The Gloucestershire Aneurysm Screening Programme: the first 2 years' experience

Ultrasound screening for abdominal aortic aneurysm: current practice, challenges and controversies

The UK screening programme began in 2009, and has now been expanded around the UK. Long-term follow-up of the original cohorts continues to demonstrate significant benefits for abdominal aortic aneurysm (AAA)-related and all-cause mortality , and results from the first 5 years of the formal screening programme have demonstrated similar success. Ultrasound scanning is an effective and safe screening tool for the detection of AAA, although a variety of measurement protocols are employed internationally. Key challenges for the future of the programme relate to declining incidence of screen detected aneurysms.  Recent publications have demonstrated a UK incidence of only 1.34%, compared to 4.9-7.2% of men invited for screening in the original trials. Work into increasing engagement amongst the target group, and expanding screening to siblings and women is underway to address this issue. This review describes the evidence behind the screening programme, its justification in addressing AAA as a significant health problem and discusses some of the potential developments in the future.

Treatment of Abdominal Aortic Pathology

Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.

[Sleep apnea syndrome and abdominal aortic aneurysm: Study of the prevalence of sleep apnea syndrome in patients with aneurysm and research of association. Clinical study on 52 patients]

OBJECTIVES

Prevalence of abdominal aortic aneurysms (AAA) in Europe is between 4.1 % and 8.9 %. The risk of rupture of AAA is related to the evolution of its diameter. The role of sleep apnea (SA) remains still discussed. The objective of this study was to study the prevalence of SA in patients presenting with AAA in comparison with the general population as well as the relation between the AAA diameter and the severity of SA.

MATERIALS AND METHODS

Between June 2012 and December 2014, we included all patients referred for surgical treatment of an AAA. All the patients had a preoperative polysomnography and angio-scanner. An apnea/hypopnea index (AHI)>10/h was chosen for the diagnosis of SA. SA prevalence was compared with the prevalence in general population. The patients were also divided into two groups according to the severity of SA: group 1 (no SA and light SAS); group 2 (moderate and severe SA).

RESULTS

Fifty-two patients were included. Fifty-six percent of the patients presented SA - prevalence was significantly higher than in the general population (56 vs. 8 %, P<0.001). The distribution of the two groups was: group 1, n=27 patients, group 2, n=25 patients. AAA diameter and BMI were higher in group 2 than in group 1, respectively 61mm vs. 55mm, P=0.03 and 28 vs. 23, P=0.02.

CONCLUSION

Prevalence of SA in patients with an AAA seems to be significantly higher than in general population. The growth of the aneurysm seems to be linked to the severity of SA.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the review first published in 2014.

OBJECTIVES

This review aims to compare the clinical outcomes of percutaneous access with surgical cut-down femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist (CIS) searched their Specialised Register (last searched October 2016) and CENTRAL (2016, Issue 9). We also searched clinical trials registries and checked the reference lists of relevant retrieved articles.

SELECTION CRITERIA

We considered only randomised controlled trials. The primary intervention was a totally percutaneous endovascular repair. We considered all device types. We compared this against surgical cut-down femoral artery access endovascular repair. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for a ruptured abdominal aortic aneurysm and those reporting aorto-uni-iliac repairs.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected all data. Owing to the small number of trials identified we did not conduct any formal sensitivity analysis. Heterogeneity was not significant for any outcome.

MAIN RESULTS

Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology.We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence).There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence).Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence).We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups.

AUTHORS' CONCLUSIONS

This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.

Chronic obstructive pulmonary disease effect on the prevalence and postoperative outcome of abdominal aortic aneurysms: A meta-analysis

Epidemiologic evidence suggested chronic obstructive pulmonary disease (COPD) might increase risk for abdominal aortic aneurysm (AAA). However, the association between COPD and AAA remains inconclusive. We searched PubMed and Cochrane databases until June 2015. Forty-eight articles were included for meta-analysis. COPD was found to be positively associated with AAA, regardless of study design and smoking status. AAA mortality is higher among COPD patients compared with non-COPD patients (postoperative [adjusted OR 2.11; 95% CI 1.33–3.34]; long-term [adjusted OR 1.70; 95% CI 1.37–2.12]). But the association between postoperative mortality and COPD was not found to be significant in patients underwent endovascular aneurysm repair (mixed OR 2.53; 95% CI 0.70–9.18). Rupture AAA may increase the postoperative mortality in COPD patients (rupture [adjusted OR 4.75; 95% CI 2.07–10.89]; non-rupture [adjusted OR 1.97; 95% CI 1.11–3.49]). The AAA postoperative morbidity was found to be positively associated with COPD (adjusted OR 1.59; 95% CI 1.14–2.21). Increased COPD severity may increase the long-term mortality (medical versus oxygen dependent: [OR 1.26; 95% CI 1.07–1.49] versus [OR 2.79; 95% CI 2.24–3.49]). In conclusion, COPD may increase the risk of AAA, morbidity and mortality of AAA patients underwent endovascular aortic repair.

Management of abdominal aortic aneurysms in the UK

Outcomes of abdominal aortic aneurysm repair are improving in the UK, at least in part as a result of vascular specialization, the reconfiguration of services to dedicated vascular centres and the advent of the national screening programme.

Totally percutaneous versus standard femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. More recently endovascular aneurysm repairs (EVARs) have become a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in patients with, for example, groin scarring or arterial calcification.

OBJECTIVES

This review aims to compare the clinical outcomes of percutaneous access with standard femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched July 2013), CENTRAL (2013, Issue 6) and clinical trials databases. Reference lists of retrieved articles were checked.

SELECTION CRITERIA

Only randomised controlled trials were considered. The primary intervention was a totally percutaneous endovascular repair. All device types were considered. This was compared against standard femoral artery endovascular repair. Only studies investigating elective repairs were considered. Studies reporting emergency surgery for a ruptured abdominal aortic aneurysm (rAAA) and those reporting aorto-uni-iliac repairs were excluded.

DATA COLLECTION AND ANALYSIS

All data were collected independently by two review authors. Owing to the small number of trials identified, no formal assessment of heterogeneity or sensitivity analysis was conducted.

MAIN RESULTS

Only one trial met the inclusion criteria, involving a total of 30 participants, 15 undergoing the percutaneous technique and 15 treated by the standard femoral cut-down approach. There were no significant differences between the two groups at baseline.No mortality or failure of aneurysm exclusion was observed in either group. Three wound infections occurred in the standard femoral cut-down group, whereas none were observed in the percutaneous group. This was not statistically significant. Only one major complication was observed in the study, a conversion to the cut-down technique in the percutaneous access group. No long-term outcomes were reported. One episode of a bleeding complication was reported in the percutaneous group. Significant differences were detected in surgery time (percutaneous 86.7 ± 27 minutes versus conventional 107.8 ± 38.5 minutes; P < 0.05).The included study had a small sample size and failed to report adequately the method of randomisation, allocation concealment and the pre-selected outcomes.

AUTHORS' CONCLUSIONS

Only one small study was identified, which did not provide adequate evidence to determine the efficacy and safety of the percutaneous approach compared with endovascular aneurysm repairs. This review has identified a clear need for further research into this potentially beneficial technique. One ongoing study was identified in the search, which may provide an improved evidence base in the future.

Prevalence and trends of the abdominal aortic aneurysms epidemic in general population--a meta-analysis

OBJECTIVE

To conduct a meta-analysis assessing the prevalence and trends of the abdominal aortic aneurysms (AAA) epidemic in general population.

METHOD

Studies that reported prevalence rates of AAA from the general population were identified through MEDLINE, EMBASE, Web of Science, and reference lists for the period between 1988 and 2013. Studies were included if they reported prevalence rates of AAA in general population from the community. In stratified analyses possible sources of bias, including areas difference, age, gender and diameter of aneurysms were examined. Publication bias was assessed with Egger's test method.

RESULTS

56 studies were identified. The overall pooled prevalence of AAA was 4.8% (4.3%, 5.3%). Stratified analyses showed the following results, areas difference: America 2.2% (2.2%, 2.2%), Europe 2.5% (2.4%, 2.5%), Australia 6.7% (6.5%, 7.0%), Asia 0.5% (0.3%, 0.7%); gender difference: male 6.0% (5.3%, 6.7%), female 1.6% (1.2%, 1.9%); age difference: 55-64years 1.3% (1.2%, 1.5%), 65-74 years 2.8% (2.7%, 2.9%), 75-84 years1.2%(1.1%, 1.3%), ≥85years0.6% (0.4%, 0.7%); aortic diameters difference: 30-39 mm, 3.3% (2.8%, 3.9%), 40-49 mm,0.7% (0.4%,1.0%), ≥50 mm, 0.4% (0.3%, 0.5%). The prevalence of AAA has decreased in Europe from 1988 to 2013. Hypertension, smoking, coronary artery disease, dyslipidemia, respiratory disease, cerebrovascular disease, claudication and renal insufficiency were risk factors for AAA in Europe.

CONCLUSION

AAA is common in general population. The prevalence of AAA is higher in Australia than America and Europe. The pooled prevalence in western countries is higher than the Asia. Future research requires a larger database on the epidemiology of AAA in general population.

Diabetes mellitus and aortic aneurysm rupture: a favorable association?

INTRODUCTION

Recent reports suggest that diabetic patients are relatively unlikely to have abdominal aortic aneurysms (AAAs). This retrospective study assesses the relationship between diabetes mellitus (DM) and aortic aneurysm rupture.

METHODS

Patients with a diagnosis of any aortic aneurysm during a 10-year period were identified from our records. Patients with diagnoses of aortic aneurysm (thoracic, thoracoabdominal, and abdominal, treated and untreated) were included. Patients with nonatheromatous aneurysms (transection, dissection, mycotic, or isolated iliac) were excluded.

RESULTS

In all, 1830 patients with nonruptured aneurysms and 232 ruptured aneurysms were included giving a total of 2062 patients with aortic aneurysms (abdominal, thoracic, and thoracoabdominal). Of these 1830, 225 (12.3%) patients with nonruptured aneurysm were diabetic; however, only 13 (5.6%) of the 232 patients with ruptured aortic aneurysm were diabetic (odds ratio [OR] = 0.42; confidence interval [CI]: 0.23-0.75, P = .004). Considering only those with AAAs, 184 (12.4%) of the 1482 nonruptured AAA were diabetic; however, only 12 (6.4%) of the 188 patients with ruptured AAA were diabetic (OR = 0.48 [CI: 0.26-0.88], P = .02). In this study group, the odds of dying due to aneurysm rupture in the diabetic group are significantly lower compared to the nondiabetic groups (OR = 0.31 [CI: 0.13-0.69], P = .004), despite the finding that diabetic patients had almost the same life expectancy as nondiabetic patients (DM, 73 years [67-80] vs non-DM, 75 years [68-82] P = .23).

CONCLUSIONS

Diabetic patients with aortic aneurysms are significantly less likely to present with rupture or to die from aneurysm rupture when compared to nondiabetic patients with aortic aneurysms. We have identified association only, not causality. However, it is plausible that DM, or the treatment of DM, may have a protective effect on aortic aneurysm rupture.

Prevalence of abdominal aortic aneurysm in Chinese patients with severe coronary artery disease

BACKGROUND

The Asian population is believed to have lower incidence of abdominal aortic aneurysm (AAA), and hence, the benefit of screening is uncertain. The size of native aorta in Asians, which shall affect the definition of AAA, has also never been reported. Our study investigated the prevalence of AAA and the infra-renal aortic diameter (AD) in Chinese patients with severe coronary artery disease.

METHODS

This is a prospective observational study of infra-renal aortic size for patients who had coronary artery bypass surgery by ultrasound. The patients' demographics, important co-morbidities and maximum AD were recorded.

RESULTS

The study included 624 consecutive Chinese patients (mean age = 63.2 years). The mean maximum infra-renal AD was 17.5 mm for men and 14.8 mm for women. The presence of AAA was defined as maximum AD greater than 30 mm. The result was also compared with an alternate definition that defines AAA as maximum AD of greater than 1.5 times of the group's mean. Eleven patients had an AD greater than 30 mm, and the prevalence of AAA was only 1.8%. With AAA defined as maximum AD of 1.5 times greater than the group's mean, 19 patients had AAA. The prevalence of AAA in this high-risk group would become 3% overall.

CONCLUSION

The prevalence of AAA in Chinese patients was low, and the result did not support routine screening. The smaller mean infra-renal AD in Chinese merits validation by large-scale study and consideration when deciding threshold for small AAA repair in our locality.

Ultrasound screening for abdominal aortic aneurysm in medicare beneficiaries

Ultrasound screening for abdominal aortic aneurysm (AAA) has been shown to be beneficial and cost-effective for men aged 65-74. However, most screening studies have been conducted in Europe and Australia, where attendance for screening was higher than the single large U.S. study involving only veterans. The prevalence of AAA in the U.S. general population is not well defined, nor is the best method of recruitment for screening. Letters of invitation for a free screening ultrasound for AAA were sent to 30,000 randomly selected Medicare beneficiaries from the hospital referral region of three university-affiliated hospitals without restriction by age, gender, or comorbidity. Attendance for screening was calculated by age, gender, and travel distance to the screening center. Telephone calls to a random sample of nonresponders were made to determine the reason for failure to attend. Prevalence of AAA by ultrasound and known risk factors for AAA (e.g., age, gender, smoking status) were determined. The attendance rate was 7% (2,005). Attendance was greater with male gender (p < 0.01), younger age (p < 0.05), and decreased travel distance to the screening center (p < 0.05). The primary reasons for failure to attend included incorrect address or vital status, poor health, and lack of interest. Prevalence of previously undetected AAA was 2.8% in men and 0.2% in women. AAA was predicted by smoking status and male gender (p < 0.01 for each). Unselected invitation of Medicare beneficiaries for ultrasound screening for AAA results in a low attendance and low yield of AAA. The prevalence estimates from this study may not reflect the entire Medicare population given the low attendance and may reflect the healthy habits of those most interested in screening. Patients should be selected for screening based on their suitability for repair if an AAA is found as well as their risk factors for AAA. The best method of recruitment for screening of those most at risk for AAA in the United States remains to be determined.

Abdominal aortic aneurysm screening: recommendations and controversies

Extensive level one evidence supports routine abdominal aortic aneurysm (AAA) screening in men aged 65 to 75 years, because AAAs are highly prevalent in this population. Physical examination is an insensitive means of detection. Ruptured AAAs are costly with respect to quality adjusted life years (QALY) lost and medical expenses. Large scale, randomized trials have demonstrated that AAA screening reduces all AAA-related mortality in the screened population and is cost-effective in mid-term follow-up. AAA screening by ultrasound has many advantages over other accepted medical screening programs in its simplicity in structure and the availability of an inexpensive, portable, and reliable means of screening. Additionally, AAA screening almost entirely avoids the negative consequences associated with other screening programs, including the adverse psychological effects and medical costs associated with false-positive examination results. There are subgroups of at-risk women who might benefit from AAA screening, and this issue should be further studied.

Screening for abdominal aortic aneurysms: single centre randomised controlled trial

OBJECTIVE

To determine whether screening Danish men aged 65 or more for abdominal aortic aneurysms reduces mortality.

DESIGN

Single centre randomised controlled trial.

SETTING

All five hospitals in Viborg County, Denmark.

PARTICIPANTS

All 12,639 men born during 1921-33 and living in Viborg County. In 1994 we included men born 1921-9 (64-73 years). We also included men who became 65 during 1995-8.

INTERVENTIONS

Men were randomised to the intervention group (screening by abdominal ultrasonography) or control group. Participants with an abdominal aortic aneurysm > 5 cm were referred for surgical evaluation, and those with smaller aneurysms were offered annual scans.

OUTCOME MEASURES

Specific mortality due to abdominal aortic aneurysm, overall mortality, and number of planned and emergency operations for abdominal aortic aneurysms.

RESULTS

4860 of 6333 men were screened (attendance rate 76.6%). 191 (4.0% of those screened) had abdominal aortic aneurysms. The mean follow-up time was 52 months. The screened group underwent 75% (95% confidence interval 51% to 91%) fewer emergency operations than the control group. Deaths due to abdominal aortic aneurysms occurred in nine patients in the screened group and 27 in the control group. The number needed to screen to save one life was 352. Specific mortality was significantly reduced by 67% (29% to 84%). Mortality due to non-abdominal aortic aneurysms was non-significantly reduced by 8%. The benefits of screening may increase with time.

CONCLUSION

Mass screening for abdominal aortic aneurysms in Danish men aged 65 or more reduces mortality.

Prevalence of abdominal aortic aneurysms--a screening program in São Paulo, Brazil

CONTEXT

Abdominal aortic aneurysm is an asymptomatic but potentially fatal condition. Elective surgery can prevent death from rupture, and is indicated for aneurysms larger than 45 mm. Because aneurysms tend to grow with time, detection of small ones (> 29 mm) may lead to a closer follow-up of patients at risk.

OBJECTIVE

To determine the prevalence of abdominal aortic aneurysms in São Paulo, Brazil.

DESIGN

Prospective, descriptive.

SETTING

University Hospital.

PARTICIPANTS

Persons aged 50 years or more were offered, through the press, the opportunity to be screened for abdominal aortic aneurysm. The total number screened was 2,756.

PROCEDURE

All were submitted to abdominal palpation and ultrasound examination. PARAMETER STUDIED: A maximum diameter of 30 mm or more was considered to be an aneurysm.

RESULTS

Sixty-four aneurysms were detected, nine of which measuring more than 49 mm. Palpation detected 60 aneurysms, but only 20 of these were confirmed by the ultrasound. Conversely, 41 of the ultrasound-detected aneurysms were not palpable. The percentages of abdominal aortic aneurysms found in the subgroups via ultrasound examination (with 95% confidence interval) were as follows: total group, 2.3 (1.8-3); men, 4.6 (3.5-5.9); women, 0.6 (0.3-1.1); men aged 60 or more, 6 (4.3-8); women aged 60 or more, 0.9 (0.4-1.8).

CONCLUSION

In Sao Paulo, Brazil, 1.8 to 3 % of persons aged 50 years or more are expected to have abdominal aortic aneurysms. In the subgroup of men aged 60 or more, the expected prevalence is between 4.3 and 8%.

Systemic levels of cotinine and elastase, but not pulmonary function, are associated with the progression of small abdominal aortic aneurysms

OBJECTIVE

to study whether smoking and impaired pulmonary function are associated with the expansion of abdominal aortic aneurysms (AAA).

METHODS AND MATERIAL

seventy-nine men with small (3-5 cm), screen-detected AAA underwent a simple 5-step smoking history, measurement of the forced first second expiratory volume (FEV1), venepuncture and annual ultrasound scan for mean follow-up period of 3.5 years.

RESULTS

all but one patient had a significantly reduced FEV1 (p<0.05, Mann-Whitney). The FEV1/expected FEV1 ratio (rFEV1) was not related to AAA expansion but was negatively correlated with P-elastase-alpha1-antitrypsin-complexes (P-Elastase). P-Elastase was positively correlated with smoking and S-cotinine. Smoking, S-cotinine, and P-elastase were positively correlated with the mean annual AAA expansion rate but not rFEV1.

CONCLUSION

in general, patients with AAA have impaired pulmonary function. A simple five step smoking classification is as predictive of AAA-expansion as S-cotinine. Smoking may cause elastase secretion leading to pulmonary and aortic elastin degradation but the lack of association between AAA-expansion and rFEV1 suggest that other mechanisms are important.

Recommendations for screening intervals for small aortic aneurysms

BACKGROUND

The aim was to determine the optimum rescreening interval for small abdominal aortic aneurysms (AAAs).

METHODS

Data from 12 years of population screening of 65-year-old men were analysed and 1121 small AAAs (less than 4.0 cm in initial diameter) were divided into groups: group 1 (2.6-2.9 cm; n = 625), group 2 (3.0-3.4 cm; n = 330) and group 3 (3.5-3.9 cm; n = 166). Expansion rate and the cumulative proportions to expand to over 5.5 cm, or require surgery, or rupture were calculated.

RESULTS

Expansion rate was related to initial aortic diameter: 0.09 cm per year in group 1, 0.16 cm per year in group 2 and 0.32 cm per year in group 3 (P < 0.001). Aneurysms in 2.4 per cent of patients in group 1 exceeded a diameter of 5.5 cm or required surgery within 5 years; there were no ruptures. In group 2, no aorta exceeded 5.5 cm but at 3 years 2.1 per cent had reached 5.5 cm and 2.9 per cent had required surgery. The rupture rate at 3 years was zero. In group 3, the aneurysm diameter exceeded 5.5 cm in 1.2 per cent of patients, but no patient required surgery or experienced rupture within 1 year; at 2 years 10.5 per cent of aneurysms had exceeded 5.5 cm in diameter or required surgery and 1.4 per cent had ruptured.

CONCLUSION

The appropriate rescreening interval can be determined by initial aortic diameter in screened 65-year-old men. AAAs of initial diameter 2.6-2.9 cm should be rescanned at 5 years, those of 3.0-3.4 cm at 3 years and those of 3.5-3.9 cm at 1 year.

The role of cytokine gene polymorphisms in the pathogenesis of abdominal aortic aneurysms: a case-control study

BACKGROUND

Cytokines are the primary mediators of inflammation and also influence matrix metalloproteinase expression, both of which are important in development of abdominal aortic aneurysm (AAA). A significant, but as yet unknown, familial factor contributes to the pathogenesis of AAA. Many cytokine genes contain polymorphic sites, some of which affect cytokine production in vitro. Cytokine gene polymorphisms may therefore influence the pathogenesis of AAA. The purpose of this study was to determine whether there is any association between cytokine gene polymorphisms and AAA.

METHODS AND RESULTS

This case-control study comprised 100 patients with AAA and 100 age-matched and sex-matched control subjects. For each case and control subject in the study, genotypes at the following cytokine gene polymorphic loci were determined: interleukin (IL)-1beta +3953, IL-6 -174, IL-10 -1082, IL-10 -592, and tumor necrosis factors-alpha -308. Allele and genotype frequencies were compared between AAA and control groups, and odds ratios (OR) were calculated for the presence of AAA with each allele at each locus examined as risk factors. The IL-10 -1082 A allele was significantly more common in the AAA group than the control group (P =.03). The OR for the IL-10 -1082 A allele as a risk factor for AAA was 1.8 (95% confidence interval, 0.9-3.6).

DISCUSSION

These associations suggest a significant role for IL-10 in the pathogenesis of AAA. This association of AAA with the IL-10 -1082 A allele is also biologically plausible; the IL-10 -1082 A allele is associated with low IL-10 secretion, and it may be that AAA develops in patients who are unable to mount the same anti-inflammatory response as those who do not have AAA.

Screening for abdominal aortic aneurysms

OBJECTIVE AND METHODS

Screening for abdominal aortic aneurysms may be useful to decrease mortality related to rupture. We conducted a study to assess the prevalence of abdominal aortic aneurysms in southern Brazil and to define risk factors associated with high prevalence of this disorder. The screening was conducted using abdominal ultrasound. Three groups were studied: Group 1 - cardiology clinic patients; Group 2 - individuals with severe ischemic disease and previous coronary surgery, or important lesions on cardiac catheterism; Group 3 - individuals without cardiac disease selected from the general population. All individuals were male and older than 54 years of age. The ultrasonographic diagnosis of aneurysm was based on an anteroposterior abdominal aorta diameter of 3 cm, or on an abdominal aorta diameter 0.5 cm greater than that of the supra-renal aorta.

RESULTS

A total of 2.281 people were screened for abdominal aortic aneurysms in all groups: Group 1 - 768 individuals, Group 2 - 501 individuals, and Group 3 - 1012 individuals. The prevalence of aneurysms was 4.3%, 6.8% and 1.7%, respectively. Age and cigarette smoking were significantly associated with increased prevalence of aneurysms, as was the diagnosis of peripheral artery disease.

DISCUSSION

We concluded that screening may be an important tool to prevent the mortality associated with abdominal aortic aneurysms surgery. Additionally, the cost of screening can be decreased if only individuals presenting significant risk factors, such as coronary and peripheral artery disease, smokers and relatives of aneurysm patients, are examined.

Endovascular versus conventional open repair of acute abdominal aortic aneurysm: feasibility and preliminary results

PURPOSE

To evaluate the feasibility of endovascular treatment of acute abdominal aortic aneurysm (AAA) with commercially prepared bifurcated systems.

METHODS

From January through July 2001, 22 patients (17 men; mean age 73.6 years, range 59-89) were referred with an acute (symptomatic/ruptured) AAA. Six patients were treated with emergent open surgery because of hemodynamic instability, but the other 16 patients underwent computed tomographic angiography with multidirectional reconstruction. Six (27%) aneurysms were suitable for endovascular repair (EVR) and were successfully treated. Procedural variables, morbidity, and mortality were compared between the EVR group and 6 patients of equivalent hemodynamic status from among the conventionally treated patients.

RESULTS

There was no mortality in either group. The median aneurysm diameter in the EVR group was 63 mm (range 48-84) versus 80 mm (45-82) in the matched surgically treated AAAs (p=0.628). Procedural duration was 193 minutes (150-265) for the EVR group compared to 203 minutes (130-270) for the matched group (p=0.630). Median blood loss was significantly less (p=0.010) in the EVR group (125 versus 3400 mL). Median length of stay (LOS) in intensive care was 8 hours (0-21) versus 62 hours (48-112) for the surgical group (p=0.004). Hospital LOS was significantly reduced (p=0.024) for the EVR patients (7.5 [2-16] versus 15.5 [10-34] days).

CONCLUSIONS

Endovascular treatment of acute aneurysm is feasible, and preliminary results are promising.

Hospital costs and benefits of screening for abdominal aortic aneurysms. Results from a randomised population screening trial

OBJECTIVES

to analyse the hospital costs and benefits of screening older males for abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

in 1994 a hospital-based screening trial of 12 658 65-73-year-old males was started. AAA >5 cm were referred for surgery. The remaining AAA were offered annual scans. Those with aortic ectasia were rescreened at 5 yearly intervals. AAA-operations and hospital AAA-related deaths were researched. The costs of screening, surveillance, and treatment were also registered.

RESULTS

the attendance rate was 76%; of whom 191 (4.0%) had AAA. Mean observation time was 5.13 years. Sixty in the screened and 41 in the control group were operated (p=0.06), of which 7 and 27 respectively were operated as an emergency (p<0.001), and 6 and 19 respectively died due to AAA (p=0.009). The costs per scan were 83.50 DKK, 81 400 DKK per emergency operation (71 485 DKK after screening), and 117 000 DKK per emergency operation. The cost per prevented hospital death was 67 855 DKK, equivalent to approximately life year saved approx. 7540 DKK (GBP1=12 DKK).

CONCLUSION

screening appears to reduce hospital AAA mortality and to be cost-effective.

A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men

BACKGROUND

Screening for abdominal aortic aneurysm (AAA) has been carried out in Gloucestershire since 1990. All men in the county are offered aortic ultrasonography in their 65th year. Men with an aortic diameter of less than 26 mm are considered 'normal' and no follow-up is arranged. The aim of this study was to ascertain if men with 'normal' aortic diameters at age 65 years ever develop a clinically significant aneurysm.

METHODS

A cohort study was performed on 223 65-year-old men who had an aorta of less than 26 mm in diameter in 1988. These men had repeat ultrasonography in 1993 and 2000. The causes of death in men who died during this interval were investigated.

RESULTS

Eight men were lost to follow-up. As far as it was possible to ascertain, none of the 86 men who died over the 12-year interval did so from ruptured AAA. There was no clinically significant increase in mean aortic diameter in the remaining 129 men who had three serial ultrasonographic scans over the 12-year interval.

CONCLUSION

A single, 'normal' ultrasound scan at age 65 years effectively rules out the risk of clinically significant aneurysm disease for life in men.

Abdominal Aortic Aneurysm in Normotensive Patients: Association with Angiotensin-converting Enzyme Gene Polymorphism

OBJECTIVE AND DESIGN

to assess if deletion of the angiotensin-converting enzyme (ACE) gene is a risk factor for abdominal aortic aneurysms (AAAs) in normotensive patients.

MATERIALS AND METHODS

ACE gene polymorphism was examined by polymerase chain reaction in 124 subjects with AAA and in 112 control subjects. AAA normotensive patients (group A, n=56) were compared to normotensive control subjects (group B, n =112) and to AAA hypertensive patients (group C, n =68). All subjects enrolled in this study were Caucasian and from central and southern Italy.

RESULTS

the distribution of ACE genotypes was: normotensive patients with AAAs (group A): 3 II, 14 ID, 39 DD; normotensive control subjects (group B): 36 II, 48 ID, 28 DD; hypertensive patients with AAAs (group C): 14 II, 32 ID, 22 DD. The DD genotype was more common in group A than in control groups (A vs B p<0.001; A vs C p <0.001). The ID genotype was more common in group A as well (A vs B p <0.05; A vs C p <0.005).

CONCLUSIONS

our data suggest a role for ACE I/D gene polymorphism in the pathogenesis of AAA in normotensive patients.

Optimal interval screening and surveillance of abdominal aortic aneurysms

OBJECTIVES

to determine safe and optimal intervals of rescreening and surveillance for AAA.

METHODS

hospital-based mass screening of 6339 65-73-year-old men from 1994-98. 76.4% attended. One hundred and ninety-one (4%) had AAA53 cm. Twenty-four (0.5%) were initially >5 cm and referred for surgery, while the rest were offered annual control scans to check for expansion. Later, all 348 (7.5%) men who 3 to 5 years ago had an ectatic aorta (infrarenal aortic diameter of 25-29 mm or distal/renal aortic diameter ratio >1.2) were offered rescreening. Of these, 62 (18%) died before rescanning, while 248 of the survivors attended rescreening (87%). Furthermore, a random sample of 380 of those with non-ectatic aortas were offered rescreening. Of these, 49 (13%) died before rescreening (p=0.06), while 275 (83%) of the survivors attended re-screening.

RESULTS

none of the controls had developed AAA. Of those who initially had an 25-29 mm aorta, 29% had developed AAA (size range 30-48 mm) with expansion rates varying from 1.0 to 4.7 mm/year. Only 3.5% with a ratio >1.2 developed AAA (size range: 30-34 mm) with expansion rates from 1.3 to 2.4 mm/year. During the fourth year of surveillance some AAA initially sized below 3.5 cm expanded to above 5 cm, while some sized 3.5-3.9 cm did so during the second year, >4 cm did so during the first year of surveillance.

CONCLUSION

rescreening for AAA can be restricted to initially ectatic aortas sized 25-29 mm at 5-year intervals. Surveillance of small AAA can be restricted to 1-4 year intervals.

Population screening reduces mortality rate from aortic aneurysm in men

BACKGROUND

Rupture of an unsuspected abdominal aortic aneurysm is a major cause of death in men over the age of 65 years. A significant reduction in deaths is likely to result only from higher rates of detection and increased numbers of elective aneurysm repairs. Screening of men reaching the age of 65 years has been taking place in the county of Gloucestershire, UK since 1990 and the aim of this study was to investigate any change in the mortality rate from aortic aneurysm in the screened portion of the population.

METHODS

Total number of deaths from all aortic aneurysm-related causes in the county's population was calculated from hospital and post-mortem records, together with computerized death certificate records, for the years 1994-1998. The overall number of aneurysm-related deaths in men aged 65-73 years, who have been progressively influenced by the screening programme, was compared with that for men of all other ages.

RESULTS

The total number of aneurysm-related deaths in men aged 65-73 years decreased progressively year by year between 1994 and 1998; this reduction is highly statistically significant (P < 0. 001). No such change was observed in the unscreened part of the population.

CONCLUSION

Screening for asymptomatic abdominal aortic aneurysm results in a significant reduction in numbers of deaths from all aneurysm-related causes in the screened portion of the male population.

High prevalence of abdominal aortic aneurysm in a primary care screening programme

BACKGROUND

The mortality rate associated with ruptured abdominal aortic aneurysm (AAA) remains high. The objective of this study was to assess the feasibility of population screening for AAA.

METHODS

In an area with a mixed rural and industrialized population of 60000 inhabitants, all 23 general practitioners (GPs) participated. The GPs selected from their patient lists men aged 60-80 years. Men whose condition was suitable for aortic surgery were invited for screening by a single postal letter. All men responding had aortic ultrasonography in or close to the GP surgery. Diagnosis of AAA was established when the aortic diameter was 30 mm or greater. Referral for surgery was advised for an aortic diameter of 50 mm or greater.

RESULTS

Of 2914 invitations, 2419 men had ultrasonography, resulting in an attendance rate of 83.0 per cent. A total of 2416 aortic measurements were made; 196 aortic aneurysms were diagnosed (prevalence 8.1 per cent). In 40 men the aortic diameter was over 50 mm.

CONCLUSION

Ultrasonographic screening for AAA is feasible in a primary care setting.

Natural history of abdominal aortic aneurysm with and without coexisting chronic obstructive pulmonary disease

PURPOSE

To study the relation between abdominal aortic aneurysms and chronical obstructive pulmonary disease (COPD), in particular the suggested common elastin degradation caused by elastase and smoking.

METHODS

A cross-sectional population study and a prospective cohort study of small abdominal aortic aneurysms was performed in a community setting. All previous diagnoses recorded in a hospital computer database were received for 4404 men 65 to 73 years of age who had been invited to a population screening for abdominal aortic aneurysm. One hundred forty-one men had AAA (4.2%). They were asked to participate in an interview, a clinical examination, and collection of blood sample. Men with an abdominal aortic aneurysm 3 to 5 cm in diameter were offered annual ultrasound scans to check for expansion.

RESULTS

Among patients with COPD 7.7% had abdominal aortic aneurysms (crude odds ratio=2.05). The adjusted odds ratio, however, was only 1.59 after adjustment for coexisting diseases associated with abdominal aortic aneurysm (P=.13). The mean annual expansion was 2.74 mm per year among patients with COPD, 2.72 among patients without COPD, and 4.7 mm among patients who used oral steroids compared with 2.6 among patients who did not use steroids (P < .05). Concentration of serum elastin peptide and plasma elastase-alpha1-antitrypsin complexes correlated negatively with forced expiratory volume in the first second (FEV1) among patients with COPD. However, multivariate regression analysis showed that concentration of serum elastin peptide, therapy with beta-agonists, and FEV1 correlated positively with degree of expansion but that concentration of plasma elastase-alpha1-antitrypsin complexes and serum alpha1-antitrypsin did not influence expansion, suggesting that elastase plays an important role in the pathogenesis of COPD but not of abdominal aortic aneurysm.

CONCLUSION

The high prevalence of abdominal aortic aneurysm among patients with COPD is more likely to be caused by medication and coexisting diseases rather than a common pathway of pathogenesis.

Abdominal aortic aneurysm rupture rates: a 7-year follow-up of the entire abdominal aortic aneurysm population detected by screening

PURPOSE

The goal of the current study was to identify the risk of rupture in the entire abdominal aortic aneurysm (AAA) population detected through screening and to review strategies for surgical intervention in light of this information.

METHODS

Two hundred eighteen AAAs were detected through ultrasound screening of a family practice population of 5394 men and women aged 65 to 80 years. Subjects with an AAA of less than 6.0 cm in diameter were followed prospectively with the use of ultrasound, according to our protocol, for 7 years. Patients were offered surgery if symptomatic, if the aneurysm expanded more than 1.0 cm per year, or if aortic diameter reached 6.0 cm.

RESULTS

The maximum potential rupture rate (actual rupture rate plus elective surgery rate) for small AAAs (3.0 to 4.4 cm) was 2.1% per year, which is less than most reported operative mortality rates. The equivalent rate for aneurysms of 4.5 to 5.9 cm was 10.2% per year. The actual rupture rate for aneurysms up to 5.9 cm using our criteria for surgery was 0.8% per year

CONCLUSION

In centers with an operative mortality rate of greater than 2%, (1) surgical intervention is not indicated for asymptomatic AAAs of less than 4.5 cm in diameter, and (2) elective surgery should be considered only for patients with aneurysms between 4.5 and 6 cm in diameter that are expanding by more than 1 cm per year or for patients in whom symptoms develop. In centers with elective mortality rates of greater than 10% for abdominal aortic aneurysm (AAA) repair, the benefit to the patient of any surgical intervention for an asymptomatic AAA of less than 6.0 cm in diameter is questionable.

Screening for abdominal aortic aneurysm: is opportunistic detection a realistic alternative?

OBJECTIVES

To determine whether abdominal aortic aneurysms (AAA) may be detected during investigation for concurrent disease and to assess whether opportunistic detection is a feasible alternative to a formal screening programme.

DESIGN

A prospective review of previous investigations in subjects attending for aortic screening.

MATERIALS AND METHODS

276 men aged 65-80 attended the Chichester AAA screening programme. They were asked whether they had consulted their General Practitioner and whether they had undergone radiological investigation within the preceding 5 years.

RESULTS

Two-hundred and sixty-one subjects had consulted their General Practitioner (94.6%) within the past 5 years. Fifty-six patients had been investigated with radiological imaging: in 22 cases (8.0%) the investigation had the potential to detect an AAA. The opportunistic detection rate was 0.4% (one AAA) in comparison to 12.0% for the screening programme (33 AAA). Imaging investigations with the potential to pick up AAA failed to detect five out of six aneurysms in this group.

CONCLUSIONS

Opportunistic screening for AAA is not a realistic alternative to a formal screening programme but may improve the detection rate in the community.

Economic analyses of radiological procedures: a methodological evaluation of the medical literature

OBJECTIVE

Increasing pressure to curb health care costs has led to considerable interest in economic analyses, including both cost-effectiveness and cost-benefit analyses. Numerous economic analyses of radiological procedures have appeared in both the radiology and non-radiology literature. The objective of this study was to evaluate the methodological quality of economic analyses of radiological procedures published in the non-radiology medical literature during the years 1990 1995.

METHODS

Original investigations from the medical (non-radiological) literature that include economic analyses of radiological interventions were identified from a computerized literature search. Each economic analysis article was evaluated by two independent reviewers for adherence to ten methodological criteria. The criteria were derived from review of the medical and radiological economic analysis methodology literature and consisted of the following: (1) Comparative options stated; (2) perspective of analysis defined; (3) outcome measure identified; (4) cost data included; (5) source of cost data stated; (6) long term costs included; (7) discounting employed; (8) summary measure provided; (9) incremental computation method used; and (10) sensitivity analysis performed. The results were compared to a previous study that evaluated the radiological literature.

RESULTS

Of the 56 articles in the medical literature that included economic analyses of radiological procedures, only eight (14%) conformed to all ten methodological criteria. The cost data (98%) and comparative options (89%) criteria exhibited high compliance, while the perspective of analysis (25%) and discounting (32%) criteria had relatively low compliance. Agreement between the reviewers was excellent (kappa = 0.88).

CONCLUSIONS

Published economic analyses of radiology procedures usually do not meet accepted methodological standards.

Epidemiology and potential for prevention of abdominal aortic aneurysm

BACKGROUND

Ruptured abdominal aortic aneurysm (AAA) is a common cause of death which is preventable by elective repair of an asymptomatic AAA.

METHODS

The literature was reviewed with emphasis on epidemiological studies and population-based screening surveys.

RESULTS AND CONCLUSION

The prevalence of small AAA ranges between 3 and 8 per cent. The incidence of asymptomatic AAA seems to be increasing, although exact incidence estimates vary. The most important risk factors for AAA are male sex, age, family history and smoking. Hypertension is associated with a mildly increased risk, but diabetes is not associated with any increase. Primary prevention of AAA is not a realistic option. There is no evidence of an effective medical treatment to prevent growth of small AAAs, although trials with propranolol are under way. The only intervention to prevent death from aneurysm is elective repair of the asymptomatic lesion. Screening for asymptomatic AAA can reduce the incidence of rupture. However, further studies are needed to determine the cost effectiveness of screening compared with that of other health programmes.

Psychological morbidity associated with abdominal aortic aneurysm screening

OBJECTIVES

To identify whether abdominal aortic aneurysm screening causes anxiety in those screened and whether the diagnosis of an aneurysm produces sustained anxiety in subjects in comparison with those in whom no abnormality is detected.

DESIGN

Prospective case controlled study.

MATERIALS AND METHODS

The 28-item General Health Questionnaire (GHQ) was used to assess psychological morbidity in 161 men attending for routine aneurysm screening in the Gloucestershire Aneurysm Screening Programme. One hundred men had a normal aorta and 61 were identified as having aneurysms. The GHQ was administered just before screening and 1 month later. An anxiety linear analogue scale was also used.

RESULTS

There was no difference in anxiety levels between those men with normal aortas and those with aneurysms either before or after screening. There was a statistically significant reduction in both these groups 1 month after screening.

CONCLUSION

This study shows that although the invitation to aneurysm screening may cause some mild anxiety, this is not prolonged even when an asymptomatic aneurysm is diagnosed.

A prospective study to define the optimum rescreening interval for small abdominal aortic aneurysm

A prospective study of 99 patients with small abdominal aortic aneurysms was undertaken using serial ultrasound to assess the optimum screening interval. Fifty-three patients had aneurysms measuring 2.5-3.9 cm and 46 patients aneurysms of 4.0-4.9 cm. Aneurysms measuring 2.5-3.9 cm were screened annually and those > 4.0 cm every 6 months. There were eight deaths in the 2.5-3.9 cm group, none attributable to a ruptured aneurysm and five patients have had their aneurysm repaired. Nine patients died in the 4.0-4.9 cm group, one with a ruptured aneurysm measuring 5.6 cm at her previous screening visit and who was unfit for operation. No other patient had an aneurysm which ruptured between scans. There were seven elective repairs in this group. No patient died following elective operation in either group. The mean growth rate of aneurysms in the 2.5-3.9 cm group was 2.2 mm in the first year, 2.8 mm in the second and 1.8 mm in the third. Corresponding growth rates in the 4.0-4.9 cm group were 2.7 mm, 4.2 mm and 2.2 mm. This study supports a policy of annual screening for aneurysms measuring 2.5-3.9 cm and 6-monthly screening for those > or = 4.0 cm.

Screening study of abdominal aortic aneurysm in a general population: lipid parameters

The level of blood lipids and apolipoproteins in subjects being screened for abdominal aortic aneurysms have been investigated. As part of an ultrasound screening programme in a population of 65- to 75-year-olds, blood samples were collected from 1460 of 1504 subjects with a normal aorta (97.1%) and 69 of 70 patients with an abdominal aortic aneurysm > 29 mm (99%). Samples were also taken from 22 of 27 patients (81%) with an ectatic aorta (26-29 mm). Total cholesterol, HDL-cholesterol, LDL-cholesterol, Apo-AI and Apo-B levels were significantly higher in women than in men (P < 0.01). Levels of HDL-cholesterol and Apo-AI were significantly lower in patients with an abdominal aortic aneurysm than in normal subjects (P < 0.001). The mean(s.d.) body mass index was 25.1(3.9) in women and 25.5(3.2) in men with aneurysms and not significantly greater than that of normal subjects (25.2(3.61) and 25.2(3.38) respectively).

Hospital based screening of 65-73 year old men for abdominal aortic aneurysms in the county of Viborg, Denmark

OBJECTIVE - To analyse the benefits of screening older men for abdominal aortic aneurysms. METHODS - A hospital based screening trial concerning 13 500 65-73 year old men using B-mode ultrasonographic scanning. To improve the response rate the invited men could change their appointment, and nonresponders were reinvited. RESULTS - Results from the first year of the trial are presented. Among 4404 invited, 3344 (76%) were scanned. The primary response rate was 64.8%, but a further 11.2% were scanned after revised appointments or reinvitation. The whole infrarenal aorta could be visualised in 97-6%, and the distal part in 99.7% of the scans. The time taken for each scan was 9-7 minutes and the costs per scan were $9.50. One hundred and fifty three subjects (4.6%) had aortic diameters of 25-29 min, and 141 (4.2%) had an abdominal aortic aneurysm, 19 (0.6%) above 49 mm in diameter. CONCLUSION - In Denmark the short term costs and benefits of screening older men for abdominal aortic aneurysms seem realistic. Long term costs and benefits need to be investigated.

Early experience with transfemoral endovascular aneurysm management (TEAM) in the treatment of aortic aneurysms

OBJECTIVES

To evaluate the early experience with transfemoral endovascular aortic aneurysm management using the Endovascular Grafting System.

DESIGN

Multi-centre prospective evaluation of the implantation procedure and early results (median follow-up 153 days).

SETTING

Department of Surgery, University Hospital Utrecht, The Netherlands; Department of Surgery, University of Sydney, Australia; University of Leicester School of Medicine, Leicester, U.K., Department of Surgery, Karolinska Hospital, Stockholm, Sweden and Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital; Oxford, U.K.

MATERIALS

31 consecutive patients treated in 13 months. CHIEF OUTCOME MEASUREMENTS: Peri and postoperative morbidity and mortality in accordance with the recommendations of the Ad Hoc Committee on Reporting Standards.

MAIN RESULTS

Graft placement was initially successful in all 31 patients. In one patient the endograft had to be replaced by a standard aortic tube graft because of extra graft flow in the aneurysm sac, and complaints of back pain. One patient died from multiple organ failure, 11 days after the operation. In three patients five severe adverse events were recorded. Breaks of the attachment system were encountered in two patients. These failures did not have severe clinical consequences for individual patients.

CONCLUSIONS

Transfemoral Endovascular Aneurysm Management is a technically demanding procedure that requires special training in both catheter and surgical techniques. The potential for less operative morbidity when compared to conventional surgery and the prospect of technical improvements in graft and introduction system design will make TEAM an important tool in aneurysm management in the near future.

Screening for abdominal aortic aneurysms and associated risk factors in a general population

OBJECTIVES

To evaluate the prevalence of abdominal aortic aneurysms (AAA) in a general population and to compare the results with those of similar studies in other countries.

DESIGN

Ultrasound screening study and collection of clinical and biochemical data.

SETTING

An urban Health Service District in Genoa, Italy.

MATERIALS

A general population, aged 65-75 years, invited by personal letter between 1991-1994.

RESULTS

1601 subjects (741 males and 860 females) out of 2734 invited (58.5%) were evaluated. According to the ultrasound findings, 27 patients (1.7%) had an aortic dilatation of 26-29 mm; an AAA of 30-39 mm was found in 37 (2.3%) and an AAA > or = 40 mm in 33 (2.1%). The overall prevalence for AAA was 4.4% (8.8% in males and 0.6% in females respectively). The prevalence of smoking, alcohol consumption, coronary heart disease, chronic obstructive pulmonary disease and arterial disease were significantly higher in patients with AAA (p < 0.01).

CONCLUSIONS

Ultrasound screening for AAA is a reliable and useful method and should be focused on men, regardless of concurrent disease.

Role of physical examination in detection of abdominal aortic aneurysms

BACKGROUND

Early detection of asymptomatic abdominal aortic aneurysms (AAAs) has been advocated to decrease the high mortality rate of ruptured AAAs. The purpose of this study was to document how AAAs were detected, whether AAAs not detected on physical examination (PE) were palpable, and what factors precluded detection by PE.

METHODS

Two hundred forty-three patients undergoing elective infrarenal AAA repair at a Veterans Affairs, county, or university hospital during a 10-year period were analyzed retrospectively. The method of initial detection of the AAA, size of the AAA at initial detection and before repair, and whether the AAA was palpable on preoperative PE were recorded, and the body mass index [BMI; weight in kg/(height in meters)2] was calculated. Obese patients were defined with BMI of greater than 85th percentile.

RESULTS

Only 93 (38%) patients had their AAAs initially detected by PE; the remainder (62%) were found incidentally on radiologic examinations performed for other indications. Patients with AAAs detected by PE had lower BMIs (PE, 23.7 +/- 3.6 kg/m2; incidental, 26.0 +/- 4.6 kg/m2, p < 0.001), but there was no difference in AAA size (PE, 5.8 +/- 1.6 cm; incidental, 5.5 +/- 1.9 cm, not significant). Forty-three percent of patients with AAAs detected on radiologic examination had palpable AAAs and should have been detected on PE. Overall, 55 (23%) AAAs were not palpable on preoperative PE, even when the diagnosis was known. Obese patients had only 15% of AAAs detected by PE, and only 33% were palpable.

CONCLUSIONS

AAAs are underdiagnosed by PE, especially in obese persons. More widespread abdominal examination to detect a widened aortic pulse would improve detection of AAAs.

Abdominal aortic aneurysm in the Irish population: a familial screening study

A pilot screening programme was undertaken in Ireland to determine the incidence of abdominal aortic aneurysm (AAA) (diameter 3 cm or greater) in the siblings of 120 patients known to have AAA. There were 621 siblings; 270 of them were dead, 32 were over 80 years old and 85 lived outside Ireland, leaving 234 under 80 years of age still living in Ireland who were invited to attend for ultrasonographic screening. Of the 270 siblings who had died, 102 were women and 168 men; eight men (4.8 per cent) had died from ruptured AAA. Only 125 (53.4 percent) of the 234 siblings agreed to participate in the screening programme, 60 brothers from 31 families and 65 sisters from 35 families. Fifteen (12.0 per cent) of the 125 siblings had an AAA (median size 4.2 (range 3.1-6.8) cm), 13 (22 per cent) of the 60 male siblings and two (3 per cent) of the 65 female siblings. The prevalence of AAA among siblings was not affected by the age or sex of the patient with aneurysm. Seven of the 14 male siblings with hypertension had an AAA, compared with only six of the 46 who were normotensive (P = 0.01). The high incidence of AAA in brothers of affected patients highlights the need to counsel this group on their risk of aneurysm. The relatively low participation rate by siblings in this screening programme indicates that a hospital-based unit is unlikely to be effective in recruiting all patient siblings at risk from an AAA.

Opportunistic screening for abdominal aortic aneurysm

OBJECTIVE

To contribute to the current debate on screening for abdominal aortic aneurysm (AAA).

SETTING

Radiology department of the John Radcliffe Hospital, Oxford.

METHODS

The prevalence of AAA in 317 clinically referred male patients aged 65-74 undergoing abdominal ultrasonography with no clinical suspicion of an AAA was investigated over a period of one year.

RESULTS

Over the year 15/317 (5%) patients were found to have an aneurysm (defined as aortic diameter (> or = 30 mm), with eight (3%) patients having an aortic diameter of > or = 40 mm. Six months later appropriate management for the AAA had been started for only four patients. A knowledge assessment questionnaire sent to 245 hospital clinicians and general practitioners showed that 17 (12%) of the 139 respondents would initiate no review of patients found to have an aneurysm of 30-39 mm and two would take no action with aneurysms of 40-49 mm. Thirty two (23%) respondents would seek advice on management for all categories of aneurysm, 14% from the radiologist.

CONCLUSIONS

Opportunistic screening for AAA in men undergoing clinically indicated abdominal ultrasonography is easy, productive, without discernible cost, and discloses a prevalence of AAA comparable with that of population screening programmes. Routine opportunistic measurement of aortic diameter during abdominal ultrasonography in the at risk group would allow 12-15% of men aged 65-74 to be screened for AAA within five years without the need for any additional resources.