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Bertrand L, Prendes CF, Melo R, Tsilimparis N, Bacharach T, Dayama A, Stana J, Rantner B. Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database. Ann Vasc Surg 2024; 99:380-388. [PMID: 37914074 DOI: 10.1016/j.avsg.2023.09.066] [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: 06/16/2023] [Revised: 08/27/2023] [Accepted: 09/04/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA. METHODS This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay. RESULTS Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27 kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P = 0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P = 0.07). Previous open abdominal surgery was significantly associated with longer operating times (P = 0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P = 0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P = 0.005 and P = 0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P = 0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. CONCLUSIONS This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.
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Affiliation(s)
- Laurence Bertrand
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany.
| | | | - Ryan Melo
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
| | - Nikolas Tsilimparis
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
| | - Thekla Bacharach
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany; Sanford USD Medical Centre and Hospital, Sioux Falls, SD
| | - Anand Dayama
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany; Sanford USD Medical Centre and Hospital, Sioux Falls, SD
| | - Jan Stana
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
| | - Barbara Rantner
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
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Hariri E, Matta M, Layoun H, Badwan O, Braghieri L, Owens AP, Burton R, Bhandari R, Mix D, Bartholomew J, Schumick D, Elbadawi A, Kapadia S, Hazen SL, Svensson LG, Cameron SJ. Antiplatelet Therapy, Abdominal Aortic Aneurysm Progression, and Clinical Outcomes. JAMA Netw Open 2023; 6:e2347296. [PMID: 38085542 PMCID: PMC10716735 DOI: 10.1001/jamanetworkopen.2023.47296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Preclinical studies suggest a potential role for aspirin in slowing abdominal aortic aneurysm (AAA) progression and preventing rupture. Evidence on the clinical benefit of aspirin in AAA from human studies is lacking. Objective To investigate the association of aspirin use with aneurysm progression and long-term clinical outcomes in patients with AAA. Design, Setting, and Participants This was a retrospective, single-center cohort study. Adult patients with at least 2 available vascular ultrasounds at the Cleveland Clinic were included, and patients with history of aneurysm repair, dissection, or rupture were excluded. All patients were followed up for 10 years. Data were analyzed from May 2022 to July 2023. Main Outcomes and Measures Clinical outcomes were time-to-first occurrence of all-cause mortality, major bleeding, or composite of dissection, rupture, and repair. Multivariable-adjusted Cox proportional-hazard regression was used to estimate hazard ratios (HR) for all-cause mortality, and subhazard ratios competing-risk regression using Fine and Gray proportional subhazards regression was used for major bleeding and composite outcome. Aneurysm progression was assessed by comparing the mean annualized change of aneurysm diameter using multivariable-adjusted linear regression and comparing the odds of having rapid progression (annual diameter change >0.5 cm per year) using logistic regression. Results A total of 3435 patients (mean [SD] age 73.7 [9.0] years; 2672 male patients [77.5%]; 120 Asian, Hispanic, American Indian, or Pacific Islander patients [3.4%]; 255 Black patients [7.4%]; 3060 White patients [89.0%]; and median [IQR] follow-up, 4.9 [2.5-7.5] years) were included in the final analyses, of which 2150 (63%) were verified to be taking aspirin by prescription. Patients taking aspirin had a slower mean (SD) annualized change in aneurysm diameter (2.8 [3.0] vs 3.8 [4.2] mm per year; P = .001) and lower odds of having rapid aneurysm progression compared with patients not taking aspirin (adjusted odds ratio, 0.64; 95% CI, 0.49-0.89; P = .002). Aspirin use was not associated with risk of all-cause mortality (adjusted HR [aHR], 0.92; 95% CI, 0.79-1.07; P = .32), nor was aspirin use associated with major bleeding (aHR, 0.88; 95% CI, 0.76-1.03; P = .12), or composite outcome (aHR, 1.16; 95% CI, 0.93-1.45; P = .09) at 10 years. Conclusions In this retrospective study of a clinical cohort of 3435 patients with objectively measured changes in aortic aneurysm growth, aspirin use was significantly associated with slower progression of AAA with a favorable safety profile.
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Affiliation(s)
- Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
- Division of Cardiology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Milad Matta
- Cardiovascular Medicine, Section of Vascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Habib Layoun
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lorenzo Braghieri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - A. Phillip Owens
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Ohio
| | - Robert Burton
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rohan Bhandari
- Cardiovascular Medicine, Section of Vascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Doran Mix
- Department of Surgery, Division of Vascular Surgery, University of Rochester Medical Center, New York
| | - John Bartholomew
- Cardiovascular Medicine, Section of Vascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David Schumick
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of Case Western Reserve University, Cleveland, Ohio
| | - Ayman Elbadawi
- Division of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stanley L. Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of Case Western Reserve University, Cleveland, Ohio
- Department of Cardiovascular Medicine, Section of Preventive Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Scott J. Cameron
- Cardiovascular Medicine, Section of Vascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of Case Western Reserve University, Cleveland, Ohio
- Department of Hematology, Taussig Cancer Institute, Cleveland, Ohio
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Epple J, Svidlova Y, Schmitz-Rixen T, Böckler D, Lingwal N, Grundmann RT. Long-Term Outcome of Intact Abdominal Aortic Aneurysm After Endovascular or Open Repair. Vasc Endovascular Surg 2023; 57:829-837. [PMID: 37224305 DOI: 10.1177/15385744231178130] [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: 05/26/2023]
Abstract
OBJECTIVE Endovascular aortic aneurysm repair (EVAR) has been established as a standard treatment option for intact abdominal aortic aneurysm (iAAA) and gained importance due to a lower perioperative mortality than open repair (OAR). However, whether this survival advantage can be maintained or if OAR is beneficial in terms of long-term complications and reinterventions remains questionable. DESIGN In this retrospective cohort study data from patients undergoing elective EVAR or OAR for iAAAs in the years 2010-2016 was analyzed. The patients were followed through 2018. METHODS In the propensity score matched cohorts the perioperative and long-term outcomes of the patients were assessed. We identified 20 683 patients undergoing elective iAAA repair (76.4% EVAR). The propensity matched cohorts included 4886 pairs of patients. RESULTS The perioperative mortality was 1.9% for EVAR and 5.9% for OAR (P = <.001). The perioperative mortality was mainly influenced by patients age (Odds-Ratio (OR):1.073, confidence interval (CI):1.058-1.088, P ≤ .001) and OAR (OR:3.242, CI:2.552-4.119, P ≤ .001). The early survival benefit after endovascular repair persisted for approximately 3 years (estimated survival EVAR 82.3%, OAR 80.9%, P = .021). After that time the estimated survival curves were similar. After 9 years the estimated survival was 51.2% after EVAR as compared to 52.8% after OAR (P = .102). The operation method didn't influence long-term survival significantly (Hazard-Ratio (HR): 1.046, CI: .975-1.122, P = .211). The vascular reintervention rate was 17.4% in the EVAR cohort and 7.1% in the OAR cohort (P ≤ .001). CONCLUSION EVAR has a significantly lower perioperative mortality than OAR, a survival benefit that lasts up to 3 years after intervention. Thereafter, no significant difference in survival was observed between EVAR and OAR. The decision between EVAR or OAR may depend on patient preference, surgeons' experience, and the institutions' ability to handle complications.
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Affiliation(s)
- Jasmin Epple
- Department of Vascular and Endovascular Surgery University Hospital, Frankfurt Am Main, Germany
| | - Yuliya Svidlova
- Department of Vascular and Endovascular Surgery University Hospital, Frankfurt Am Main, Germany
| | - Thomas Schmitz-Rixen
- German Institute for Vascular Healthcare Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital, Heidelberg, Germany
| | - Neelam Lingwal
- Institute for Biostatistics and Mathematical Modeling, Goethe University Frankfurt Am Main, Germany
| | - Reinhart T Grundmann
- German Institute for Vascular Healthcare Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
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The Effect of Smoking Status on Perioperative Morbidity and Mortality after Open and Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2022; 88:373-384. [PMID: 36058453 DOI: 10.1016/j.avsg.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study quantifies the extent to which active tobacco smoking is deleterious towards outcomes following open and endovascular AAA repair. METHODS Open and endovascular abdominal aortic aneurysm (AAA) repairs between January 2003 and June 2020 in the Vascular Quality Initiative (VQI) were queried. Rupture, symptomatic status, and lack of 90 day follow up were exclusions. Patients were then placed into one of six groups : open AAA with active smoking (n=3788); open AAA with prior smoking (n=4614); open AAA never smokers (817); endovascular AAA active smokers (n=14173); endovascular AAA former smokers (n=25,831); and, endovascular AAA never smokers (n=6064). Comparison of baseline characteristics, co-morbidities, and adverse outcomes across each of the 6 cohorts was performed with open AAA in active smokers serving as the reference. Sub-analysis investigating open AAA repair in active smokers relative to open AAA in patients confirmed in VQI to have quit smoking between 30 and 90 days before surgery was performed. Smoking cessation for a minimum of 30 days before surgery was required to fall into the former smoker category. RESULTS In comparing open AAA in active smokers to open AAA in former and never smokers, the active smokers experienced significantly higher rates of pneumonia (P<.001). Combined additive morbidity and mortality was highest (54%) in active smokers (P<.001 relative to all cohorts other than open AAA former smokers P=.21). Smoking status did not impact morbidity or mortality incidence across individuals undergoing EVAR. Binary logistic regression for all AAA patients (open and endovascular combined) revealed those with any history of smoking to be more likely to experience 90 day mortality (adjusted OR 2.5 (2.2-2.9), P<.001) relative to never-smokers. Active smokers were similarly more likely to experience 90 day mortality than prior/never smokers combined (OR 1.23 (1.07-1.38), P<.001). Mortality within 90 days was significantly more likely (P<.001) with aging, female gender, larger aneurysms, preoperative history of congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral artery disease, body mass index under 20 and over 35 mg/kg2. Diabetes and coronary artery disease were also associated with 90 day mortality (P= .045 and .049 respectively). Quitting smoking between 30 and 90 days before open repair reduced combined additive morbidity and mortality relative to active smokers (OR 1.34, P =.038). CONCLUSIONS Smoking cessation 30 days before open AAA repair reduces perioperative morbidity and mortality. Smoking status does not impact morbidity and mortality in patients undergoing endovascular AAA repair. When combining all patients (open and endovascular), higher rates of 90 day mortality are associated with any history of smoking, aging, female gender and advanced pre-existing co-morbidities on multivariable analysis.
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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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Mangel T, Mastracci TM. Outcomes of endovascular repair of abdominal and thoracoabdominal aneurysms in women - A review. Semin Vasc Surg 2022; 35:334-340. [DOI: 10.1053/j.semvascsurg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/30/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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Torsello G, Bertoglio L, Kellersmann R, Wever JJ, van Overhagen H, Stavroulakis K. One-Year Results of the INSIGHT Study on Endovascular Treatment of Abdominal Aortic Aneurysms. J Vasc Surg 2022; 75:1904-1911.e3. [PMID: 34995719 DOI: 10.1016/j.jvs.2021.12.066] [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: 06/21/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Endovascular repair of abdominal aortic aneurysms (AAA) using the INCRAFT™ AAA Stent Graft System was safe and effective in regulatory approval studies. We herein report on the 1-year results of a real-world clinical study. METHODS The INSIGHT study is a multi-center, prospective, open label, post-approval study conducted to continually evaluate the safety and performance of the INCRAFT ™ System. Between 2015 and 2016, 150 consecutive patients with AAA at 23 centers in Europe were treated with the device in routine clinical practice. The primary endpoint was freedom from major adverse events (MAEs), namely death, myocardial infarction (MI), cerebrovascular accident (CVA) and renal failure, within 30 days of the index procedure. Endpoint data were assessed by a core laboratory. The secondary endpoints included technical success at the conclusion of the procedure and clinical success. RESULTS All 150 patients studied (mean age: 73.6 ± 8.0 and 89.3% men) met the primary endpoint without MAEs at 30-day follow up. Technical success was achieved in 99.3% of patients without stent fractures at 30 days. Among the 146 patients eligible for 1-year follow-up, the MAE rate was 8.2%, i.e., 12 patients suffered 13 MAEs: CVA in 8, MI in 1, and 4 died (resulting in a 2.7% all-cause mortality rate). There were no reports of new onset renal failure requiring dialysis. Only 2.7% of patients had type I endoleak and no III endoleaks were identified through 1 year. The rate of clinical success at 1 year was 91.8%. CONCLUSIONS The 1-year results of this multicenter real-world study underscore the safety and effectiveness of endovascular treatment of AAA with the INCRAFT System in routine clinical practice.
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Affiliation(s)
- Giovanni Torsello
- Department of Vascular Surgery St. Franziskus Hospital, Muenster, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Richard Kellersmann
- Clinic and Polyclinic for General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Jan J Wever
- Department of Vascular Surgery & Interventional Radiology , Haga Hospital, The Hague, the Netherlands
| | - Hans van Overhagen
- Department of Vascular Surgery & Interventional Radiology , Haga Hospital, The Hague, the Netherlands
| | - Konstantinos Stavroulakis
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany; Department of Vascular and Endovascular Surgery, Ludwig-Maximilian-University Hospital, Munich, Germany
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OUP accepted manuscript. Br J Surg 2022; 109:340-345. [DOI: 10.1093/bjs/znab465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/10/2021] [Accepted: 12/17/2021] [Indexed: 11/14/2022]
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Haque MA, McCollum C. Patients on AAA surveillance are at greater threat of cardiovascular events or malignancy than their AAA: Outcomes of AAA surveillance over 19 years at a tertiary vascular centre. Ann Vasc Surg 2021; 83:158-167. [PMID: 34933105 DOI: 10.1016/j.avsg.2021.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/02/2021] [Accepted: 11/10/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To analyse 19 years' worth of data from a Major UK Vascular Centre to determine the outcome of patients after they enter AAA surveillance (surgery, death, discharge or transfer), this may inform interventions to improve these outcomes in the AAA surveillance population. METHODS This was a retrospective analysis of a prospectively collected database of outcomes of every patient entered on AAA surveillance at Manchester University NHS Foundation Trust - Wythenshawe Hospital between September 2000 and June 2019. Analyses included what proportion suffered death, discharge, transfer or surgery whilst on surveillance. Multi-variate analysis was used to determine the effect of initial AAA size, age when entering surveillance and gender. Boxplots were produced in those who had already reached an outcome to determine historic median times. Causes of death/discharge were also analysed. RESULTS 1951 patients were identified from the databased after data cleaning and were included in the final analysis. 32.0% of patients had died, 23.8% had surgery, 13.3% were discharged due to worsening/severe comorbidity, 3.1% had been transferred and 27.7% were still active in surveillance. A longer time to surgery was significantly associated with increasing age on entering surveillance OR (95% CI) 0.95 (0.94 - 0.96) (p<0.001), smaller initial AAA size 4.26 (3.80 - 4.78) (p<0.001) but not female gender. Impaired survival was associated with increasing age 1.06 (1.05 - 1.07) (p<0.001), initial AAA size, 1.56 (1.39 - 1.74) (p<0.001) and female gender 1.40 (1.18 - 1.67) (p<0.001). Overall, death occurred more frequently than operative repair every year over all 15 years. Out of the deaths where cause was known (n=401), 34.9% (n=108) were due to cardiovascular events, 27.3% (n=109) due to malignancy (primarily lung), and 19.3% due to respiratory disease. CONCLUSIONS Based on this data, death, primarily due to cardiovascular events, is a more likely outcome than operative repair in patients on AAA surveillance and is associated with increasing age, increasing AAA size and female gender. A median time on surveillance of over three and a half years provides sufficient time to affect subsequent health outcomes in this population and therefore a shift of focus of AAA surveillance programmes to address cardiovascular, malignancy and respiratory disease risk is warranted.
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Affiliation(s)
- Mr Adam Haque
- Academic Unit of Surgery, University of Manchester, Southmoor Road, Manchester, M23 9LT.
| | - Charles McCollum
- Academic Unit of Surgery, University of Manchester, Southmoor Road, Manchester, M23 9LT
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Nana P, Dakis K, Brodis A, Spanos K, Kouvelos G, Eckstein HH, Giannoukas A. A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective setting. J Vasc Surg 2021; 75:1082-1088.e6. [PMID: 34740807 DOI: 10.1016/j.jvs.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR) or open (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings. METHODS The protocol of the review was registered to the PROSPERO (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, from inception to March 5, 2021, using the Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective setting, comparing EVAR and OSR, in female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the ROBINS-I tool. The GRADE approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis. RESULTS Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs. 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared to OSR (OR, 0.25; 95% CI, 0.23-0.27; P<.001, Ι2=86%). Also a reduced 30-day mortality was found in females that underwent elective EVAR compared to OSR (OR, 0.37; 95% CI, 0.33-0.41; P< .001, Ι2=48%). Despite that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P< .001, Ι2=84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P<.001, Ι2=0%). CONCLUSIONS In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.
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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 Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brodis
- Department of Neurosurgery, 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
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University of Munich TUM, Germany
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Pouncey AL, David M, Morris RI, Ulug P, Martin G, Bicknell C, Powell JT. Editor's Choice - Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women. Eur J Vasc Endovasc Surg 2021; 62:367-378. [PMID: 34332836 DOI: 10.1016/j.ejvs.2021.05.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 05/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Previously, reports have shown that women experience a higher mortality rate than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex specific disparity has been ameliorated by modern practice, and to define sex specific differences in peri- and post-operative complications and pre-operative status; factors which may contribute to poor outcome. METHODS This was a systematic review, meta-analysis, and meta-regression of sex specific differences in 30 day mortality and complications conducted according to PRISMA guidance (Prospero registration CRD42020176398). Papers with ≥ 50 women, reporting sex specific outcomes, following intact primary AAA repair, from 2000 to 2020 worldwide were included; with separate analyses for EVAR and OAR. Data sources were Medline, Embase, and CENTRAL databases 2005 - 2020 searched using ProQuest Dialog. RESULTS Twenty-six studies (371 215 men, 65 465 women) were included. Meta-analysis and meta-regression indicated that sex specific odds ratios (ORs) for 30 day mortality were unchanged from 2000 to 2020. Mortality risk was higher in women for OAR and more so for EVAR (OR [95% CI] 1.49 [1.37 - 1.61]; 1.86 [1.59 - 2.17], respectively) and this remained following multivariable risk adjustment. Transfusion, pulmonary complications, and bowel ischaemia were more common in women after OAR and EVAR (OAR: ORs 1.81 [1.60 - 2.04], 1.40 [1.28 - 1.53], 1.54 [1.36 - 1.75]; EVAR: ORs 2.18 [2.08 - 2.29] 1.44 [1.17 - 1.77], 1.99 [1.51 - 2.62], respectively). Arterial injury, limb ischaemia, renal and cardiac complications were more common in women after EVAR (ORs 3.02 [1.62 - 5.65], 2.13 [1.48 - 3.06], 1.46 [1.22 - 1.72] and 1.19 [1.03 - 1.37], respectively); the latter was associated with greater mortality risk on meta-regression. CONCLUSION Increased mortality risk for women following AAA repair remains. Women had a higher incidence of transfusion, pulmonary and bowel complications after EVAR and OAR. Higher mortality risk ratios for EVAR may result from cardiac complications, additional arterial injury, and embolisation, leading to renal and limb ischaemia. These findings indicate possible causes for observed outcome disparities and targets for quality improvement.
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Affiliation(s)
- Anna L Pouncey
- Department of Surgery and Cancer, Imperial College London, UK.
| | - Michael David
- Care Research and Technology Centre, Dementia Research Institute, Imperial College London, UK
| | - Rachael I Morris
- Academic Department of Vascular Surgery, Cardiovascular Division, St. Thomas' Hospital, King's College London, UK
| | - Pinar Ulug
- Department of Surgery and Cancer, Imperial College London, UK
| | - Guy Martin
- Department of Surgery and Cancer, Imperial College London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, UK
| | - Janet T Powell
- Department of Surgery and Cancer, Imperial College London, UK
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Tedjawirja VN, de Wit MCJ, Balm R, Koelemay MJW. Differences in Comorbidities Between Women and Men Treated with Elective Repair for Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 76:330-341. [PMID: 33905844 DOI: 10.1016/j.avsg.2021.03.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/09/2021] [Accepted: 03/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Elective abdominal aortic aneurysm (AAA) repair is performed to prevent rupture. For reasons as yet unknown, the 30-day mortality risk after elective AAA repair is higher in women than in men. We hypothesised that this higher risk might be related to differences in comorbidity. METHODS Systematic review (PROSPERO CRD42019133314) according to PRISMA guidelines. A search in the EMBASE/MEDLINE/CENTRAL databases identified 1870 studies that included patients who underwent elective AAA repair (final search February 17th, 2021). Ultimately, 28 studies were included and all reported comorbidities were categorised into 17 comorbidity groups. Additionally, 15 groups of clearly defined comorbidities were used for sensitivity analysis. For both groups, meta-analyses of each comorbidity were performed to estimate the difference in pooled prevalence between women and men with a random effects model. RESULTS When analysing data of all reported comorbidities (17 groups), smoking [risk difference (RD) 11%, 95% confidence interval (CI) 4-18], diabetes (RD 3%, 95% CI 2-4), ischaemic heart disease (RD 12%, 95% CI 8-16), arrhythmia (RD 3%, 95% CI 0.4-5), liver disease (RD 0.1%, 95% CI 0.01-0.2), and cancer (RD 3%, 95% CI 2-4)) were less prevalent in women, whereas, hypertension (RD 4%, 95% CI 3-6) and pulmonary disease (RD 4%, 95% CI 3-5) were more prevalent in women. At the time of surgery women were significantly older than men (74.9 years versus 72.4; mean difference 2.4 years (95% CI 2.1-2.7)). In the sensitivity analysis of 15 comorbidity groups, the same comorbidities remained significantly different between women and men, except smoking and arrhythmia. Women had a higher mortality risk than men (RD 1%, 95% CI 1-2). CONCLUSIONS Although women undergoing elective AAA repair have fewer baseline comorbidities than men, their 30-day mortality risk is higher. In-depth studies on the cause of death in women after elective AAA repair are needed to explain this discrepancy in mortality.
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Affiliation(s)
- V N Tedjawirja
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - M C J de Wit
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - R Balm
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - M J W Koelemay
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Barry IP, Turley LP, Thomas AR, Mwipatayi MT, Mwipatayi BP. The Impact of Endograft Selection on Mid-Term Outcomes in Female Patients Following Endovascular Aortic Aneurysm Repair (EVAR) for Abdominal Aortic Aneurysm (AAA). Cureus 2021; 13:e14584. [PMID: 33889469 PMCID: PMC8057124 DOI: 10.7759/cureus.14584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Abdominal aortic aneurysms (AAA) are far more common in male than female gender, although they appear to have a more aggressive pathophysiology in females. Given the lower incidence of AAA in females, it has been difficult to assess the impact of graft selection for endovascular aortic aneurysm repair (EVAR) in this cohort. Purpose To identify whether graft selection influences outcomes following AAA endoluminal repair in female patients. Methodology A retrospective analysis of published data for 711 female patients was conducted, collating data from three cohorts - Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE), Global Registry for Endovascular Aortic Treatment (GREAT) and U.S. Zenith multicenter trial in combination with the Zenith female registry. Patients were recruited into the ENGAGE registry between 2009 and 2011, the GREAT registry between August 2010 and October 2016, and into the Zenith registry between 2000 and 2003. Patients from ENGAGE received the Medtronic Endurant stent graft for infrarenal AAA repair, patients analysed in GREAT received the Gore Excluder stent graft and the Zenith group received the Cook Zenith stent graft. Analyses were performed to evaluate all-cause mortality, aorta-related mortality, endoleak occurrence and surgical reintervention rates between the three cohorts. Results Of the 711 females, 133 were from ENGAGE (mean age 76 years), 538 were from GREAT (mean age 75 years) and 40 were from Zenith (mean age 74 years). The rates of co-morbidities between the three groups were broadly similar except for atherosclerotic disease which was more commonly observed in those treated with the GORE Excluder. The rate of endoleaks was lower when the Excluder stent was utilised as compared to the other two stents (Excluder 6.7% vs. Zenith 12.5% vs. Endurant 35.3%) even considering the limited follow-up of the Zenith group to two years as compared to five years for both ENGAGE and GREAT. All-cause mortality was similar in all three groups across the period examined while aorta-related mortality was uncommon. Reintervention rate was 15% at two years following the utilisation of the Zenith aortic graft while the rate of intervention at five years was broadly similar between ENGAGE and GREAT. Conclusion The newer generation, lower profile aortic endografts appear to have provided a safe and successful tool in the management of AAA in female patients, despite more complex aortic anatomy with shorter infrarenal neck length and larger aortic neck angulation.
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Affiliation(s)
- Ian P Barry
- Vascular Surgery, Royal Perth Hospital, Perth, AUS
| | - Luke P Turley
- Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Angel R Thomas
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, AUS
| | | | - Bibombe P Mwipatayi
- Vascular Surgery, Royal Perth Hospital, Perth, AUS.,Surgery, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, AUS
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15
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Editor's Choice - Decrease in Mortality from Abdominal Aortic Aneurysms (2001 to 2015): Is it Decreasing Even Faster? Eur J Vasc Endovasc Surg 2021; 61:900-907. [PMID: 33773903 DOI: 10.1016/j.ejvs.2021.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/17/2021] [Accepted: 02/09/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The early twenty first century witnessed a decrease in mortality from abdominal aortic aneurysms (AAA), which was associated with variations in the prevalence of cardiovascular risk factors. This study investigated whether these trends continued into the second decade of the twenty first century. METHODS Information on AAA mortality (2001 - 2015) using International Classification of Diseases codes was extracted from the World Health Organization (WHO) mortality database. Data on risk factors were extracted from the Institute of Health Metrics and Evaluation and WHO InfoBase, and data on population from the World Development Indicators database. Regression analysis of temporal trends in cardiovascular risk factors was done independently for correlations with AAA mortality trends. RESULTS Seventeen countries across four continents met the inclusion criteria (Australasia, two; Europe, 11; North America, two; Asia, two). Male AAA mortality decreased in 13 countries (population weighted average: -2.84%), while female AAA mortality decreased in 11 countries (population weighted average: -1.64%). The decrease in AAA mortality was seen in both younger (< 65 years) and older (> 65 years) patients. The decrease in AAA mortality was more marked in the second decade of the twenty first century (2011 - 2015) compared with the first decade (2001 - 2005 and 2006 - 2010). Trends in AAA mortality positively correlated with smoking (males: p = .03X, females: p = .001) and hypertension (males: p = .001, females: p = .01X). Conversely, AAA mortality negatively correlated with obesity (males: p = .001, females: p = .001), while there was no significant correlation with diabetes. CONCLUSION AAA mortality has continued to decline and seems to have declined at an even faster rate in the second decade of the twenty first century, albeit with heterogeneity among countries. These variations are multifactorial in origin but further efforts targeting smoking cessation and blood pressure control will probably contribute to continued reductions in AAA mortality.
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16
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Talvitie M, Stenman M, Roy J, Leander K, Hultgren R. Sex Differences in Rupture Risk and Mortality in Untreated Patients With Intact Abdominal Aortic Aneurysms. J Am Heart Assoc 2021; 10:e019592. [PMID: 33619974 PMCID: PMC8174277 DOI: 10.1161/jaha.120.019592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Studies on intact abdominal aortic aneurysms mainly focus on treated patients, and data on untreated patients are sparse. The objective was to investigate sex differences among untreated patients regarding rupture and mortality rates and to determine predictors for these events. Sex‐specific causes of death were evaluated. Methods and Results All patients ≥40 years diagnosed from 2001 to 2015 (n=32 393) with intact abdominal aortic aneurysms were identified in national registries; 60% (n=19 569) were untreated. Comorbid loads, crude rupture, and mortality rates were assessed. Predictors of 5‐year rupture and mortality were analyzed in Cox models (sex, age, comorbidities, income, and marital status). The proportion of men and women with multiple comorbidities was similar. Within 5 years, 798 ruptures occurred (9.7% women versus 6.9% men, P<0.001). Ruptures were independently predicted by female sex (hazard ratio [HR], 1.23; 95% CI, 1.07–1.42; P=0.004), chronic obstructive pulmonary disease (HR, 1.36; 95% CI, 1.15–1.62; P<0.001), age (HR, 11.49; 95% CI, 5.68–23.25 for ≥80 years; P<0.001), and income (HR, 0.63; 95% CI, 0.53–0.75 for highest tertile; P<0.001). After 5 years, 56.5% women and 50.4% men were deceased. Mortality was not independently predicted by female sex. Rupture was the third most common cause of death (11.9% women versus 8.7% men; P<0.001). The median time‐to‐events was 2.8 years. Conclusions A considerable proportion of patients with intact abdominal aortic aneurysms in surveillance remain untreated. Despite surveillance algorithms, the healthcare system fails to prevent a high number of ruptures, especially among women. The time‐to‐event data highlight the urgency to develop more individualized surveillance.
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
| | - Malin Stenman
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Perioperative Medicine and Intensive Care Function Karolinska University Hospital Stockholm Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
| | - Karin Leander
- Institute of Environmental Medicine, Karolinska Institutet Stockholm Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Vascular Surgery Karolinska University Hospital Stockholm Sweden
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17
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Erben Y, Bews KA, Hanson KT, Da Rocha-Franco JA, Money SR, Stone W, Farres H, Meltzer AJ, Gloviczki P, Oderich GS, Hakaim AG, Habermann EB. Female Sex is a Marker for Higher Morbidity and Mortality after Elective Endovascular Aortic Aneurysm Repair: A National Surgical Quality Improvement Program Analysis. Ann Vasc Surg 2020; 69:1-8. [DOI: 10.1016/j.avsg.2020.06.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/09/2020] [Accepted: 06/13/2020] [Indexed: 01/27/2023]
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18
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Grandi A, Carta N, Cambiaghi T, Bilman V, Melissano G, Chiesa R, Bertoglio L. Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft. J Endovasc Ther 2020; 28:283-294. [DOI: 10.1177/1526602820964916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: To evaluate the potential anatomical feasibility of using the off-the-shelf multibranched Zenith t-Branch for the treatment of thoracoabdominal aortic aneurysms (TAAAs) in female patients. Materials and Methods: A total of 268 patients (median age 68 years; 69 women) with degenerative TAAA treated at a single institution by means of open or endovascular repair between 2007 and 2019 were retrospectively analyzed to determine the feasibility of using the Zenith t-Branch based on the manufacturer’s instructions for use. The factors determining overall anatomical feasibility were divided into vascular access, aortic anatomy, and visceral vessels. The results were stratified by sex and compared. A logistic regression model was constructed to determine any association between feasibility and clinical factors or potential confounding variables; results are expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: The overall anatomical feasibility was 39% (22% women vs 45% men, p=0.001). The feasibility was negatively influenced by female sex (p<0.001) in multivariable analysis (OR 2.9, 95% CI 1.5 to 5.4, p=0.001). Vascular access feasibility was 82% (61% women vs 89% men, p<0.001). Aorta feasibility was 65% (52% women vs 69% men, p<0.001), and visceral vessel feasibility was 74% (78% women vs 73% men, p=0.260). An access diameter ≤8.5 mm excluded 17% of the patients (39% women vs 9% men, p<0.001). The aortic feasibility was limited by the infrarenal aortic diameter in 16% of patients (45% women vs 6% men, p<0.001) and the aortic lumen at the visceral vessels in 17% patients (19% women vs 17% men, p=0.741). The visceral vessel feasibility was mainly limited by inadequate numbers or diameters of target vessels. Location and orientation of the target vessels were adequate in 96% of patients. Conclusion: A little more than a third of an all-comers cohort of patients with degenerative TAAA could have been treated with on-label use of the Zenith t-Branch. However, only 22% of women could have been treated because of sex-related anatomical limitations. New generations of multibranched devices should address these differences.
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Affiliation(s)
- Alessandro Grandi
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Tommaso Cambiaghi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX, USA
| | - Victor Bilman
- Cirurgia Vascular e Endovascular, Pontifícia Universidade Católica do Rio de Janeiro, Brazil
| | - Germano Melissano
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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19
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Dawkins C, Hollingsworth AC, Milburn S, Walker P, Cheesman M, Mofidi R. Is gender still a risk factor for mortality in patients who undergo elective repair of abdominal aortic aneurysms? Experience of a single center. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:713-719. [PMID: 32241090 DOI: 10.23736/s0021-9509.20.11196-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vascular Services Quality Improvement Program (VSQIP) was introduced to reduce mortality from elective repair of AAA in the UK. This study examines the differences in perioperative mortality and postoperative survival between men and women following elective repair of AAAs in the 10 years after implementation of the (VSQIP). METHODS Consecutive patients who underwent elective repair of AAA between 1st January 2008 and 31st March 2018 were included. All patients were assessed using the nationally agreed VSQIP pathway which involved cardiopulmonary exercise testing as well as contrast enhanced CT scan of aorta and multidisciplinary assessment to plan each treatment. CT scans were examined to assess the morphology of AAA. Patients were stratified by age, gender, AAA morphology and preoperative anaerobic threshold. Postoperative survival was assessed using Kaplan-Meier analysis. Cox regression analysis was used to determine predictors of postoperative mortality. RESULTS A total of 702 patients underwent elective repair of AAA of whom 632 were men and 70 were women. The mean age of study cohort was 73.5±7.3 years and mean AAA diameter was 62±9.9 mm. Two hundred and forty-four patients underwent open repair, 402 underwent infrarenal endovascular aneurysm repair (EVAR) and 56 underwent complex EVAR with perioperative and 30-day mortality of 1.13%. No significant difference was observed in perioperative/30-day mortality between men and women (χ2=0.06, P=0.81). Anaerobic threshold <8 (HR=0.68 [95% CI: 0.51-0.92]), complex aneurysm morphology (HR=1.7 [95% CI: 1.39-2.19]) risk category (HR=1.89 [95% CI: 1.48-2.42]) and patients age (HR=1.41 [95% CI: 1.13-1.89]) were independent risk factor for mortality following repair of AAA, whilst female gender (HR=0.89 [95% CI: 0.54-1.48]) and AAA size (HR=1.01 [95% CI: 0.84-1.22]) were not. There was no difference in postoperative survival between men and women who underwent elective repair of AAA (Log rank: 1.82, P=0.61). CONCLUSIONS Following the implementation of VSQIP female gender is no longer a significant risk factor for perioperative mortality or reduced survival following elective repair of large asymptomatic AAA.
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Affiliation(s)
- Claire Dawkins
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Simon Milburn
- Department of Interventional Radiology, James Cook University Hospital, Middlesbrough, UK
| | - Paul Walker
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Matthew Cheesman
- Department of Anesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Reza Mofidi
- Department of Vascular Surgery, James Cook University Hospital, Middlesbrough, UK -
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20
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Multicentre Covariate Adjustment Analysis of Short-Term and 5-Year Outcomes after Endovascular Repair according to Sex. Surg Res Pract 2020; 2020:8970759. [PMID: 32232118 PMCID: PMC7085369 DOI: 10.1155/2020/8970759] [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: 06/05/2019] [Accepted: 02/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background Several studies have reported worse outcomes in women compared to men after endovascular aneurysm repair (EVAR). This study aimed to evaluate sex-specific short-term and 5-year outcomes after EVAR. Methods A total of 409 consecutive patients underwent elective EVAR from 2004 to 2017 at two tertiary hospitals in Western Australia. Baseline, intraoperative, and postoperative variables were examined retrospectively according to sex. The primary outcome was 30-day mortality (death within 30 days after EVAR). Secondary outcomes were 30-day composite endpoint, length of stay after EVAR, 5-year survival, freedom from reintervention, residual aneurysm size after EVAR, and major adverse event rate at 5-year follow-up. Results A cohort of 409 patients, comprising 57 women (14%) and 352 men (86%), was analysed. Female patients were older (median age, 76.8 versus 73.5 years, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%. Conclusion This study found no significant differences in 30-day and 5-year outcomes between female and male patients treated with EVAR, implying that EVAR remains a safe treatment choice for female patients.
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21
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Mwipatayi BP, Anwari T, Wong J, Verhoeven E, Dubenec S, Heyligers JM, Milner R, Mascoli C, Gargiulo M, Shutze WP. Sex-Related Outcomes After Endovascular Aneurysm Repair Within the Global Registry for Endovascular Aortic Treatment. Ann Vasc Surg 2020; 67:242-253.e4. [PMID: 32194136 DOI: 10.1016/j.avsg.2020.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 02/02/2020] [Accepted: 02/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are more common in men. However, women have been shown to have more short- and long-term adverse outcomes after endovascular aneurysm repair. This disparity is thought to be multifactorial, including anatomical differences, hormonal differences, older age of presentation, and a greater degree of preoperative comorbidities. METHODS A retrospective analysis that included data for 3,758 patients from the Global Registry for Endovascular Aortic Treatment (GREAT) was conducted. Patients were recruited into GREAT between August 2010 and October 2016 and received the Gore Excluder stent graft for infrarenal AAAs repair. Cox multivariate regression analyses were performed to analyze any reintervention and device-related intervention rates. RESULTS Of the 3,758 patients, 3,220 were male (mean age 73 years) and 538 were female (mean age 75 years). Women had higher prevalence rates of chronic obstructive pulmonary disease (P < 0.0001) and renal insufficiency (P = 0.03), whereas men had higher rates of cardiovascular comorbidities. The AAAs in women were smaller in diameter with shorter and more angulated necks. Women did not experience a significantly higher rate of endoleaks but did exhibit higher reintervention rates, including reintervention for device-related issues. In terms of mortality, aorta-related mortality was most prevalent within the first 30 days after procedure in both sexes. CONCLUSIONS Women were treated at an older age and had a more hostile aneurysmal anatomy. Although the mortality rates were lower in women, they had significantly higher rates of reintervention, and thus higher morbidity rates after endovascular aneurysm repair.
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Affiliation(s)
- Bibombe P Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia; Faculty of Medicine, School of Surgery, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.
| | - Tahmina Anwari
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Jackie Wong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Eric Verhoeven
- Department of Vascular and Endovascular Surgery, Paracelsus, Medical University, Nuremberg, Germany
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred, Sydney, Australia
| | - Jan M Heyligers
- Department of Vascular Surgery, University Medical Center Utrecht, Heidelberglaan, the Netherlands
| | - Ross Milner
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, GA
| | - Chiara Mascoli
- Department of Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - William P Shutze
- Division of Vascular Surgery, The Heart Hospital Baylor, Plano, TX
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22
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Systematic review and meta-analysis of sex differences in outcomes after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm. J Vasc Surg 2020; 71:283-296.e4. [DOI: 10.1016/j.jvs.2019.06.105] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022]
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23
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Aber A, Tong T, Chilcott J, Maheswaran R, Thomas SM, Nawaz S, Michaels J. Outcomes of aortic aneurysm surgery in England: a nationwide cohort study using hospital admissions data from 2002 to 2015. BMC Health Serv Res 2019; 19:988. [PMID: 31870354 PMCID: PMC6929362 DOI: 10.1186/s12913-019-4755-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 11/19/2019] [Indexed: 11/26/2022] Open
Abstract
Background The United Kingdom aortic aneurysms (AA) services have undergone reconfiguration to improve outcomes. The National Health Service collects data on all hospital admissions in England. The complex administrative datasets generated have the potential to be used to monitor activity and outcomes, however, there are challenges in using these data as they are primarily collected for administrative purposes. The aim of this study was to develop standardised algorithms with the support of a clinical consensus group to identify all AA activity, classify the AA management into clinically meaningful case mix groups and define outcome measures that could be used to compare outcomes among AA service providers. Methods In-patient data about aortic aneurysm (AA) admissions from the 2002/03 to 2014/15 were acquired. A stepwise approach, with input from a clinical consensus group, was used to identify relevant cases. The data is primarily coded into episodes, these were amalgamated to identify admissions; admissions were linked to understand patient pathways and index admissions. Cases were then divided into case-mix groups based upon examination of individually sampled and aggregate data. Consistent measures of outcome were developed, including length of stay, complications within the index admission, post-operative mortality and re-admission. Results Several issues were identified in the dataset including potential conflict in identifying emergency and elective cases and potential confusion if an inappropriate admission definition is used. Ninety six thousand seven hundred thirty-five patients were identified using the algorithms developed in this study to extract AA cases from Hospital episode statistics. From 2002 to 2015, 83,968 patients (87% of all cases identified) underwent repair for AA and 12,767 patients (13% of all cases identified) died in hospital without any AA repair. Six thousand three hundred twenty-nine patients (7.5%) had repair for complex AA and 77,639 (92.5%) had repair for infra-renal AA. Conclusion The proposed methods define homogeneous clinical groups and outcomes by combining administrative codes in the data. These methodologically robust methods can help examine outcomes associated with previous and current service provisions and aid future reconfiguration of aortic aneurysm surgery services.
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Affiliation(s)
- Ahmed Aber
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Thaison Tong
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jim Chilcott
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ravi Maheswaran
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steven M Thomas
- Sheffield Vascular Institute, Sheffied Teaching Hospitals, Sheffield, UK
| | - Shah Nawaz
- Sheffield Vascular Institute, Sheffied Teaching Hospitals, Sheffield, UK
| | - Jonathan Michaels
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Guirguis-Blake JM, Beil TL, Senger CA, Coppola EL. Primary Care Screening for Abdominal Aortic Aneurysm: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:2219-2238. [PMID: 31821436 DOI: 10.1001/jama.2019.17021] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%. OBJECTIVE To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019. STUDY SELECTION Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality. MAIN OUTCOMES AND MEASURES AAA and all-cause mortality; AAA rupture; treatment complications. RESULTS Fifty studies (N = 323 279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 [95% CI, 0.57-0.74]; 4 RCTs [n = 124 926]), AAA-related ruptures over 12 to 15 years (OR, 0.62 [95% CI, 0.55-0.70]; 4 RCTs [n = 124 929]), and emergency surgical procedures over 4 to 15 years (OR, 0.57 [95% CI, 0.48-0.68]; 5 RCTS [n = 175 085]). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 [95% CI 0.98-1.00]; 4 RCTs [n = 124 929]). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 [95% CI, 1.34-1.55]; 5 RCTs [n = 175 085]). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies [n = 14 424]) showed that women had higher surgical complications and postoperative mortality compared with men. CONCLUSIONS AND RELEVANCE One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.
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Affiliation(s)
- Janelle M Guirguis-Blake
- Department of Family Medicine, University of Washington, Tacoma
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Tracy L Beil
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Erin L Coppola
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research, Portland, Oregon
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Johal AS, Loftus IM, Boyle JR, Heikkila K, Waton S, Cromwell DA. Long-term survival after endovascular and open repair of unruptured abdominal aortic aneurysm. Br J Surg 2019; 106:1784-1793. [DOI: 10.1002/bjs.11215] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/07/2019] [Accepted: 03/24/2019] [Indexed: 11/10/2022]
Abstract
Abstract
Background
The aim of this study was to examine patterns of 10-year survival after elective repair of unruptured abdominal aortic aneurysms (AAAs) in different patient groups.
Methods
Patients having open repair or endovascular aneurysm repair (EVAR) in the English National Health Service between January 2006 and December 2015 were identified from Hospital Episode Statistics data. Postoperative survival among patients of different age and Royal College of Surgeons of England (RCS) modified Charlson co-morbidity score profiles were analysed using flexible parametric survival models. The relationship between patient characteristics and risk of rupture after repair was also analysed.
Results
Some 37 138 patients underwent elective AAA repair, of which 15 523 were open and 21 615 were endovascular. The 10-year mortality rate was 38·1 per cent for patients aged under 70 years, and the survival trajectories for open repair and EVAR were similar when patients had no RCS-modified Charlson co-morbidity. Among older patients or those with co-morbidity, the 10-year mortality rate rose, exceeding 70 per cent for patients aged 80 years. Mean survival times over 10 years for open repair and EVAR were often similar in subgroups of older and more co-morbid patients, but their survival trajectories became increasingly dissimilar, with open repair showing greater short-term risk within 6 months but lower 10-year mortality rates. The risk of rupture over 9 years was 3·4 per cent for EVAR and 0·9 per cent for open repair, and was weakly associated with patient factors.
Conclusion
Long-term survival patterns after elective open repair and EVAR for unruptured AAA vary markedly across patients with different age and co-morbidity profiles.
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Affiliation(s)
- A S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - I M Loftus
- St George's University Hospitals NHS Foundation Trust Vascular Institute, London, UK
| | - J R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Heikkila
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Indrakusuma R, Jalalzadeh H, Vahl AC, Koelemay MJW, Balm R. Editor's Choice - Sex Related Differences in Peri-operative Mortality after Elective Repair of an Asymptomatic Abdominal Aortic Aneurysm in the Netherlands: a Retrospective Analysis of 2013 to 2018. Eur J Vasc Endovasc Surg 2019; 58:813-820. [PMID: 31706741 DOI: 10.1016/j.ejvs.2019.05.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/27/2019] [Accepted: 05/22/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim was to compare peri-operative (30 day and/or in hospital) mortality between women and men in the Netherlands after elective repair of an asymptomatic abdominal aortic aneurysm (AAA). METHODS This was a retrospective study using data from the Dutch Surgical Aneurysm Audit (DSAA), a mandatory nationwide registry of patients undergoing AAA repair in the Netherlands. Patients who underwent elective open surgical (OSR) or endovascular aneurysm repair (EVAR) of an asymptomatic abdominal aortic aneurysm (AAA) between 2013 and 2018 were included. Absolute risk differences (ARDs) with 95% confidence intervals (CIs) in peri-operative mortality between women and men were estimated. Logistic regression analyses were performed to estimate adjusted odds ratios (ORs) for mortality. Confounders included pre-operative cardiac and pulmonary comorbidity, serum haemoglobin, serum creatinine, type of AAA repair, and AAA diameter. RESULTS Some 1662 women and 9637 men were included, of whom 507 (30.5%) women and 2056 (21.3%) men underwent OSR (p < .001). Crude peri-operative mortality was 3.01% in women and 1.60% in men (ARD = 1.41%, 95% CI 0.64-2.37). This significant difference was also observed for OSR (ARD = 2.63%, 95% CI 0.43-5.36), but not for EVAR (ARD = 0.36%, 95% CI -0.16 to 1.17). Female sex remained associated with peri-operative mortality after adjusting for confounders (OR = 1.79, 95% CI 1.20-2.65, p = .004), which was similarly observed for OSR (OR = 1.85, 95% CI 1.16-2.94, p = .01), but not for EVAR (OR = 1.46, 95% CI 0.72-2.95, p = .29). CONCLUSIONS Peri-operative mortality after elective repair of an asymptomatic AAA in the Netherlands is higher in women than in men. This disparity might be explained by the higher peri-operative mortality in women undergoing OSR, because no such difference was found in patients undergoing EVAR. Yet, it is likely that there are unaccounted factors at play since female sex remained significantly associated with mortality after adjusting for type of repair.
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Affiliation(s)
- Reza Indrakusuma
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Hamid Jalalzadeh
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Anco C Vahl
- OLVG, Department of Surgery, Amsterdam, the Netherlands
| | - Mark J W Koelemay
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Ron Balm
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
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Li B, Khan S, Salata K, Hussain MA, de Mestral C, Greco E, Aljabri BA, Forbes TL, Verma S, Al-Omran M. A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. J Vasc Surg 2019; 70:954-969.e30. [DOI: 10.1016/j.jvs.2019.01.076] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/11/2019] [Indexed: 01/09/2023]
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Thurston JS, Camara A, Alcasid N, White SB, Patel PJ, Rossi PJ, Hieb RE, Lee CJ. Outcomes and Cost Comparison of Percutaneous Endovascular Aortic Repair versus Endovascular Aortic Repair With Open Femoral Exposure. J Surg Res 2019; 240:124-129. [DOI: 10.1016/j.jss.2019.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/12/2019] [Accepted: 02/06/2019] [Indexed: 12/17/2022]
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Nicolini F, Vezzani A, Corradi F, Gherli R, Benassi F, Manca T, Gherli T. Gender differences in outcomes after aortic aneurysm surgery should foster further research to improve screening and prevention programmes. Eur J Prev Cardiol 2019; 25:32-41. [PMID: 29708035 DOI: 10.1177/2047487318759121] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Gender-related biases in outcomes after thoracic aortic surgery are an important factor to consider in the prevention of potential complications related to aortic diseases and in the analysis of surgical results. Methods The aim of this study is to provide an up-to-date review of gender-related differences in the epidemiology, specific risk factors, outcome, and screening and prevention programmes in aortic aneurysms. Results Female patients affected by aortic disease still have worse outcomes and higher early and late mortality than men. It is difficult to plan new specific strategies to improve outcomes in women undergoing major aortic surgery, given that the true explanations for their poorer outcomes are as yet not clearly identified. Some authors recommend further investigation of hormonal or molecular explanations for the sex differences in aortic disease. Others stress the need for quality improvement projects to quantify the preoperative risk in high-risk populations using non-invasive tests such as cardiopulmonary exercise testing. Conclusions The treatment of patients classified as high risk could thus be optimised before surgery becomes necessary by means of numerous strategies, such as the administration of high-dose statin therapy, antiplatelet treatment, optimal control of hypertension, lifestyle improvement with smoking cessation, weight loss and careful control of diabetes. Future efforts are needed to understand better the gender differences in the diagnosis, management and outcome of aortic aneurysm disease, and for appropriate and modern management of female patients.
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Affiliation(s)
| | - Antonella Vezzani
- 2 General and Specialistic Surgery Department, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Francesco Corradi
- 3 Anaesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Italy
| | - Riccardo Gherli
- 4 Department of Cardiovascular Sciences, San Camillo Forlanini Hospital, Italy
| | - Filippo Benassi
- 2 General and Specialistic Surgery Department, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Tullio Manca
- 2 General and Specialistic Surgery Department, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Tiziano Gherli
- 1 Department of Medicine and Surgery, University of Parma, Italy
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Thompson SG, Bown MJ, Glover MJ, Jones E, Masconi KL, Michaels JA, Powell JT, Ulug P, Sweeting MJ. Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation. Health Technol Assess 2019; 22:1-142. [PMID: 30132754 DOI: 10.3310/hta22430] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain. OBJECTIVE To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options. DESIGN A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses. SETTING Population screening in the UK. PARTICIPANTS Women aged ≥ 65 years, followed up to the age of 95 years. INTERVENTIONS Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs. MAIN OUTCOME MEASURES Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting. DATA SOURCES AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP). REVIEW METHODS Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters. RESULTS The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was -£12.03 (95% uncertainty interval -£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination. LIMITATIONS The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women. CONCLUSION The accepted criteria for a population-based AAA screening programme in women are not currently met. FUTURE WORK A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020444 and CRD42016043227. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Simon G Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew J Bown
- Department of Cardiovascular Sciences and National Institute of Health Research (NIHR) Leicester Biomedical Research Unit, University of Leicester, Leicester, UK
| | - Matthew J Glover
- Health Economics Research Group, Brunel University London, London, UK
| | - Edmund Jones
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katya L Masconi
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jonathan A Michaels
- Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Pinar Ulug
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Michael J Sweeting
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Sarcopenia predicts mortality and adverse outcomes after endovascular aneurysm repair and can be used to risk stratify patients. J Vasc Surg 2019; 70:1576-1584. [PMID: 30852041 DOI: 10.1016/j.jvs.2018.12.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/12/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is currently the most common treatment of abdominal aortic aneurysms. Potential predictors of long-term survival after EVAR include physiologic, functional, and cognitive status, but assessments of these conditions have been difficult to standardize. Objective radiographic findings, such as skeletal muscle atrophy, or sarcopenia, may provide an additional means for selection of patients. This study investigates sarcopenia as a method to predict 1-year survival in patients undergoing EVAR. METHODS A single-institution retrospective review was conducted of all patients who underwent elective EVAR from September 2002 to June 2014. Patients with an available periprocedural computed tomography (CT) scan and clinical data were included in the analysis. Normalized total psoas cross-sectional area (nTPA) was measured on axial CT images using the area of the bilateral psoas muscle at the third lumbar vertebral level normalized to the square of patient height. A threshold for optimal estimate of sarcopenia based on nTPA was determined using a receiver operating characteristic curve. Sarcopenia was evaluated as an independent risk predictor using univariate, multivariate, and survival analysis. RESULTS A total of 272 EVAR-treated patients were evaluated, including 237 men and 35 women with a median age of 72 years and mean body mass index of 28.6 kg/m2. There was a significant increase in overall mortality in patients in the lowest quartile of nTPA (Q1, 23.53%; Q2, 13.24%; Q3, 7.35%; Q4, 5.88%; P = .01). The estimated nTPA threshold for increased mortality after EVAR was 500 mm2/m2. Using this threshold, sarcopenia accounted for 57% of the risk effect in our 1-year survival model. CONCLUSIONS Sarcopenia can assist in identifying EVAR candidates who are less likely to benefit from surgery. It can be readily evaluated from preoperative CT scans and may be a useful tool in evaluation of abdominal aortic aneurysm patients with applications in risk evaluation and telemedicine.
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Anatomic predictors for late mortality after standard endovascular aneurysm repair. J Vasc Surg 2018; 69:1444-1451. [PMID: 30477942 DOI: 10.1016/j.jvs.2018.07.082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 07/29/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Abdominal aortic aneurysm (AAA) management involves a decision process that takes into account anatomic characteristics, surgical risks, patients' preferences, and expected survival. Whereas larger AAA diameter has been associated with increased mortality after both standard endovascular aneurysm repair (EVAR) and open repair, it is unclear whether survival after EVAR is influenced by other anatomic characteristics. The purpose of this study was to determine the importance of baseline anatomic features on survival after EVAR. METHODS All patients treated at a tertiary teaching center with EVAR for intact standard infrarenal AAA from 2000 to 2014 were included. The civil data registry was queried to determine survival status; causes of death were obtained from death certificates. The primary study end point was to determine the impact of baseline morphologic features on all-cause and cardiovascular mortality after EVAR. RESULTS This study included 404 EVAR patients (12.1% women; mean age, 73 years) with a median follow-up of 5.8 years (interquartile range, 3.1-7.4 years). The 5- and 10-year overall survival rates for the entire population after EVAR were 70% (95% confidence interval [CI], 66%-75%) and 43% (95% CI, 37%-50%), respectively. Only AAA diameter >70 mm (hazard ratio [HR], 1.75; 95% CI, 1.20-3.56) was identified as an independent anatomic predictor of all-cause mortality. Death due to cardiovascular causes occurred in 60 (38.5%) patients. Aneurysm-related mortality was responsible for six of the cardiovascular-related deaths. In multivariable analysis, both neck diameter ≥30 mm (HR, 2.16; 95% CI, 1.05-4.43) and AAA diameter >70 mm (HR, 2.45; 95% CI, 1.34-4.46) were identified as independent morphologic risk factors for cardiovascular mortality, whereas >25% circumferential neck thrombus (HR, 0.32; 95% CI, 0.13-0.77) was protective. CONCLUSIONS This study suggests that patients with AAA diameters >70 mm are at increased risk of all-cause and cardiovascular mortality. In addition, patients with infrarenal neck diameters ≥30 mm have a greater risk of cardiovascular mortality, although AAA-related deaths were not more frequent in this group of patients. Consequently, a more aggressive management of cardiovascular medical comorbidities may be warranted to improve survival after standard EVAR in these patients.
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Kühnl A, Erk A, Trenner M, Salvermoser M, Schmid V, Eckstein HH. Incidence, Treatment and Mortality in Patients with Abdominal Aortic Aneurysms. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:391-398. [PMID: 28655374 DOI: 10.3238/arztebl.2017.0391] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 12/16/2016] [Accepted: 03/16/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Aim of this study was to analyze hospital incidence, type of treatment, and hospital mortality rates of patients with abdominal aortic aneurysm (AAA) in Germany from 2005 to 2014. METHODS Microdata of the diagnosis-related group (DRG) statistics compiled by the German Federal Statistical Office for the years 2005-2014 were analyzed. Patients who were hospitalized for a ruptured AAA (rAAA, ICD-10 code I71.3, treated either surgically or conservatively) or received surgical treatment for an unruptured AAA (nrAAA, ICD-10-Code I71.4, treated either with open surgery or an endovascular procedure) were included in the analysis. The "European Standard Population 2013" was used for direct standardization of the hospital incidences. In-hospital mortality was calculated with standardization for age and risk. RESULTS The standardized overall hospital incidence of AAA was 27.9 and 3.3 cases per 100 000 people for men and women, respectively; over the period of the study, the incidence of rAAA fell by 30% in both sexes and that of nrAAA rose by 16% in men and 42% in women. The percentage of patients receiving endovascular treatment rose from 29% to 75% in patients with nrAAA and from 8% to 36% in patients with rAAA. The age- and risk-standardized in-hospital mortality of nrAAA was 3.3% in men and 5.3% in women. The in-hospital mortality of surgically treated rAAA was 39% in men and 48% in women. CONCLUSION The hospital incidence of AAA rose from 2005 to 2014, while that of rAAA fell. Endovascular treatment became more common for nrAAA as well as rAAA, and in-hospital mortality fell for both.
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Affiliation(s)
- Andreas Kühnl
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar, Technical University of Munich; Department of Statistics, Ludwig-Maximilians-University Munich
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Deery SE, Schermerhorn ML. Should Abdominal Aortic Aneurysms in Women be Repaired at a Lower Diameter Threshold? Vasc Endovascular Surg 2018; 52:543-547. [DOI: 10.1177/1538574418773247] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Abdominal aortic aneurysm (AAA) primarily affects male patients; however, female patients with AAA have a faster rate of aneurysm growth, have higher risk of rupture even at smaller diameters, and have worse outcomes following repair of ruptured and intact aneurysms. Furthermore, early natural history studies and randomized controlled trials evaluating surveillance versus repair in small aneurysms were conducted primarily in male patients. Therefore, there are limited data regarding the ideal threshold for elective repair of AAA in women, either by aortic diameter or by alternative measures. We review the existing literature regarding AAA in women and consider the most appropriate threshold for repair.
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Affiliation(s)
- Sarah E. Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Karthikesalingam A, Grima MJ, Holt PJ, Vidal-Diez A, Thompson MM, Wanhainen A, Bjorck M, Mani K. Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden. Br J Surg 2018; 105:520-528. [PMID: 29468657 PMCID: PMC5900926 DOI: 10.1002/bjs.10749] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/21/2017] [Accepted: 10/09/2017] [Indexed: 12/04/2022]
Abstract
Background There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non‐operative factors influence risk‐adjusted outcomes. This study compared 90‐day and 5‐year mortality for patients undergoing elective AAA repair in England and Sweden. Methods Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety‐day mortality and 5‐year survival were compared after adjustment for age and sex. Separate within‐country analyses were performed to examine the impact of co‐morbidity, hospital teaching status and hospital annual caseload. Results The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69–79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68–78) years, of whom 82·9 per cent were men. Ninety‐day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five‐year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates. Conclusion Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England. Improving in England
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Affiliation(s)
- A Karthikesalingam
- St George's Vascular Institute, St George's University of London, London, UK.,Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - M J Grima
- St George's Vascular Institute, St George's University of London, London, UK.,Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - P J Holt
- St George's Vascular Institute, St George's University of London, London, UK.,Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Vidal-Diez
- St George's Vascular Institute, St George's University of London, London, UK.,Population Health Research Institute, St George's University of London, London, UK
| | - M M Thompson
- St George's Vascular Institute, St George's University of London, London, UK
| | - A Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - M Bjorck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - K Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Robinet P, Milewicz DM, Cassis LA, Leeper NJ, Lu HS, Smith JD. Consideration of Sex Differences in Design and Reporting of Experimental Arterial Pathology Studies-Statement From ATVB Council. Arterioscler Thromb Vasc Biol 2018; 38:292-303. [PMID: 29301789 DOI: 10.1161/atvbaha.117.309524] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 12/20/2017] [Indexed: 12/15/2022]
Abstract
There are many differences in arterial diseases between men and women, including prevalence, clinical manifestations, treatments, and prognosis. The new policy of the National Institutes of Health, which requires the inclusion of sex as a biological variable for preclinical studies, aims to foster new mechanistic insights and to enhance our understanding of sex differences in human diseases. The purpose of this statement is to suggest guidelines for designing and reporting sex as a biological variable in animal models of atherosclerosis, thoracic and abdominal aortic aneurysms, and peripheral arterial disease. We briefly review sex differences of these human diseases and their animal models, followed by suggestions on experimental design and reporting of animal studies for these vascular pathologies.
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Affiliation(s)
- Peggy Robinet
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Dianna M Milewicz
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Lisa A Cassis
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Nicholas J Leeper
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Hong S Lu
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.)
| | - Jonathan D Smith
- From the Department of Cellular and Molecular Medicine, Cleveland Clinic, OH (P.R., J.D.S.); Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (D.M.M.); Department of Pharmacology and Nutritional Sciences (L.A.C.) and Saha Cardiovascular Research Center and Department of Physiology (H.S.L.), University of Kentucky, Lexington; and Division of Vascular Surgery, Department of Surgery, Stanford University, CA (N.J.L.).
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Villard C, Hultgren R. Abdominal aortic aneurysm: Sex differences. Maturitas 2017; 109:63-69. [PMID: 29452784 DOI: 10.1016/j.maturitas.2017.12.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysm (AAA) predominantly affects an elderly male population. Even so, AAA appears more detrimental in women, who experience a higher risk of aneurysm rupture and a worse outcome after surgery than men. Why women are privileged from yet are worse off once affected has been attributed to an effect of sex hormones. This review summarizes the knowledge of sex differences in AAA and addresses the changes in the aneurysm wall from a gender perspective. METHOD Standard reporting guidelines set by the PRISMA Group were followed to identify studies examining AAA from a gender perspective. Relevant reports were identified using two electronic databases: PubMed and Web of Science. The systematic search was performed in two stages: firstly, using the terms AAA and gender/sex/women; and secondly, adding the terms "elastin", "collagen" and "vascular smooth muscle cells", in order to filter the search for studies relevant to our focus on the aneurysm wall. CONCLUSION Current studies support the theory that sex has an effect on aneurysm formation, yet are inconclusive about whether or not aneurysm formation is dependent on female/male sex hormones or a lack thereof. The studies in women are scarce and out of those most reports primarily address other end-points, which limit their ability to illuminate an effect of sex on aneurysm formation. The complexity of the human menstrual cycle and menopausal transition are difficult to mimic in animal models, which limit their applicability to AAA formation in humans.
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Affiliation(s)
- Christina Villard
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Sidloff DA, Saratzis A, Sweeting MJ, Michaels J, Powell JT, Thompson SG, Bown MJ. Sex differences in mortality after abdominal aortic aneurysm repair in the UK. Br J Surg 2017; 104:1656-1664. [PMID: 28745403 PMCID: PMC5655705 DOI: 10.1002/bjs.10600] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/15/2017] [Accepted: 04/20/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND The UK abdominal aortic aneurysm (AAA) screening programmes currently invite only men for screening because the benefit in women is uncertain. Perioperative risk is critical in determining the effectiveness of screening, and contemporary estimates of these risks in women are lacking. The aim of this study was to compare mortality following AAA repair between women and men in the UK. METHODS Anonymized data from the UK National Vascular Registry (NVR) for patients undergoing AAA repair (January 2010 to December 2014) were analysed. Co-variables were extracted for analysis by sex. The primary outcome measure was in-hospital mortality. Secondary outcome measures included mortality by 5-year age groups and duration of hospital stay. Logistic regression was performed to adjust for age, calendar time, AAA diameter and smoking status. NVR-based outcomes were checked against Hospital Episode Statistics (HES) data. RESULTS A total of 23 245 patients were included (13·0 per cent women). Proportionally, more women than men underwent open repair. For elective open AAA repair, the in-hospital mortality rate was 6·9 per cent in women and 4·0 per cent in men (odds ratio (OR) 1·48, 95 per cent c.i. 1·08 to 2·02; P = 0·014), whereas for elective endovascular AAA repair it was 1·8 per cent in women and 0·7 per cent in men (OR 2·86, 1·72 to 4·74; P < 0·001); the results in HES were similar. For ruptured AAA, there was no sex difference in mortality within the NVR; however, in HES, for ruptured open AAA repair, the in-hospital mortality rate was higher in women (33·6 versus 27·1 per cent; OR 1·36, 1·16 to 1·59; P < 0·001). CONCLUSION Women have a higher in-hospital mortality rate than men after elective AAA repair even after adjustment. This higher mortality may have an impact on the benefit offered by any screening programme offered to women.
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Affiliation(s)
- D A Sidloff
- Vascular Surgery Group, Department of Cardiovascular Sciences and National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - A Saratzis
- Vascular Surgery Group, Department of Cardiovascular Sciences and National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - M J Sweeting
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - J Michaels
- Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - J T Powell
- Vascular Surgery Research Group, Imperial College, London, UK
| | - S G Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - M J Bown
- Vascular Surgery Group, Department of Cardiovascular Sciences and National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
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Ulug P, Sweeting MJ, von Allmen RS, Thompson SG, Powell JT. Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. Lancet 2017; 389:2482-2491. [PMID: 28455148 PMCID: PMC5483509 DOI: 10.1016/s0140-6736(17)30639-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prognosis for women with abdominal aortic aneurysm might be worse than the prognosis for men. We aimed to systematically quantify the differences in outcomes between men and women being assessed for repair of intact abdominal aortic aneurysm using data from study periods after the year 2000. METHODS In these systematic reviews and meta-analysis, we identified studies (randomised, cohort, or cross-sectional) by searching MEDLINE, Embase, CENTRAL, and grey literature published between Jan 1, 2005, and Sept 2, 2016, for two systematic reviews and Jan 1, 2009, and Sept 2, 2016, for one systematic review. Studies were included if they were of both men and women, with data presented for each sex separately, with abdominal aortic aneurysms being assessed for aneurysm repair by either endovascular repair (EVAR) or open repair. We conducted three reviews based on whether studies reported the proportion morphologically suitable (within manufacturers' instructions for use) for EVAR (EVAR suitability review), non-intervention rates (non-intervention review), and 30-day mortality (operative mortality review) after intact aneurysm repair. Studies had to include at least 20 women (for the EVAR suitability review), 20 women (for the non-intervention review), and 50 women (for the operative mortality review). Studies were excluded if they were review articles, editorials, letters, or case reports. For the operative review, studies were also excluded if they only provided hazard ratios or only reported in-hospital mortality. We assessed the quality of the studies using the Newcastle-Ottawa scoring system, and contacted authors for the provision of additional data if needed. We combined results across studies by random-effects meta-analysis. This study is registered with PROSPERO, number CRD42016043227. FINDINGS Five studies assessed the morphological eligibility for EVAR (1507 men, 400 women). The overall pooled proportion of women eligible (34%) for EVAR was lower than it was in men (54%; odds ratio [OR] 0·44, 95% CI 0·32-0·62). Four single-centre studies reported non-intervention rates (1365 men, 247 women). The overall pooled non-intervention rates were higher in women (34%) than men (19%; OR 2·27, 95% CI 1·21-4·23). The review of 30-day mortality included nine studies (52 018 men, 11 076 women). The overall pooled estimate for EVAR was higher in women (2·3%) than in men (1·4%; OR 1·67, 95% CI 1·38-2·04). The overall estimate for open repair also was higher in women (5·4%) than in men (2·8%; OR 1·76, 95% CI 1·35-2·30). INTERPRETATION Compared with men, a smaller proportion of women are eligible for EVAR, a higher proportion of women are not offered intervention, and operative mortality is much higher in women for both EVAR and open repair. The management of abdominal aortic aneurysm in women needs improvement. FUNDING National Institute for Health Research (UK).
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Affiliation(s)
- Pinar Ulug
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Regula S von Allmen
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK; Clinic for Vascular Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Simon G Thompson
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK.
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40
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Spiliotopoulos K, Price MD, Amarasekara HS, Green SY, Zhang Q, Preventza O, Coselli JS, LeMaire SA. Are outcomes of thoracoabdominal aortic aneurysm repair different in men versus women? A propensity-matched comparison. J Thorac Cardiovasc Surg 2017; 154:1203-1214.e6. [PMID: 28668459 DOI: 10.1016/j.jtcvs.2017.05.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 04/12/2017] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Women fare worse than men after many cardiovascular operations, including coronary artery bypass grafting and valve surgery. We sought to determine whether sex affects outcomes after open thoracoabdominal aortic aneurysm repair. METHODS We evaluated data on 3353 consecutive patients (1281 women, 38.2%) who underwent open thoracoabdominal aortic aneurysm repair between October 1986 and July 2015. We compared preoperative characteristics, surgical variables, and outcomes between men and women in the overall group. A propensity-matching analysis was performed to adjust for preoperative and intraoperative differences. A multivariable analysis was conducted to identify predictors of poor outcomes using relevant preoperative and intraoperative factors. RESULTS Men had a significantly higher prevalence of comorbid conditions, including coronary artery disease, and presented more often with dissection; women were slightly older than men (median age, 69 [62-74] years vs 67 [57-73] years; P < .001) and more often symptomatic. Men underwent extent II and IV repairs more often, whereas women more often had extent I and III repairs. The propensity analysis resulted in 958 matched pairs. Overall, women and men had similar early mortality (7.9% vs 7.2%, P = .5) and adverse event rates (14.8% vs 14.1%, P = .6), which were similar in propensity-matched groups. Multivariable analysis showed that predictors of operative death and adverse event differed between the sexes. Survival and freedom from repair failure were similar between the overall and matched groups. CONCLUSIONS Men and women who undergo thoracoabdominal aortic aneurysm repair have similar outcomes, but there are important differences in several perioperative factors and predictors of poor outcomes.
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Affiliation(s)
- Konstantinos Spiliotopoulos
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
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Lüscher TF. Outcomes of acute coronary syndromes: clinical presentation, gender, inflammation, and cell therapy. Eur Heart J 2017; 38:125-129. [PMID: 28158616 DOI: 10.1093/eurheartj/ehw676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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42
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Lüscher TF. Catheter-based and surgical interventions in cardiac and aortic conditions. Eur Heart J 2016; 37:3421-3424. [PMID: 28039217 DOI: 10.1093/eurheartj/ehw624] [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: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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Powell JT. Diverse Requirements for Efficient Population Screening for Abdominal Aortic Aneurysm: From Program Management to Maintaining Skills in Open Repair. Circulation 2016; 134:1149-1151. [PMID: 27754947 DOI: 10.1161/circulationaha.116.024916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Janet T Powell
- From Imperial College London, Vascular Surgery Research Group, Charing Cross Hospital, London, United Kingdom.
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