% p = 0.183). MAEs were more common in females; 33.7% vs. 21.4% (p = 0.022). Multivariate analysis did not identify sex as an independent predictor of adverse events. The 12-month survival rate was 75.7% (SE 0.045) for females and 84.1% (SE 0.026) for males (log rank, p = 0.10). CONCLUSIONS Sex was not detected as an independent factor of mortality, MAEs and SCI within patients managed with the t-Branch device. Feasibility was high in both groups. No significant difference was shown in survival during the 12-month follow-up.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Eppendorf, 20251 Hamburg, Germany; (T.K.); (K.S.); (G.P.); (F.R.)
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, 02-006 Warsaw, Poland; (K.J.); (T.J.)
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Eppendorf, 20251 Hamburg, Germany; (T.K.); (K.S.); (G.P.); (F.R.)
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Eppendorf, 20251 Hamburg, Germany; (T.K.); (K.S.); (G.P.); (F.R.)
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Eppendorf, 20251 Hamburg, Germany; (T.K.); (K.S.); (G.P.); (F.R.)
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, 02-006 Warsaw, Poland; (K.J.); (T.J.)
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Eppendorf, 20251 Hamburg, Germany; (T.K.); (K.S.); (G.P.); (F.R.)
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24
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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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25
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Nana P, Spanos K, Kölbel T, Panuccio G, Jama K, Jakimowicz T, Rohlffs F. Early and Mid-Term Outcomes of Females Treated with t-Branch off the Shelf Device. Ann Vasc Surg 2023; 95:32-41. [PMID: 37268105 DOI: 10.1016/j.avsg.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/16/2023] [Accepted: 05/26/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Female sex has been characterized as a risk factor of increased mortality in patients managed for complex aortic aneurysm using endovascular means. This study aimed to present the perioperative and follow-up outcomes of females managed electively or urgently with the t-Branch device and investigate factors affecting the early outcomes. METHODS A 2-center retrospective observational study was conducted including elective and urgent female patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) for thoracoabdominal and pararenal aneurysms between January 1, 2018 and September 30, 2020. Primary early outcomes included technical success and 30-day mortality and morbidity [spinal cord ischemia (SCI) and acute kidney injury]. Follow-up survival and freedom from reintervention rates were assessed using Kaplan-Meier estimates. RESULTS In total, 153 females were included; 81 (52.9%) treated urgently. Urgent patients were older (73.2 ± 8.6 vs. 68.5 ± 6.8 years; P < 0.001) and presented higher previous coronary angioplasty/stenting (16.0% vs. 5.6%, P = 0.005) and lower double antiplatelet therapy (DAPT, 46.3% vs. 53.7%, P = 0.04) rates. Technical success was 97.4%. Early mortality was 16.3% (22% in urgent; 12% in elective; P = 0.2) and SCI and acute kidney injury were diagnosed in 13.7% (11% in urgent; 16% in elective; P = 0.2) and 18.3% (22.2% in urgent; 13.9% in elective; P = 0.18), respectively. Multivariate regression analyses showed that DAPT and b-blockers were related to lower 30-day mortality. DAPT was also preventive for SCI. Survival rates were 68.4% [standard error (SE) 0.07] at 12 months for the urgent and 75.6% (SE 0.09) at 24 months for the elective group (P = 0.14). Freedom from reintervention rates were 81.4% (SE 0.06) at 6 months and 64.7% (SE 0.09) at 18 months for the urgent and 81.7% (SE 0.06) at 6 months and 75.4% (SE 0.081) at 18 months for the elective group (P = 0.94). CONCLUSIONS Female patients managed with the t-Branch device for thoracoabdominal and pararenal aneurysms in elective and urgent setting presented similar 30-day mortality and SCI rates.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany.
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany; Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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26
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Zalewski D, Chmiel P, Kołodziej P, Borowski G, Feldo M, Kocki J, Bogucka-Kocka A. Dysregulations of Key Regulators of Angiogenesis and Inflammation in Abdominal Aortic Aneurysm. Int J Mol Sci 2023; 24:12087. [PMID: 37569462 PMCID: PMC10418409 DOI: 10.3390/ijms241512087] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Abdominal aortic aneurysm (AAA) is a chronic vascular disease caused by localized weakening and broadening of the abdominal aorta. AAA is a clearly underdiagnosed disease and is burdened with a high mortality rate (65-85%) from AAA rupture. Studies indicate that abnormal regulation of angiogenesis and inflammation contributes to progression and onset of this disease; however, dysregulations in the molecular pathways associated with this disease are not yet fully explained. Therefore, in our study, we aimed to identify dysregulations in the key regulators of angiogenesis and inflammation in patients with AAA in peripheral blood mononuclear cells (using qPCR) and plasma samples (using ELISA). Expression levels of ANGPT1, CXCL8, PDGFA, TGFB1, VEGFB, and VEGFC and plasma levels of TGF-alpha, TGF-beta 1, VEGF-A, and VEGF-C were found to be significantly altered in the AAA group compared to the control subjects without AAA. Associations between analyzed factors and risk factors or biochemical parameters were also explored. Any of the analyzed factors was associated with the size of the aneurysm. The presented study identified dysregulations in key angiogenesis- and inflammation-related factors potentially involved in AAA formation, giving new insight into the molecular pathways involved in the development of this disease and providing candidates for biomarkers that could serve as diagnostic or therapeutic targets.
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Affiliation(s)
- Daniel Zalewski
- Chair and Department of Biology and Genetics, Medical University of Lublin, 4a Chodźki St., 20-093 Lublin, Poland; (P.C.); (P.K.); (A.B.-K.)
| | - Paulina Chmiel
- Chair and Department of Biology and Genetics, Medical University of Lublin, 4a Chodźki St., 20-093 Lublin, Poland; (P.C.); (P.K.); (A.B.-K.)
| | - Przemysław Kołodziej
- Chair and Department of Biology and Genetics, Medical University of Lublin, 4a Chodźki St., 20-093 Lublin, Poland; (P.C.); (P.K.); (A.B.-K.)
| | - Grzegorz Borowski
- Chair and Department of Vascular Surgery and Angiology, Medical University of Lublin, 11 Staszica St., 20-081 Lublin, Poland; (G.B.); (M.F.)
| | - Marcin Feldo
- Chair and Department of Vascular Surgery and Angiology, Medical University of Lublin, 11 Staszica St., 20-081 Lublin, Poland; (G.B.); (M.F.)
| | - Janusz Kocki
- Department of Clinical Genetics, Chair of Medical Genetics, Medical University of Lublin, 11 Radziwiłłowska St., 20-080 Lublin, Poland;
| | - Anna Bogucka-Kocka
- Chair and Department of Biology and Genetics, Medical University of Lublin, 4a Chodźki St., 20-093 Lublin, Poland; (P.C.); (P.K.); (A.B.-K.)
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27
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Özdemir-van Brunschot DMD, Holzhey D, Botsios S. Sex-Related Differences in Proximal Neck Anatomy and Their Consequences in Patients after EVAR: A Matched Cohort Analysis. J Clin Med 2023; 12:4929. [PMID: 37568333 PMCID: PMC10419678 DOI: 10.3390/jcm12154929] [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: 06/18/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Studies comparing male and female patients with abdominal aortic aneurysms have shown that female patients are generally older and more often experience postoperative complications after endovascular and open repair. There are also indications that female patients have more extensive neck pathologies and that they more often have postoperative complications related to proximal neck pathology. MATERIAL AND METHODS This retrospective study describes all consecutive female patients who underwent EVAR between 1 January 2012 and 31 December 2021. Propensity-score matching was used to obtain a matched control male cohort. Propensity scores were generated with the following anatomic parameters: infrarenal and suprarenal angulation, proximal and distal neck diameter and neck length. 1 Female patient was matched with 3 male patients. RESULTS A total of 160 patients were included, namely 120 male patients and 40 female patients. Due to matching, there were no significant differences regarding infrarenal and suprarenal angulation and proximal and distal neck diameter and length. All-cause and aneurysm-related mortality were comparable (p = 0.19 and p = 0.98). The necessity of neck-related secondary procedures was significantly higher in female patients (p = 0.02). In the multivariate analysis, the female sex was a significant predictor of endoleak type IA within 30 days. However, there was no significant association between intraoperative endoleak type IA and endoleak type IA at the end of follow-up. CONCLUSIONS This study suggests that there was a higher initial incidence of endoleak type IA in female patients, despite thematched preoperative anatomic parameter. Due to the relatively low number of included female patients, conclusions should be drawn carefully.
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Affiliation(s)
- Denise Michelle Danielle Özdemir-van Brunschot
- German Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group, 40472 Düsseldorf, Germany
| | - David Holzhey
- German Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Spiridon Botsios
- German Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group, 40472 Düsseldorf, Germany
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Martinelli O, Cuozzo S, Miceli F, Gattuso R, D'Andrea V, Sapienza P, Bellini MI. Elective Endovascular Aneurysm Repair (EVAR) for the Treatment of Infrarenal Abdominal Aortic Aneurysms of 5.0-5.5 cm: Differences between Men and Women. J Clin Med 2023; 12:4364. [PMID: 37445398 DOI: 10.3390/jcm12134364] [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: 05/24/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND There is significant debate regarding the existence of sex-related differences in the presentation, treatment, and outcomes of men versus women affected by abdominal aortic aneurysm (AAA). The purpose of this study is to compare endovascular aneurysm repair (EVAR) of infrarenal AAAs with the current sex-neutral 5.0-5.5 cm-diameter threshold for intervention between the two sexes. METHODS Retrospective review of consecutive cases from a single teaching institution over a period of five years of patients who had undergone elective EVAR for AAAs between 5.0 and 5.5 cm in diameter. Outcomes of interest were compared according to sex. RESULTS Ninety-four patients were included in the analysis, with a higher prevalence of men (53%). Females were older at the time of repair, 78 ± 5.1 years, versus 71.7 ± 7 years (p < 0.01), and had higher incidence of underlying comorbidities, namely, arrhythmia, chronic kidney disease, and previous carotid revascularization. Women had higher incidence of immediate systemic complications (p = 0.021), post-operative AMI (p = 0.001), arrhythmia (p = 0.006), pulmonary oedema (p < 0.001), and persistent renal dysfunction (p = 0.029). Multivariate analysis for post-operative factors associated to mortality and adjusted for sex confirmed that AMI (p = 0.015), arrhythmia (p = 0.049), pulmonary oedema (p = 0.015), persistent renal dysfunction (p < 0.001), cerebral ischemia (p < 0.001), arterial embolism of lower limbs (p < 0.001), and deep-vein thrombosis of lower limbs (p < 0.001) were associated to higher EVAR-related mortality; a higher incidence of post-operative AMI (p = 0.014), pulmonary edema (p = 0.034), and arterial embolism of lower limbs (p = 0.046) were associated to higher 30-days mortality. In females there was also a higher rate of suprarenal fixation (p = 0.026), insertion outside the instruction for use (p = 0.035), and a more hostile neck anatomy with different proximal aortic diameter (p < 0.001) and angle (p = 0.003). CONCLUSIONS A similar threshold of size of AAA for elective surgery for both males and females might not be appropriate for surgical intervention, as females tend to have worse outcomes. Further population-based studies are needed to guide on sex-related differences and intervention on AAA.
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Affiliation(s)
- Ombretta Martinelli
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Simone Cuozzo
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesca Miceli
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Gattuso
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito D'Andrea
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Sapienza
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
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29
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Alberga AJ, de Bruin JL, Bastos Gonçalves F, Karthaus EG, Wilschut JA, van Herwaarden JA, Wever JJ, Verhagen HJM. Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic Aneurysms. J Endovasc Ther 2023; 30:419-432. [PMID: 35311414 PMCID: PMC10209502 DOI: 10.1177/15266028221083460] [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] [Indexed: 01/29/2024]
Abstract
PURPOSE Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data. METHODS All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians. RESULTS The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8). CONCLUSION Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
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Affiliation(s)
- Anna J. Alberga
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jorg L. de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frederico Bastos Gonçalves
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário de Lisboa Central, NOVA Medical School, Lisboa, Portugal
| | - Eleonora G. Karthaus
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Janneke A. Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | | | - Jan J. Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hence J. M. Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Horiguchi R, Takehara Y, Sugiyama M, Hyodo R, Komada T, Matsushima M, Naganawa S, Mizuno T, Sakurai Y, Sugimoto M, Banno H, Komori K, Itatani K. Postendovascular Aneurysmal Repair Increase in Local Energy Loss for Fusiform Abdominal Aortic Aneurysm: Assessments With 4D flow MRI. J Magn Reson Imaging 2023; 57:1199-1211. [PMID: 35861188 DOI: 10.1002/jmri.28359] [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: 04/07/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Although endovascular aneurysmal repair (EVAR) is a preferred treatment for abdominal aortic aneurysm (AAA) owing to its low invasiveness, its impact on the local hemodynamics has not been fully assessed. PURPOSE To elucidate how EVAR affects the local hemodynamics in terms of energy loss (EL). STUDY TYPE Prospective single-arm study. FIELD STRENGTH/SEQUENCE A 3.0 T/4D flow MRI using a phase-contrast three-dimensional cine-gradient-echo sequence. POPULATION A total of 13 consecutive patients (median [interquartile range] age: 77.0 [73.0, 78.8] years, 11 male) scheduled for EVAR as an initial treatment for fusiform AAA. ASSESSMENT 4D flow MRI covering the abdominal aorta and bilateral common iliac arteries and the corresponding stent-graft (SG) lumen was performed before and after EVAR. Plasma brain natriuretic peptide (BNP) was measured within 1 week before and 1 month after EVAR. The hemodynamic data, including mean velocity and the local EL, were compared pre-/post-EVAR. EL was correlated with AAA neck angle and with BNP. Patients were subdivided into deformed (N = 5) and undeformed SG subgroups (N = 8) and pre-/post-EVAR BNP compared in each. STATISTICS Parametric or nonparametric methods. Spearman's rank correlation coefficients (r). The interobserver/intraobserver variabilities with Bland-Altman plots. A P value < 0.05 is considered significant. RESULTS The mean velocity (cm/sec) at the AAA was five times greater after EVAR: 4.79 ± 0.32 vs. 0.91 ± 0.02. The total EL (mW) increased by 1.7 times after EVAR: 0.487 (0.420, 0.706) vs. 0.292 (0.192, 0.420). The total EL was proportional to the AAA neck angle pre-EVAR (r = 0.691) and post-EVAR (r = 0.718). BNP (pg/mL) was proportional to the total EL post-EVAR (r = 0.773). In the deformed SG group, EL (0.349 [0.261, 0.416]) increased 2.4-fold to 0.848 (0.597, 1.13), and the BNP 90.3 (53.6, 105) to 100 (67.2, 123) post-EVAR. CONCLUSION The local EL showed a 1.7-fold increase after EVAR. The larger increase in the EL in the deformed SG group might be a potential concern for frail patients. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Ryota Horiguchi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuo Takehara
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masataka Sugiyama
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryota Hyodo
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Tomohiro Komada
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masaya Matsushima
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Mizuno
- Department of Medical Technology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yasuo Sakurai
- Department of Medical Technology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masayuki Sugimoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Banno
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Osaka City University, Osaka, Japan
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31
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Kristensen JSS, Obel LM, Dahl M, Høgh A, Lindholt JS. Gender-specific Predicted Normal Aortic Size and Its Consequences of the Population-Based Prevalence of Abdominal Aortic Aneurysms. Ann Vasc Surg 2023; 91:127-134. [PMID: 36563844 DOI: 10.1016/j.avsg.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/07/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND To investigate if a relative-size-index of the abdominal aortic diameter influences the prevalence estimates of abdominal aortic dilatations compared to absolute diameters. METHODS Cross-sectional study. Participants from the Viborg Vascular Screening Trial, Viborg Women Cohort, and the Viborg Screening Program. Through multivariate linear regression analyses, 2 gender-specific prediction-equations were developed based upon body-surface area and age. The definitions of absolute and relative size of aortic ectasies were 25-29 mm and 1.25-1.49× individual-predicted size (IPS), abdominal aortic aneurysm (AAA) 30 mm and 1.5× IPS, and large repair-recommendable AAA ≥55 mm or ≥ 2.75× IPS, respectively. RESULTS Nineteen thousand two hundred and sixty nine males (69.6 years) and 2,426 females (67.1 years) attended the population- and ultrasound-based screening studies for AAA. The mean peak systolic abdominal anterior-posterior inner to inner diameter was 19.1 mm (±5.3 mm) and 16.6 mm (±2.8 mm) (P < 0.001) in males and females, respectively. Body surface area showed the strongest correlation with aortic diameters in both males (r = 0.19, P < 0.001) and females (r = 0.17, P < 0.001). Age correlated significantly with size, but only in males (r = 0.03, P < 0.001). The prevalence in men of absolute size-defined and relative size index-defined screening-detected aortic ectasies, AAAs and repair-recommendable AAAs were: 5.9% and 9.5% (P < 0.001), 3.3% and 4.2% (P < 0.001) and 9.9% and 15.2% (P = 0.004), respectively. Prevalence in females of absolute-size-defined and relative-size-index-defined screening-detected aortic ectasies, AAAs and repair-recommendable AAAs were 1.2% and 5.8% (P < 0.001), 0.5% and 1.3% (P = 0.003) and 0.0% and 23.1% (P = 0.553), respectively. CONCLUSIONS Despite statistical differences, ultrasound-based absolute diameters to detect AAA seem acceptable in men. In females, poor agreements were noticed concerning all 3 categories of aneurysms, indicating that the current absolute diagnostic cut-points do not reflect female anatomy.
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Affiliation(s)
- Joachim S S Kristensen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Odense, Odense C, Denmark; University Hospital of Odense, Elitary research Centre of Individualized Medicine in Arterial Disease (CIMA), Denmark; Cardiovascular Centre of Excellence in Southern Denmark (CAVAC), Denmark.
| | - Lasse M Obel
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Odense, Odense C, Denmark; University Hospital of Odense, Elitary research Centre of Individualized Medicine in Arterial Disease (CIMA), Denmark; Cardiovascular Centre of Excellence in Southern Denmark (CAVAC), Denmark
| | - Marie Dahl
- Department of Surgery, Vascular Research Unit, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Cardiac, Thoracic, and Vascular Research Unit, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Annette Høgh
- Department of Surgery, Vascular Research Unit, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Odense, Odense C, Denmark; University Hospital of Odense, Elitary research Centre of Individualized Medicine in Arterial Disease (CIMA), Denmark; Cardiovascular Centre of Excellence in Southern Denmark (CAVAC), Denmark; Department of Surgery, Vascular Research Unit, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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32
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Forbes SM, Mahmood DN, Rocha R, Tan KT, Ouzounian M, Chung JCY, Lindsay TF. Females experience elevated early morbidity and mortality but similar mid-term survival compared to males after branched/fenestrated endovascular aortic aneurysm repair. J Vasc Surg 2022; 77:1349-1358.e5. [PMID: 36581014 DOI: 10.1016/j.jvs.2022.12.031] [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: 08/19/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this study was to identify sex-related differences in outcomes following branched and/or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal (TAAA) and juxtarenal (JRAA) aortic aneurysms. METHODS Chart review completed on 242 B/FEVAR patients (57 female; 23.5%) between 2007 and 2020 at a single center. Median follow-up time was 3.3 years (interquartile range [IQR], 1.6-5.3 years). RESULTS No statistically significant differences in age (females, 75.9 ± 5.4 years vs males, 74.7 ± 7.2 years; P = .162) or aneurysm size (64.9 ± 6.8 vs 65.8 ± 9.4 mm; P = .41) at presentation were observed between sexes. Females presented with fewer JRAAs (45.6% vs 73%; P < .001) and received more Crawford extent II (26.3% vs 10.8%; P =.004) TAAA coverage. Increased incidence of moderate/severe target vessel stenosis (29.8% vs 14%; P = .022) was observed in female patients. Intraoperatively, females had higher procedure times (530 [IQR, 425-625] vs 420 [IQR, 350-510] minutes; P < .001), fluoroscopy times (124.1 ± 49 vs 107.3 ± 43.5 minutes; P = .017), and contrast usage (200 [IQR, 150-270] vs 175 [IQR, 130-225] mL; P = .005). Unplanned intraoperative maneuvers (45.6% vs 28.1%; P = .043), graft delivery issues (24.6% vs 4.9%; P < .001), and additional intraoperative complications (61.4% vs 35.7%; P < .001) were also increased in females. Postoperatively, females had a longer intensive care unit (3 [IQR, 1-5] vs 1 [IQR, 1-3] days; P = .002) and hospital stay (8 [IQR, 5-13] vs 5 [IQR, 3-9] days; P < .001) and experienced increased rates of spinal cord ischemia (15.8% vs 3.8%; P = .001) and bowel ischemia (10.5% vs 2.7%; P = .013). In-hospital mortality (12.3% vs 2.7%; P = .004) was higher in female patients but mid-term (6-year) survival was 60.2% for all patients (95% confidence interval, 53.0%-68.5%) and was similar between sexes (hazard ratio, 0.95; P = .83), which were the primary endpoints. No sex differences in mid-term follow-up reintervention, endoleak, and rupture rates were observed. CONCLUSIONS Females experienced significantly higher B/FEVAR intraoperative times, complications, and in-hospital morbidity and mortality compared with males but similar mid-term outcomes. Anatomic and atherosclerotic differences may have contributed to the observed in-hospital differences.
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Affiliation(s)
- Samantha M Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kongteng Tan Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Hultgren R, Fattahi N, Nilsson O, Svensjö S, Roy J, Linne A. Evaluating feasibility of using national registries for identification, invitation, and ultrasound examination of persons with hereditary risk for aneurysm disease-detecting abdominal aortic aneurysms in first degree relatives (adult offspring) to AAA patients (DAAAD). Pilot Feasibility Stud 2022; 8:252. [PMID: 36503690 PMCID: PMC9742022 DOI: 10.1186/s40814-022-01196-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sweden and the UK invite all 65-year-old men to a population-based ultrasound-based screening program to detect abdominal aortic aneurysms (AAA). First-degree relatives of patients with AAA are reported to have an increased risk to develop AAA, both women and men, but are not invited to screening. The "Detecting AAA in First Degree Relatives to AAA patients" (DAAAD) was designed to detect the true prevalence in adult offspring to AAA patients and to evaluate if national registries could be used for identification of index persons and their adult children with a high risk for the disease. The aim of this study is to summarize the design and methodology for this registry-based study. METHODS The study is based on a registry-based extraction and identification of a risk group in the population with a subsequent identification of their adult offspring. The targeted risk group suffers a heredity for a potentially lethal disease, AAA (n = 750) and matched control group without heredity for AAA is also identified and invited (n = 750). The participation rate in the population-based AAA screening program for men is 75% regionally. This population is younger and have a lower prevalence. A participation rate of 65% is considered clinically adequate. For the DAAAD study, a stratified analysis of the primary outcome, prevalence, will be performed for women and men separately. Two other planned projects are based on the material: firstly, evaluation of the anxiety for disease and health-related quality of life (HRQoL) and, secondly, the cost-effectiveness of the study. DISCUSSION In conclusion, this feasibility study will be instrumental in supporting the development of a possible new model to invite persons with high risk to develop hereditary rare diseases. To our knowledge, this is a unique, safe, and most likely to be a cost-efficient model to invite targeted risk groups for selected screening. If the study design and the results are shown to be cost-effective at the detected participation rate and prevalence, it should be further evaluated and adopted to a national screening program. The model also invites both women and men, which is unique for this specific patient group, considering that all population-based screening programs only include men. TRIAL REGISTRATION This trial is registered at the website of Clinical Trials. CLINICALTRIALS gov identifier, NCT4623268.
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Affiliation(s)
- Rebecka Hultgren
- grid.24381.3c0000 0000 9241 5705Department of Vascular Surgery, Karolinska University Hospital Stockholm, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Stockholm Aneurysm Research group, STAR, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Nina Fattahi
- grid.4714.60000 0004 1937 0626Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden ,grid.416648.90000 0000 8986 2221Section of Vascular Surgery, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Olga Nilsson
- grid.24381.3c0000 0000 9241 5705Department of Vascular Surgery, Karolinska University Hospital Stockholm, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Stockholm Aneurysm Research group, STAR, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Sverker Svensjö
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Uppsala University, Uppsala, Sweden ,Centre for Clinical Research, Falun, Sweden
| | - Joy Roy
- grid.24381.3c0000 0000 9241 5705Department of Vascular Surgery, Karolinska University Hospital Stockholm, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Stockholm Aneurysm Research group, STAR, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anneli Linne
- grid.4714.60000 0004 1937 0626Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden ,grid.416648.90000 0000 8986 2221Section of Vascular Surgery, Department of Surgery, Södersjukhuset, Stockholm, Sweden
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Maheswaran R, Tong T, Michaels J, Brindley P, Walters S, Nawaz S. Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival. Br J Surg 2022; 109:958-967. [PMID: 35950728 PMCID: PMC10364757 DOI: 10.1093/bjs/znac222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival. METHODS The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression. RESULTS Some 77 606 patients (83.4 per cent men) in four age categories (55-64, 65-74, 75-84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55-64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (-1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women. CONCLUSION There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.
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Affiliation(s)
- Ravi Maheswaran
- Correspondence to: Ravi Maheswaran, Public Health, School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK (e-mail: )
| | - Thaison Tong
- School of Health and Related Research, University of Sheffield, UK
| | - Jonathan Michaels
- Clinical Decision Science, School of Health and Related Research, University of Sheffield, UK
| | - Paul Brindley
- Department of Landscape Architecture, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- Medical Statistics and Clinical Trials, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Shah Nawaz
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, UK
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Hensley SE, Upchurch GR. Repair of Abdominal Aortic Aneurysms: JACC Focus Seminar, Part 1. J Am Coll Cardiol 2022; 80:821-831. [PMID: 35981826 DOI: 10.1016/j.jacc.2022.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 10/15/2022]
Abstract
Abdominal aortic aneurysms (AAAs), defined by an aortic diameter >3 cm, affect >1 million people in the United States. Risk factors for AAA include male sex, family history of AAA, smoking, Caucasian ethnicity, and age. Patients with known AAA should undergo regular surveillance via ultrasonography. Medical management, including smoking cessation and blood pressure management, is recommended for asymptomatic patients who do not meet the threshold for intervention. Repair options include endovascular aortic repair and open surgical repair, with good outcomes in long-term follow-up. Men with AAA >5.5 cm and women with AAA >5.0 cm in general should undergo elective repair. Medical management, including smoking cessation and blood pressure management, is recommended for asymptomatic patients who do not meet the threshold for intervention.
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Affiliation(s)
- Sara E Hensley
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Nana P, Spanos K, Behrendt CA, Dakis K, Brotis A, Kouvelos G, Giannoukas A, Kölbel T. Editor's Choice - Sex Specific Outcomes After Complex Fenestrated and Branched Endovascular Aortic Repair: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2022; 64:200-208. [PMID: 35598720 DOI: 10.1016/j.ejvs.2022.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/17/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE As females are at higher mortality risk after endovascular aortic repair, this study aimed to compare the 30-day and 12-month mortality, morbidity, and re-intervention rates between the sexes, treated with fenestrated or branched endovascular aortic repair (F/BEVAR). DATA SOURCES A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL, up to 30 July 2021, was performed. REVIEW METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, and its protocol was registered in PROSPERO (CRD42021273418). Observational studies (2010-21), with ≥ 20 patients, reporting on sex specific outcomes (mortality, acute kidney injury [AKI], spinal cord ischaemia [SCI], and re-intervention, after F/BEVAR), were considered eligible. Risk of bias in the studies was assessed using ROBINS-I, and evidence quality was assessed using GRADE. The primary outcome was the sex specific 30-day mortality rate, AKI, SCI, and re-intervention rates; secondary outcomes were survival and freedom from re-intervention at 12 months after F/BEVAR. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS Four retrospective and one prospective study (2 421 patients; 26% females) were included. The 30-day mortality rate was 12% in females vs. 3% in males (OR 2.65, 95% CI 1.79 - 3.92; Ι2 = 0%). The 30-day AKI, SCI, and re-intervention rates were similar (OR 1.45, 95% CI 1.03 - 2.03; Ι2 = 0%; OR 1.86, 95% CI 1.27 - 2.74; Ι2 = 38%; and OR 1.06, 95% CI 0.66 - 1.77; Ι2 = 0%, respectively). The 12-month survival rate was lower in females (OR 0.95, 95% CI 0.91 - 0.99; Ι2 = 38%). When excluding 30-day deaths, there was no difference in 12-month survival between sexes (OR 0.99, 95% CI 0.95 - 1.02; Ι2 = 32%). The 12-month freedom from re-intervention was similar between sexes (OR 0.87, 95% CI 0.75 - 1.01; Ι2 = 0%). CONCLUSION Female patients treated by F/BEVAR may present worse outcomes in terms of 30-day and 12-month survival. The high peri-operative mortality rate remains an issue. When excluding 30-day deaths, the 12-month survival rate was similar between the sexes. Early morbidity and re-intervention rates were comparable.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
| | | | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Heart Centre Hamburg, Hamburg, Germany
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Dias NV, Hultgren R. Sex Differences in Complex Endovascular Aortic Repair: Confused on a Higher Level? Eur J Vasc Endovasc Surg 2022; 64:209. [PMID: 35598722 DOI: 10.1016/j.ejvs.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 05/14/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Nuno V Dias
- Vascular Centre Malmö, Department of Thoracic Surgery and Vascular Diseases, Skåne University Hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Rebecka Hultgren
- Department of Molecular medicine and Surgery, Karolinska Institutet and Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Sex-based Differences in Patients Undergoing Thoracic Endovascular Aortic Repair for Acute Complicated Type B Dissection. J Vasc Surg 2022; 76:1198-1204.e1. [PMID: 35788367 DOI: 10.1016/j.jvs.2022.06.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/03/2022] [Accepted: 06/20/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Sex-based differences in outcomes for patients undergoing degenerative aortic aneurysm repair are well-described with female subjects having worse early and long-term outcomes compared with males. However, differences between males and females after thoracic endovascular aortic repair (TEVAR) of acute complicated type B aortic dissection (TBAD) have not been well characterized. Therefore, the objective of this study was to assess sex-based differences in clinical presentation, time to repair, morbidity and mortality in patients undergoing TEVAR for TBAD. METHODS All TEVAR procedures performed for acute complicated TBAD from a single academic medical center from August 2005 to January 2020 were analyzed. Clinical presentation, time to repair and outcomes were compared by sex. The primary outcome was 30-day mortality. Secondary outcomes were in-hospital complications, re-intervention, aorta-related death, and out of hospital survival. Predictors of mortality, including sex, were determined using multi-variable logistic regression. RESULTS A total of 159 patients, 24% (n=38) female were included in the analysis. There were no sex-based differences in clinical presentation or comorbidity prevalence for female and male patients. Female patients had a longer overall time from initial symptom onset to TEVAR implant (median: female, 3.5 days (IQR 1, 10) vs. male, 1 day (IQR 1, 3); p=0.007). However, there were no differences in time to repair after admission to the academic medical center (median: female, 1 day (IQR 0, 5), vs. male, 1 day (IQR 0, 3); p=0.176). There were no differences in unadjusted aortic-related, in-hospital, or 30-day death between female and male patients. Similarly, with risk-adjusted analysis, sex was not associated with adverse outcomes. One- and five-year freedom from aorta-related mortality were 82±4% for males vs. 87±6% for females and 79±4% for males vs. 80 ±8% for females, respectively. CONCLUSIONS Female and male patients with acute complicated TBAD undergoing TEVAR had no differences in clinical presentation or comorbidities. Female patients underwent TEVAR after a longer duration of symptoms, but this was not associated with sex-based differences in early or late morbidity or mortality.
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Corsi T, Ciaramella MA, Palte NK, Carlson JP, Rahimi SA, Beckerman WE. Female Sex Is Associated With Reintervention and Mortality Following Elective Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1494-1501.e1. [PMID: 35705120 DOI: 10.1016/j.jvs.2022.05.011] [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: 02/25/2022] [Revised: 04/15/2022] [Accepted: 05/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE While sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes are increasingly reported, but contributing factors remain without consensus. We investigated disparities in sex-specific outcomes following elective EVAR at our institution and evaluated factors that may predispose females to increased morbidity and mortality. METHODS A retrospective chart review of all patients undergoing elective EVAR from 2011 to 2020 at a suburban tertiary care center was performed. The primary outcomes were five-year survival and freedom from reintervention. Fisher's exact test, t-tests, and Kaplan-Meier analysis using the rank-log test investigated associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. RESULTS Two hundred and seventy-three patients underwent elective EVAR during the study period, including 68 (25%) females and 205 (75%) males. Females were older on average than males (76 years vs. 73 years, p= <0.01) and were more likely to have chronic obstructive pulmonary disease (COPD; 38% versus 23%, p=0.01), require home oxygen therapy (9% versus 2%, p=0.04) or dialysis preoperatively (4% versus 0%, p=0.02). Distribution of other common vascular comorbidities was similar between the sexes. Thirty-day readmission was greater in females than males (18% versus 8%, p=0.02). Females had significantly lower survival at five years (48% ± 7.9% versus 65% ± 4.3%, p<0.01) and significantly lower one-year (89% ± 4.1% for females vs. 94% ± 1.7% for males, p=0.01) and five-year freedom from reintervention (69% ± 8.9% versus 84% ± 3.3%, p=0.02). On multivariable analysis, female sex (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.1-2.9), congestive heart failure (HR: 2.2, 95% CI: 1.2-3.9) and age (HR: 1.1, 95% CI: 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with five-year reintervention (HR: 2.4, 95% CI: 1.1-4.9). CONCLUSIONS Female sex was associated with decreased five-year survival and increased one and five-year reintervention following elective EVAR. Data from our institution suggests factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for females following elective EVAR.
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Affiliation(s)
- Taylor Corsi
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | | | - Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - John P Carlson
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Saum A Rahimi
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - William E Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
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40
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Pratesi C, Esposito D, Apostolou D, Attisani L, Bellosta R, Benedetto F, Blangetti I, Bonardelli S, Casini A, Fargion AT, Favaretto E, Freyrie A, Frola E, Miele V, Niola R, Novali C, Panzera C, Pegorer M, Perini P, Piffaretti G, Pini R, Robaldo A, Sartori M, Stigliano A, Taurino M, Veroux P, Verzini F, Zaninelli E, Orso M. Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE). THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:328-352. [PMID: 35658387 DOI: 10.23736/s0021-9509.22.12330-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.
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Affiliation(s)
- Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy -
| | | | - Luca Attisani
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Filippo Benedetto
- Department of Vascular Surgery, AOU Policlinico Martino, Messina, Italy
| | | | | | - Andrea Casini
- Department of Intensive Care, Careggi University Hospital, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Elisabetta Favaretto
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Freyrie
- Department of Vascular Surgery, Parma University Hospital, Parma, Italy
| | - Edoardo Frola
- Department of Vascular Surgery, AO S. Croce e Carle, Cuneo, Italy
| | - Vittorio Miele
- Department of Diagnostic Imaging, Careggi University Hospital, Florence, Italy
| | - Raffaella Niola
- Department of Vascular and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Claudio Novali
- Department of Vascular Surgery, GVM Maria Pia Hospital, Turin, Italy
| | - Chiara Panzera
- Department of Vascular Surgery, AOU Sant'Andrea, Rome, Italy
| | - Matteo Pegorer
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Paolo Perini
- Department of Vascular Surgery, Parma University Hospital, Parma, Italy
| | | | - Rodolfo Pini
- Department of Vascular Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Alessandro Robaldo
- Department of Vascular Surgery, Ticino Vascular Center - Lugano Regional Hospital, Lugano, Switzerland
| | - Michelangelo Sartori
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | | | | | - Fabio Verzini
- Department of Vascular Surgery, AOU Città della Salute e della Scienza, Turin, Italy
| | - Erica Zaninelli
- Department of General Medical Practice, ATS Bergamo - ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche, Perugia, Italy
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Impact of Female Sex on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Aneurysm Repair: A Ten-Year Retrospective Nationwide Study in France. J Clin Med 2022; 11:jcm11082253. [PMID: 35456346 PMCID: PMC9029404 DOI: 10.3390/jcm11082253] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 12/04/2022] Open
Abstract
The impact of sex on the outcomes of patients with cardiovascular disease is still incompletely understood. The aim of this nationwide multicenter observational study was to investigate the impact of sex on post-operative outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for intact thoracic aortic aneurysm (iTAA). The French National Health Insurance Information System was searched to identify these patients over a ten-year retrospective period. Post-operative outcomes, 30-day and overall mortality were recorded. Among the 7383 patients included (5521 men and 1862 women), females were significantly older than males (66.8 vs. 64.8 years, p < 0.001). They were less frequently diagnosed with cardiovascular comorbidities. Post-operatively, women had less frequently respiratory (10.9 vs. 13.7%, p = 0.002) as well as cardiac complications (34.3 vs. 37.3%, p = 0.023), but they had more frequently arterial complications (52.8 vs. 49.8%, p = 0.024). There was no significant difference on overall mortality for a mean follow-up of 2.2 years (26.9 vs. 27.6%, p = 0.58). In the multivariable regression model, female sex was not associated with 30-day or overall mortality. Although women had a favorable comorbidity profile, the short-term and long-term survival was similar. The significantly higher rate of arterial complications suggests that women may be at higher risk of access-vessel-related complications.
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Nikol S, Nikol L. Update Aortenerkrankungen. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1746-8079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie vorliegende Arbeit berichtet über die neuesten wissenschaftlichen Erkenntnisse im Zusammenhang mit Aortenaneurysmen und -dissektionen. Schwerpunkt hierbei sind die Pathophysiologie und
Genetik, der Einfluss von Fluorochinolonen auf Aortenaneurysmen und -dissektionen sowie Marker der Aortitis. Ferner werden die wichtigsten aktuellen Leitlinienempfehlungen aus den Jahren
2017 bis 2020 zusammengefasst – der Fokus liegt hierbei auf dem Screening, der Diagnostik, den Grenzwerten für die Therapieindikationen, der Art und den technischen Details der Behandlung
sowie Nachsorge von Aneurysmen der Aorta ascendens, des Aortenbogens, der Aorta descendens und abdominalis, Penetrating aortic Ulcers, bei genetisch bedingten Bindegewebserkrankungen mit
Aortenbeteiligungen, Aortitis und mykotischen Aneurysmen.
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Affiliation(s)
- Sigrid Nikol
- Klinische und Interventionelle Angiologie, Asklepios Kliniken Hamburg GmbH, Hamburg, Deutschland
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Gontarz B, Majeed R, Staff I, DeMartino R, Jain A, Aitcheson E, Shah P, Divinagracia T, Gallagher J, Healy L, Ayach M, Gifford E. Female sex is associated with worse outcomes following complex fenestrated or branched endovascular aortic repair. Ann Vasc Surg 2022; 87:113-123. [PMID: 35339593 DOI: 10.1016/j.avsg.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Sex-related discrepancies after standard endovascular aneurysm repair (EVAR) are noted to disproportionally affect females. A growing body of literature suggests similar disparities may extend to complex fenestrated or branched endovascular aneurysm repair (FBEVAR). However, recent examination of complex FBEVAR by a consortium of high-volume centers noted equivalent mortality among sexes. Whether similar results extend to non-trial data is unknown. METHODS We examined all juxta-renal through type IV thoraco-abdominal aneurysms (sealing zones 6-8) who underwent elective FBEVAR within the Vascular Quality Initiative (VQI) database from January 2012 to December 2020. Urgent, symptomatic, ruptured, and staged cases were excluded, as were parallel stent grafts. Demographics, comorbid conditions, and technical factors were compared between sexes. Univariate analysis with Wilcoxon ranked sum tests and Chi-square tests of proportion were performed, followed by multivariate logistic regression for failure of target vessel technical success, reintervention, complications, and in-hospital mortality. RESULTS Our analysis included 1521 patients, 1180 males (77.6%) and 341 females (22.4%). There were noted differences in pre-operative demographics, medical optimization, and technical aspects of the procedure. However, no difference was noted in proximal or distal sealing stents, number of fenestrations, or immediate endoleaks. On multi variate logistic regression, female sex was an independent predictor of failure of target vessel technical success (OR 3.339, 95% CI: 2.173-5.132, p<.001), reintervention (OR 2.192, 95% CI: 1.304-3.683, p=.003), complications (OR 1.747, 95% CI: 1.282-2.381, p<.001), and in-hospital mortality (OR 2.836, 95% CI: 1.510-5.328, p=.001). CONCLUSION Females suffer worse outcomes after FBEVAR despite similar extent of disease, number of fenestrations, and incidence of immediate endoleak. Notable discrepancies were higher rates of COPD and lower rates of pre-operative aspirin, statin, and beta blocker therapy in females. Controlling for pre-operative demographics, female sex remained an independent predictor of worse outcomes. These discrepancies warrant further examination and should impact case planning for female patients undergoing complex aortic aneurysm repair.
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Affiliation(s)
- Brendan Gontarz
- Department of Surgery, University of Connecticut Health Center, Farmington, CT
| | - Rashad Majeed
- Department of Surgery, University of Connecticut Health Center, Farmington, CT; Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Ilene Staff
- Department of Clinical Research, Hartford Hospital, Hartford, CT
| | | | - Akhilesh Jain
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - Parth Shah
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - James Gallagher
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Laura Healy
- Department of Surgery, University of Connecticut Health Center, Farmington, CT; Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Mouhanad Ayach
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Edward Gifford
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT.
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Hypothesis of the high mortality of female patients following elective open abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2022; 63:773-774. [DOI: 10.1016/j.ejvs.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 01/07/2022] [Accepted: 02/01/2022] [Indexed: 11/23/2022]
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Kessler V, Klopf J, Eilenberg W, Neumayer C, Brostjan C. AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis. Biomedicines 2022; 10:94. [PMID: 35052774 PMCID: PMC8773452 DOI: 10.3390/biomedicines10010094] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.
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Affiliation(s)
| | | | | | | | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria; (V.K.); (J.K.); (W.E.); (C.N.)
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Virmani R, Sato Y, Sakamoto A, Romero ME, Butany J. Aneurysms of the aorta: ascending, thoracic, and abdominal and their management. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Commentary. J Vasc Surg 2021; 75:37. [PMID: 34949385 DOI: 10.1016/j.jvs.2021.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/10/2021] [Indexed: 11/23/2022]
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Leeuwerke SJG, de Niet A, Geelkerken RH, Reijnen MMPJ, Zeebregts CJ. Incidence and predictive factors for endograft limb patency of the Fenestrated Anaconda™ endograft used for complex endovascular aneurysm repair. J Vasc Surg 2021; 75:1512-1520.e1. [PMID: 34921964 DOI: 10.1016/j.jvs.2021.11.066] [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: 06/12/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the incidence, risk factors and outcomes of treatment for limb occlusion in patients treated for complex (thoraco-)abdominal aortic aneurysms (AAA) with the Fenestrated Anaconda™. METHODS Between June 2010 and May 2018, 335 patients underwent elective fenestrated aortic aneurysm repair in 11 participating centers using the Fenestrated Anaconda™ with a median follow-up of 14.3 months (IQR 27.4). The primary outcome measure was freedom-from-limb-occlusion. Secondary outcome measures were freedom-from-limb-related-reintervention, secondary patency, and risk factors associated with limb occlusion. RESULTS Thirty (9.0%) patients presented with limb occlusion during follow-up with freedom-from-limb-occlusion of 98.5%, 91.2%, and 81.7% at 30-days, 1 and 5 years, respectively. In 87% of cases, no obvious cause for limb occlusion was documented. Primary occlusion occurred within 30-days in 36.7% and within 1 year in 80.0%. Twenty-three (6.9%) patients underwent an occlusion-related reintervention; seven (23.3%) patients were treated conservatively. Freedom-from-limb-occlusion-related-reintervention at 30-days, one and five years was 97.8%, 93.2% and 88.6%, respectively. Secondary patency was 91.3% after 1-month and 86.2% after 1 and 5 years, respectively. Female sex (OR 3.27 - 95% CI 1.28 to 8.34, P = .01) was a statistically significant predictor for limb occlusion. A higher percentage of thrombus in the aneurysm sac appeared to be protective for limb occlusion (0% compared to <25%: OR 0.22 - 95% CI 0.07 to 0.63, P = .01; 0% compared to 25-50%: OR 0.20 - 95% CI 0.07 to 0.57, P = .00 and 0% compared to >50%: OR 0.08 - 95% CI 0.02 to 0.38, P = .00), as did iliac angulation (OR 0.99 - 95% CI 0.98 to 1.00, P = .04). CONCLUSION Limb occlusion remains a significant impediment of endograft durability in patients treated with the Fenestrated Anaconda™, especially in female patients. Controversially, a high aneurysmal thrombus load and a high degree of iliac angulation appeared to be protective for limb occlusion, for which no obvious cause could be identified.
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Affiliation(s)
- S J G Leeuwerke
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - A de Niet
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - R H Geelkerken
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M M P J Reijnen
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - C J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Tenorio ER, Balachandran PW, Marcondes GB, Lima GBB, Boba LM, Mendes BC, Macedo TA, Oderich GS. Incidence, predictive factors, and outcomes of intraprocedure adverse events during fenestrated-branched endovascular aortic repair of complex abdominal and thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:783-793.e4. [PMID: 34742884 DOI: 10.1016/j.jvs.2021.10.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/07/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the incidence of intraoperative adverse events (IAEs) and their impact on outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysm (TAAAs). METHODS We reviewed the clinical and imaging data of 600 consecutive patients (445 males; mean age, 75 ± 8 years) who underwent FB-EVAR between 2007 and 2019 in a single institution. IAE was defined as any intraoperative complication or technical problem requiring additional and unplanned procedures, and was classified as access-related, target artery (TA)-related, or graft-related. End points included rates of IAEs, 30-day or in-hospital mortality, major adverse events, patient survival, freedom from secondary intervention, and TA instability. RESULTS A total of 122 IAEs were identified in 105 patients (18%). IAEs were TA-related in 55 patients (9%), access-related in 46 patients (8%), and graft-related in seven patients (1%). Female sex was more frequent among patients with IAEs (44% vs 22%; P < .001). Patients with IAEs had smaller renal artery diameter (-0.4 mm, 5.4 ± 0.8 mm vs 5.8 ± 0.9 mm; P < .001), and were treated more often for TAAAs (72% vs 54%; P < .03). Technical success was achieved in 96.5% of patients and was lower for patients with IAEs (82% vs 99%; P < .001). Major adverse events were significantly more frequent among patients who had IAEs (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.21-3.25), most due to acute kidney injury (27% vs 11%; P < .001) including new-onset dialysis (5% vs 1%; P = .01). On multivariate logistic regression model, female sex (OR, 2.5; 95% CI, 1.5-4.0), TA stenosis >50% (OR, 2.0; 95% CI, 1.3-3.3), and Crawford Extent II TAAA (OR, 1.9; 95% CI, 1.1-3.3) were predictive of IAEs, whereas preloaded design (OR, 0.6; 95% CI, 0.4-0.9) and TA diameter (+1 mm; OR, 0.6; 95% CI, 0.4-0.9) were protective of IAEs. IAEs negatively affected secondary intervention (hazard ratio [HR], 1.6; 95% CI, 1.1-2.3) and TA instability (HR, 2.5; 95% CI, 1.2-5.4); however, IAEs did not affect patient survival (HR, 1.0; 95% CI, 0.7-1.4). CONCLUSIONS IAEs are common, occurring in nearly one of five patients treated with FB-EVAR for complex aortic aneurysms, and have a negative impact on clinical outcomes. IAEs were associated with female sex, TA diameter, and more extensive aortic disease.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex; Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Parvathi W Balachandran
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Giulianna B Marcondes
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Guilherme B B Lima
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Lukasz M Boba
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Bernardo C Mendes
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Thanila A Macedo
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex.
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How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study. Eur J Vasc Endovasc Surg 2021; 62:849-856. [PMID: 34686454 DOI: 10.1016/j.ejvs.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/03/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort. METHODS This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes. RESULTS In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay. CONCLUSION In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.
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