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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Lindholt JS, Søgaard R, Rasmussen LM, Mejldal A, Lambrechtsen J, Steffensen FH, Frost L, Egstrup K, Urbonaviciene G, Busk M, Diederichsen ACP. Five-Year Outcomes of the Danish Cardiovascular Screening (DANCAVAS) Trial. N Engl J Med 2022; 387:1385-1394. [PMID: 36027560 DOI: 10.1056/nejmoa2208681] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Limited data suggest a benefit of population-based screening for cardiovascular disease with respect to the risk of death. METHODS We performed a population-based, parallel-group, randomized, controlled trial involving men 65 to 74 years of age living in 15 Danish municipalities. The participants were randomly assigned in a 1:2 ratio to undergo screening (the invited group) or not to undergo screening (the control group) for subclinical cardiovascular disease. Randomization was based on computer-generated random numbers and stratified according to municipality. Only the control group was unaware of the trial-group assignments. Screening included noncontrast electrocardiography-gated computed tomography to determine the coronary-artery calcium score and to detect aneurysms and atrial fibrillation, ankle-brachial blood-pressure measurements to detect peripheral artery disease and hypertension, and a blood sample to detect diabetes mellitus and hypercholesterolemia. The primary outcome was death from any cause. RESULTS A total of 46,611 participants underwent randomization. After exclusion of 85 men who had died or emigrated before being invited to undergo screening, there were 16,736 men in the invited group and 29,790 men in the control group; 10,471 of the men in the invited group underwent screening (62.6%). In intention-to-treat analyses, after a median follow-up of 5.6 years, 2106 men (12.6%) in the invited group and 3915 men (13.1%) in the control group had died (hazard ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00; P = 0.06). The hazard ratio for stroke in the invited group, as compared with the control group, was 0.93 (95% CI, 0.86 to 0.99); for myocardial infarction, 0.91 (95% CI, 0.81 to 1.03); for aortic dissection, 0.95 (95% CI, 0.61 to 1.49); and for aortic rupture, 0.81 (95% CI, 0.49 to 1.35). There were no significant between-group differences in safety outcomes. CONCLUSIONS After more than 5 years, the invitation to undergo comprehensive cardiovascular screening did not significantly reduce the incidence of death from any cause among men 65 to 74 years of age. (Funded by the Southern Region of Denmark and others; DANCAVAS ISRCTN Registry number, ISRCTN12157806.).
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Affiliation(s)
- Jes S Lindholt
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Rikke Søgaard
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Lars M Rasmussen
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Anne Mejldal
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Jess Lambrechtsen
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Flemming H Steffensen
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Lars Frost
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Kenneth Egstrup
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Grazina Urbonaviciene
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Martin Busk
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
| | - Axel Cosmus Pyndt Diederichsen
- From the Departments of Cardiac, Thoracic, and Vascular Surgery (J.S.L., R.S.), Clinical Biochemistry and Pharmacology (L.M.R.), and Cardiology (A.C.P.D.), Elite Research Center for Individualized Medicine in Arterial Diseases, and the Open Patient Data Explorative Network (A.M.), Odense University Hospital, Clinical Institute, University of Southern Denmark (R.S.), Odense, the Department of Cardiology, Odense University Hospital, Svendborg (J.L., K.E.), the Department of Cardiology, Lillebaelt Hospital, Vejle (F.H.S., M.B.), and the Department of Cardiology, Diagnostic Center, Regional Hospital Silkeborg, Silkeborg (L.F., G.U.) - all in Denmark
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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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Akpan E, Kitundu J, Ekpo E. Public Health Radiography: A Scoping Review of Benefits, and Growth Opportunities for Radiographers. J Med Imaging Radiat Sci 2021; 52:615-625. [PMID: 34531164 DOI: 10.1016/j.jmir.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 06/17/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There is growing adoption of radiographic techniques in public health to improve outcomes of chronic and communicable diseases. This review examines the applications, benefits, and implications of radiography in public health. It also examines the challenges and potential advanced practice roles for radiographers in public health radiography (PHR). METHODOLOGY Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping review extension (PRISMA- ScR) checklist was employed, and the search was conducted using PubMed, Medline, Web of Science, ScienceDirect, and Google Scholar to identify relevant articles that explored the concept of radiography in public health. Evidence was analysed using an inductive iterative approach. RESULTS Radiographic imaging modalities such as ultrasound, computed tomography, and plain X-ray had wide applicability in public health fields of preventive cardiology, preventive oncology, maternal health, infectious disease epidemiology, and radiographic informatics. PHR effectively reduced mortality, improved outcomes, informed lifestyle changes to mitigate the risk of impending disease. PHR also helped in monitoring disease progression and predicting treatment outcomes. However, evidence establishing a competency framework that supports PHR is scarce. CONCLUSION Radiography makes a significant contribution to public health in reducing mortality and morbidity. Therefore, developing a PHR competency framework can accentuate the contribution Radiographers make to solving public health issues.
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Affiliation(s)
- Eyo Akpan
- Grayscale International Ltd, Lagos, Nigeria.
| | - Jane Kitundu
- Vijibweni District Hospital, Kigamboni Municipal, Dar es Salaam, Tanzania
| | - Ernest Ekpo
- Image Optimisation and Perception Group, Discipline of Medical Imaging Science, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Cumberland Campus C42
- 75 East Street, Lidcombe, NS, W
- 2141
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Long Term Outcome of Screen Detected Sub-Aneurysmal Aortas in 65 Year Old Men: a Single Scan After Five Years Identifies Those at Risk of Needing AAA Repair. Eur J Vasc Endovasc Surg 2021; 62:380-386. [PMID: 34362628 DOI: 10.1016/j.ejvs.2021.05.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The epidemiology of sub-aneurysmal aortic dilatation (SAA) 25 - 29 mm is not fully understood, and the management of SAA is debated. Lack of evidence is particularly problematic in the screening setting. This study aimed to evaluate the long term outcome of men with screen detected SAAs, focusing on progression to an abdominal aortic aneurysm (AAA), and on the AAAs reaching the threshold diameter for surgical repair. METHODS Between 2006 and 2015, all 65 year old men with a screen detected SAA in middle Sweden were re-examined with ultrasound after five and 10 years. The primary outcomes were expansion to AAA ≥ 30 mm and progression to AAA ≥ 55 mm. Secondary outcomes were risk factors for progression, repair rate, and mortality. RESULTS A total of 1 020 65 year old men with a SAA were identified, of whom 940 (92.2%; 95% confidence interval 91.0 - 93.8) had follow up. The Kaplan-Meier estimated incidence of AAA ≥ 30 mm development after the five year follow up (which was de facto carried out after a mean of 4.9 years) was 65.8% (61.6 - 69.4), all < 55 mm. The corresponding KM-estimated incidence after the 10 year follow up (carried out after a mean of 11.9 years) was 95.1% (90.1 - 97.4), and 29.7% (18.0 - 39.7) reached ≥ 55 mm. All 41 SAAs eventually expanding to ≥ 55 mm were ≥ 30 mm at the five year follow up. Of these, 32 had surgical repair with 100% survival, six have scheduled repairs, and three (7.3%) were unfit for repair. The KM estimated all cause mortality rates at five and 10 years were 7.0% and 17.9%, respectively, with no proven AAA related deaths. CONCLUSION A majority of SAAs eventually progress to an AAA, of which 30% are estimated to eventually reach the threshold for repair within 10 years. A follow up policy with an ultrasound examination after five years can safely and effectively identify those SAAs at risk of developing into clinically significant AAAs needing repair and may be considered for anyone with reasonably good life expectancy.
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Earnshaw JJ, Lindholt J. Effective, But Will It Be Cost Effective? Eur J Vasc Endovasc Surg 2021; 62:387. [PMID: 34362629 DOI: 10.1016/j.ejvs.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Affiliation(s)
| | - Jes Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark; Vascular Research Unit, Viborg Hospital, Clinical Institute, Aarhus University, Aarhus, Denmark
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Affiliation(s)
- Jes Sanddal Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Elitary Research Centre for Individualized Medicine in Arterial Disease (CIMA), University of Southern Denmark, Odense, Denmark
| | - Rikke Søgaard
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Elitary Research Centre for Individualized Medicine in Arterial Disease (CIMA), University of Southern Denmark, Odense, Denmark
- Advisory Board Regarding the National Screening Programmes, Danish National Board of Health, Copenhagen, Denmark
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FitÉ J, Gimenez E, Soto B, Artigas V, Escudero JR, Bellmunt-Montoya S, Espallargues M. Systematic review on abdominal aortic aneurysm screening cost-efficiency and methodological quality assessment. INT ANGIOL 2020; 40:67-76. [PMID: 33086780 DOI: 10.23736/s0392-9590.20.04547-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) is a silent, progressive disease that can lead to death. It is easily diagnosed with noninvasive methods and its routine treatment has excellent results. This creates an optimal situation for population screening programs. The aim of this paper was to assess results and methodological quality of cost-utility studies on screening versus no screening scenarios for AAA to assess future establishment of new AAA screening programs. EVIDENCE ACQUISITON A systematic review of efficiency (cost-effectiveness and cost-utility) studies was performed, finally selecting cost-utility studies on AAA screening versus no screening. Papers were selected that dealt with efficiency of screening for AAA according to PICOTS framework and the methodological quality assessed according to the economic evaluation analyses described by Drummond and Caro. Two independent reviewers were involved in the procedure. EVIDENCE SYNTHESIS Research retrieved 88 studies. From those, 26 showed cost-effectiveness and cost-utility results. Finally, 10 studies had cost-utility results and suited criteria (published in the last 10 years; time-horizon: 10 years or more) for exhaustive analysis. All publications, except one, showed adequate incremental cost-utility ratios according to different national perspectives. Methodological assessment showed some quality limitations, but the majority of items analyzed were favorably answered after applying the questionnaires. CONCLUSIONS Confirmation of the cost-utility results in this revision at a national/regional level should be the basis for the implantation of new national screening programs worldwide. The methodological evaluation applied in this revision is crucial for the corresponding future piggy-back trials to assess routine application of national AAA screening programs.
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Affiliation(s)
- Joan FitÉ
- Centro de Investigación Biomédica en Red (CIBER) Cardiovascular, Department of Vascular Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Emmanuel Gimenez
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Generalitat de Catalunya, Barcelona, Spain
| | - Begoña Soto
- Centro de Investigación Biomédica en Red (CIBER) Cardiovascular, Department of Vascular Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Vicente Artigas
- Centro de Investigación Biomédica en Red (CIBER) Cardiovascular, Department of Vascular Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jose R Escudero
- Centro de Investigación Biomédica en Red (CIBER) Cardiovascular, Department of Vascular Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Sergi Bellmunt-Montoya
- Universitat Autónoma de Barcelona, Barcelona, Spain - .,Department of Vascular Surgery, Hospital Universitari Vall d'Hebron, University of Barcelona, Barcelona, Spain
| | - Mireia Espallargues
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Generalitat de Catalunya, Barcelona, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
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Reile R, Võrno T, Kals J, Ilves P, Kiivet RA. The Cost-Effectiveness of Abdominal Aortic Aneurysm Screening in Estonia. Value Health Reg Issues 2020; 22:1-6. [DOI: 10.1016/j.vhri.2019.08.477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 08/21/2019] [Accepted: 08/31/2019] [Indexed: 10/25/2022]
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Lindholt JS, Diederichsen AC, Rasmussen LM, Frost L, Steffensen FH, Lambrechtsen J, Urbonaviciene G, Busk M, Egstrup K, Kristensen KL, Behr Andersen C, Søgaard R. Survival, Prevalence, Progression and Repair of Abdominal Aortic Aneurysms: Results from Three Randomised Controlled Screening Trials Over Three Decades. Clin Epidemiol 2020; 12:95-103. [PMID: 32158272 PMCID: PMC6986168 DOI: 10.2147/clep.s238502] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/10/2020] [Indexed: 11/26/2022] Open
Abstract
Aim The prevalence and mortality of abdominal aortic aneurysms (AAA) has been reported to decline. The aim of this study is to compare survival, prevalence, and repair rate of AAA in Denmark in the 1990s, the 2000s and the 2010s – and to examine any change in factors known to influence the prevalence. Methods Baseline status and up to 5-year outcomes of 34,079 general population men aged 65–74 were obtained from three RCTs; the Viborg study (1994–1998, n=4,860), the Viborg Vascular (VIVA) trial (2008–2011, n=18,748), and the Danish Cardiovascular (DANCAVAS) trial (2015–2018, n=10,471). After the millennium (VIVA and DANCAVAS) men with AAA were further offered low dose aspirin and statins. Follow-up data were not available for the DANCAVAS trial yet. Results Across the three decades, the AAA prevalence was 3.8% (Reference), 3.3% (p<0.001) and 4.2% (p=0.882), the proportion of smokers were 62%, 42% and 34% (p<0.001) amongst men with AAA, but AAA risk associations with smoking increased during the decades suggesting increased tobacco consumption of smokers. In addition, the proportions of attenders with ischemic heart disease or stroke increased significantly. The aneurysmal progression rate in the 1990s was 2.90 vs 2.98 mm/year in the 2000s (p=0.91). The need for preventive AAA repair increased insignificantly in the 2000s (Age adj. HR= 1.29, 95% C.I.: 0.95; 1.71, p=0.10), and mortality of men with screen-detected AAA was lower in the 2000s compared to the 1990s (Age-adj. HR= 0.28, 95% C.I.: 0.22; 0.36, p<0.001). Conclusion The Danish prevalence of AAA today compares to the nineties. Unchanged aneurysmal progression rates combined with improved survival of men at risk of AAA leave them in longer time to develop an AAA, be diagnosed and to need later aneurysmal repair or experience rupture. Clinical Trial Registrations Viborg study: No possibility of registration in the nineties. VIVA: NCT00662480, URL: https://clinicaltrials.gov/show/NCT00662480, DANCAVAS: ISRCTN12157806, URL: http://www.isrctn.com/ISRCTN12157806.
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Affiliation(s)
- Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark.,Elitary Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense, Denmark.,Department of Vascular Surgery, Viborg Hospital, Viborg, Denmark
| | - Axel C Diederichsen
- Elitary Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Lars M Rasmussen
- Elitary Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense, Denmark.,Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Lars Frost
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Grazina Urbonaviciene
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Martin Busk
- Department of Cardiology, University Hospital Odense Svendborg, Svendborg, Denmark
| | | | - Katrine L Kristensen
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark.,Elitary Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense, Denmark.,Department of Vascular Surgery, Viborg Hospital, Viborg, Denmark
| | | | - Rikke Søgaard
- Department of Public Health and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Thorbjørnsen K, Svensjö S, Djavani Gidlund K, Gilgen NP, Wanhainen A. Prevalence and natural history of and risk factors for subaneurysmal aorta among 65-year-old men. Ups J Med Sci 2019; 124:180-186. [PMID: 31460822 PMCID: PMC6758690 DOI: 10.1080/03009734.2019.1648611] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: The aims of this study were to determine the prevalence of screening-detected subaneurysmal aorta (SAA), i.e. an aortic diameter of 2.5-2.9 cm, its associated risk factors, and natural history among 65-year-old men. Methods: A total of 14,620 men had their abdominal aortas screened with ultrasound and completed a health questionnaire containing information on smoking habits and medical history. They were categorized based on the aortic diameter: normal aorta (<2.5 cm; n = 14,129), SAA (2.5-2.9 cm; n = 258), and abdominal aortic aneurysm (AAA) (≥3.0 cm; n = 233). The SAA-group was rescanned after 5 years. Associated risk factors were analyzed. Results: The SAA-prevalence was 1.9% (95% confidence interval 1.7%-2.1%), with 57.0% (50.7%-63.3%) expanding to ≥3.0 cm within 5 years. Frequency of smoking, coronary artery disease, hypertension, hyperlipidemia, and claudication were significantly higher in those with SAA and AAA compared to those with normal aortic diameter. Current smoking was the strongest risk factor for SAA (odds ratio [OR] 2.8; P < 0.001) and even stronger for AAA (OR 3.6; P < 0.001). Men with SAA expanding to AAA within 5 years presented pronounced similarities to AAA at baseline. Conclusions: Men with SAA and AAA presented marked similarities in the risk factor profile. Smoking was the strongest risk factor with an incremental association with disease severity, and disease progression. This indicates that SAA and AAA may have the same pathophysiological origin and that SAA should be considered as an early stage of aneurysm formation. Further research on the cost-effectiveness and potential benefits of surveillance as well as smoking cessation and secondary cardiovascular prevention in this subgroup is warranted.
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Affiliation(s)
- Knut Thorbjørnsen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Centre for Research and Development, Uppsala University/County Council of Gävleborg, Gävle, Sweden
- CONTACT Knut Thorbjørnsen Centre for Research and Development, Uppsala University/County Council of Gävleborg, 80188 Gävle, Sweden
| | - Sverker Svensjö
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgery, Falun County Hospital, Falun, Sweden
| | - Khatereh Djavani Gidlund
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Centre for Research and Development, Uppsala University/County Council of Gävleborg, Gävle, Sweden
| | - Nils-Peter Gilgen
- Department of Surgery, Eskilstuna County Hospital, Eskilstuna, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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12
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Nair N, Kvizhinadze G, Jones GT, Rush R, Khashram M, Roake J, Blakely A. Health gains, costs and cost-effectiveness of a population-based screening programme for abdominal aortic aneurysms. Br J Surg 2019; 106:1043-1054. [PMID: 31115915 DOI: 10.1002/bjs.11169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/24/2018] [Accepted: 02/12/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) rupture carries a high fatality rate. AAAs can be detected before rupture by abdominal ultrasound imaging, allowing elective repair. Population-based screening for AAA in older men reduces AAA-related mortality by about 40 per cent. The UK began an AAA screening programme offering one-off scans to men aged 65 years in 2009. Sweden has a similar programme. Currently, there is no AAA screening programme in New Zealand. This cost-utility analysis aimed to assess the cost-effectiveness of a UK-style screening programme in the New Zealand setting. METHODS The analysis compared a formal AAA screening programme (one-off abdominal ultrasound imaging for about 20 000 men aged 65 years in 2011) with no systematic screening. A Markov macrosimulation model was adapted to estimate the health gains (in quality-adjusted life-years, QALYs), health system costs and cost-effectiveness in New Zealand. A health system perspective and lifetime horizon was adopted. RESULTS With New Zealand-specific inputs, the adapted model produced an estimate of about NZ $15 300 (€7746) per QALY gained, with a 95 per cent uncertainty interval (UI) of NZ $8700 to 31 000 (€4405 to 15 694) per QALY gained. Health gains were estimated at 117 (95 per cent UI 53 to 212) QALYs. Health system costs were NZ $1·68 million (€850 535), with a 95 per cent UI of NZ $820 200 to 3·24 million (€415 243 to €1·65 million). CONCLUSION Using New Zealand's gross domestic product per capita (about NZ $45 000 or €22 100) as a cost-effectiveness threshold, a UK-style AAA screening programme would be cost-effective in New Zealand.
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Affiliation(s)
- N Nair
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
| | - G Kvizhinadze
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
| | - G T Jones
- Vascular Research Group, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - R Rush
- Waitemata District Health Board, University of Auckland, Auckland, New Zealand
| | - M Khashram
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - J Roake
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - A Blakely
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, New Zealand
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13
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Lindholt JS, Rasmussen LM, Søgaard R, Lambrechtsen J, Steffensen FH, Frost L, Egstrup K, Urbonaviciene G, Busk M, Olsen MH, Hallas J, Diederichsen AC. Baseline findings of the population-based, randomized, multifaceted Danish cardiovascular screening trial (DANCAVAS) of men aged 65–74 years. Br J Surg 2019; 106:862-871. [DOI: 10.1002/bjs.11135] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 12/24/2022]
Abstract
Abstract
Background
The challenge of managing age-related diseases is increasing; routine checks by the general practitioner do not reduce cardiovascular mortality. The aim here was to reduce cardiovascular mortality by advanced population-based cardiovascular screening. The present article reports the organization of the study, the acceptability of the screening offer, and the relevance of multifaceted screening for prevention and management of cardiovascular disease.
Methods
Danish men aged 65–74 years were invited randomly (1 : 2) to a cardiovascular screening examination using low-dose non-contrast CT, ankle and brachial BP measurements, and blood tests.
Results
In all, 16 768 of 47 322 men aged 65–74 years were invited and 10 471 attended (uptake 62·4 per cent). Of these, 3481 (33·2 per cent) had a coronary artery calcium score above 400 units. Thoracic aortic aneurysm was diagnosed in the ascending aorta (diameter 45 mm or greater) in 468 men (4·5 per cent), in the arch (at least 40 mm) in 48 (0·5 per cent) and in the descending aorta (35 mm or more) in 233 (2·2 per cent). Abdominal aortic aneurysm (at least 30 mm) and iliac aneurysm (20 mm or greater) were diagnosed in 533 (5·1 per cent) and 239 (2·3 per cent) men respectively. Peripheral artery disease was diagnosed in 1147 men (11·0 per cent), potentially uncontrolled hypertension (at least 160/100 mmHg) in 835 (8·0 per cent), previously unknown atrial fibrillation confirmed by ECG in 50 (0·5 per cent), previously unknown diabetes mellitus in 180 (1·7 per cent) and isolated severe hyperlipidaemia in 48 men (0·5 per cent).
In all, 4387 men (41·9 per cent), excluding those with potentially uncontrolled hypertension, were referred for additional cardiovascular prevention. Of these, 3712 (35·5 per cent of all screened men, but 84·6 per cent of those referred) consented and were started on medication.
Conclusion
Multifaceted cardiovascular screening is feasible and may optimize cardiovascular disease prevention in men aged 65–74 years. Uptake is lower than in aortic aneurysm screening.
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Affiliation(s)
- J S Lindholt
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - L M Rasmussen
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - R Søgaard
- Department of Public Health and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - J Lambrechtsen
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark
| | - F H Steffensen
- Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark
| | - L Frost
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark
| | - K Egstrup
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark
| | - G Urbonaviciene
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark
| | - M Busk
- Department of Cardiology, Lillebaelt Hospital, Vejle, Denmark
| | - M H Olsen
- CIMA, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - J Hallas
- Institute of Pharmacology, University of Southern Denmark, Odense, Denmark
| | - A C Diederichsen
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Cardiology, Odense University Hospital, Odense, Denmark
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14
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Abdominal Aortic Aneurysm Screening: A Systematic Review and Meta-analysis of Efficacy and Cost. Ann Vasc Surg 2019; 54:298-303.e3. [DOI: 10.1016/j.avsg.2018.05.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/05/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
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15
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Koshty A, Bork M, Böning A, Gündüz D, Pleger SP. Coronary Artery Disease as a Relevant Risk Factor in Screening of Abdominal Aortic Ectasia and Aneurysm. Thorac Cardiovasc Surg 2018; 69:57-62. [PMID: 30572367 DOI: 10.1055/s-0038-1676336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of this study was to investigate the prevalence of abdominal aortic aneurysm (AAA) and abdominal aortic ectasia (AAE) in coronary artery disease (CAD) patients in a multicenter setting to obtain significant data to establish an AAA screening program in our departments. METHODS Between January and September 2016, 500 patients with suspected or diagnosed CAD planned for coronary angiography or coronary artery bypass graft (CABG) underwent a sonographic examination of the infrarenal abdominal aorta to diagnose AAA or AAE. We calculated the prevalence of AAA and AAE in patients diagnosed of CAD and investigated factors potentially associated with the occurrence of AAA. RESULTS The overall prevalence in all grades of CAD for AAE was 35.1% and for AAA 5.4%. In patients with three-vessel CAD, the prevalence of AAE was 34% and of AAA 6.8%. Significant correlation was found between the three-vessel CAD and AAA (p = 0.039). The logistic regression analysis showed significant correlation between AAA and age > 65 years (p = 0.05). The multivariate analysis of risk factors and CAD revealed significant correlations between one-vessel CAD and arterial hypertension (AH) (p = 0.004) and age > 65 years (p = 0.001) as well as between three-vessel CAD and AH (p = 0.01), peripheral artery disease (p = 0.01), and age > 65 years (p = 0.03). CONCLUSION Our results confirm, that in comparison to other data, the prevalence of AAA in patients with CAD is high. Thus, it is recommended to include patients with CAD, especially elderly patients with three-vessel CAD, in future AAA screening programs.
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Affiliation(s)
- Ahmed Koshty
- Department of Vascular Surgery, Evangelisches Jung Stilling Krankenhaus GmbH, Siegen, Nordrhein-Westfalen, Germany
| | - Magdalena Bork
- Department of Cardiovascular Surgery, University Hospital Giessen, Justus Liebig University Giessen, Giessen, Germany.,Department of Cardiology and Angiology, Universitatsklinikum Giessen und Marburg, Standort Marburg, Giessen, Hessen, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Dursun Gündüz
- Department of Cardiology and Angiology, Universitatsklinikum Giessen und Marburg, Standort Marburg, Giessen, Hessen, Germany.,Department of Cardiology and Angiology, Evangelisches Jung Stilling Krankenhaus GmbH, Siegen, Nordrhein-Westfalen, Germany
| | - Sebastian Paul Pleger
- Department of Vascular Surgery, Evangelisches Jung Stilling Krankenhaus GmbH, Siegen, Nordrhein-Westfalen, Germany
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16
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Sánchez Barrancos IM, Guerrero García FJ, Rico López MDC, Fernández Rodríguez V, Vegas Jiménez T, Alonso Roca R, Domínguez Tristancho D. [Usefulness and reliability of abdominal point of care ultrasound in family practice (2): Large abdominal vessels, spleen, nephrourological and gynecological ultrasound]. Aten Primaria 2018; 50:430-442. [PMID: 29858122 PMCID: PMC6837077 DOI: 10.1016/j.aprim.2018.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/26/2018] [Indexed: 10/28/2022] Open
Abstract
This article is a continuation of the review initiated in the previous issue about the usefulness of point of care ultrasound in Primary Care, completing the scenarios of large abdominal vessels, spleen, nephrourological and gynecological ultrasound.
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Affiliation(s)
- Ignacio Manuel Sánchez Barrancos
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Consultorio local de Membrilla, Centro de Salud Manzanares 2, Gerencia de Atención Integrada de Manzanares, Ciudad Real, España.
| | - Francisco José Guerrero García
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Unidad de Gestión Clínica Gran Capitán, Distrito Sanitario Granada Metropolitano, Granada, España
| | - María Del Carmen Rico López
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro Médico Adeslas, Almería, España
| | - Vicente Fernández Rodríguez
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Os Rosales, Estructura Organizativa de Xestión Integrada, A Coruña, España
| | - Tomás Vegas Jiménez
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud San Fernando, Gerencia de Atención Primaria de Badajoz, Badajoz, España
| | - Rafael Alonso Roca
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Mar Báltico, Área Este, Madrid, España
| | - Daniel Domínguez Tristancho
- Médico especialista en Medicina Familiar y Comunitaria; Miembro del Grupo de Trabajo de Ecografía, Sociedad Española de Medicina Familiar y Comunitaria; Centro de Salud Santa Marta de los Barros, Gerencia de Atención Primaria de Badajoz, Badajoz, España
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17
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Wang LJ, Prabhakar AM, Kwolek CJ. Current status of the treatment of infrarenal abdominal aortic aneurysms. Cardiovasc Diagn Ther 2018; 8:S191-S199. [PMID: 29850431 DOI: 10.21037/cdt.2017.10.01] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aortic aneurysms are the 13th leading cause of death in the United States. While aneurysms can occur along the entire length of the aorta, the infrarenal location is the most common. Targeted ultrasound screening has been found to be an effective and economical means of preventing aortic aneurysm rupture. The indication for repair includes either symptomatic aneurysms or aneurysms with a diameter greater than 5.4 cm. Treatment options for the repair of infrarenal aortic aneurysms are open surgical repair (OSR) and endovascular aneurysm repair (EVAR). Currently, EVAR is the primary treatment method for the repair of infrarenal aortic aneurysms due to improved short-term morbidity and mortality outcomes. This article is intended to review the current status of the management of infrarenal abdominal aortic aneurysms (AAA).
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Affiliation(s)
- Linda J Wang
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand M Prabhakar
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Kwolek
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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18
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Dahl M, Søgaard R, Frost L, Høgh A, Lindholt J. Effectiveness of Screening Postmenopausal Women for Cardiovascular Diseases: A Population Based, Prospective Parallel Cohort Study. Eur J Vasc Endovasc Surg 2018; 55:721-729. [DOI: 10.1016/j.ejvs.2018.02.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
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19
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Søgaard R, Lindholt JS. Cost-effectiveness of population-based vascular disease screening and intervention in men from the Viborg Vascular (VIVA) trial. Br J Surg 2018; 105:1283-1293. [DOI: 10.1002/bjs.10872] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/22/2018] [Accepted: 03/08/2018] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Population-based screening and intervention for abdominal aortic aneurysm, peripheral artery disease and hypertension was recently reported to reduce the relative risk of mortality among Danish men by 7 per cent. The aim of this study was to investigate the cost-effectiveness of vascular screening versus usual care (ad hoc primary care-based risk assessment) from a national health service perspective.
Methods
A cost-effectiveness evaluation was conducted alongside an RCT involving all men from a region in Denmark (50 156) who were allocated to screening (25 078) or no screening (25 078) and followed for up to 5 years. Mobile nurse teams provided screening locally and, for individuals with positive test results, referrals were made to general practices or hospital-based specialized centres for vascular surgery. Intention-to-treat-based, censoring-adjusted incremental costs (2014 euros), life-years and quality-adjusted life-years (QALYs) were estimated using Lin's average estimator method. Incremental net benefit was estimated using Willan's estimator and sensitivity analyses were conducted.
Results
The cost of screening was estimated at €148 (95 per cent c.i. 126 to 169), and the effectiveness at 0·022 (95 per cent c.i. 0·006 to 0·038) life-years and 0·069 (0·054 to 0·083) QALYs, generating average costs of €6872 per life-year and €2148 per QALY. At a willingness-to-pay threshold of €40 000 per QALY, the probabilities of cost-effectiveness were 98 and 99 per cent respectively. The probability of cost-effectiveness was 71 per cent when all the sensitivity analyses were combined into one conservative scenario.
Conclusion
Vascular screening appears to be cost-effective and compares favourably with current screening programmes.
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Affiliation(s)
- R Søgaard
- Departments of Public Health and Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - J S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, and Department of Vascular Surgery, Viborg Hospital, Viborg, Denmark
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20
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Dahl M, Frost L, Søgaard R, Klausen IC, Lorentzen V, Lindholt J. A population-based screening study for cardiovascular diseases and diabetes in Danish postmenopausal women: acceptability and prevalence. BMC Cardiovasc Disord 2018; 18:20. [PMID: 29402233 PMCID: PMC5800093 DOI: 10.1186/s12872-018-0758-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reducing women's cardiovascular risk and the economic costs associated with cardiovascular diseases (CVD) and diabetes (DM) continues to be a challenge. Whether a multifaceted CVD screening programme is beneficial as a preventive strategy in women remains uncertain. The aim of this study was to investigate the prevalence of CVD and DM as well as the acceptability toward screening and preventive actions. METHODS An observational study was performed among all women born in 1936, 1941, 1946 and 1951 living in Viborg Municipality, Denmark, from October 2011. In total, 1984 were invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension (HT), atrial fibrillation (AF), DM and dyslipidaemia. Participants with positive tests were offered prophylactic intervention including follow-up consultations in case of AAA, PAD and/or CP. Participants with AAA ≥ 50 mm were referred to specialists in vascular surgery. Women with AF or potential familial hypercholesterolaemia (FH) were referred to cardiology work-up. RESULTS Among those invited, 1474 (74.3%) attended screening, but the attendees' share decreased with increasing age groups (p < 0.001). AAA was diagnosed in 10 (0.7%) women, PAD in 101 (6.9%) and CP in 602 (40.8%). The percentage of women with these conditions rose with increasing age group (p < 0.05). Unconfirmed potential HT was observed in 94 (6.4%), unknown AF in 6 (0.4%), DM in 14 (1%) and potential FH in 35 (2.4%). None of these findings differed across age groups. Among the 631 women diagnosed with AAA, PAD and/or CP, 182 (28.8%) were already in antiplatelet and 223 (35.3%) in lipid-lowering therapy prior to screening. Antiplatelet therapy was initiated in 215 (34.1%) and lipid-lowering therapy in 191 (30.3%) women. Initiation of antiplatelet and lipid-lowering therapy was further recommended to 134 (21.2%) and 141 (22.4%) women, respectively, who hesitated to follow the recommendation. CONCLUSIONS The study recorded an acceptable total attendance rate, even though a significantly lower attendance rate was observed in the eldest women. The identified hesitation towards prophylactic therapy may affect the rationale and effectiveness of CVD screening, and hesitation seems a critical issue that should be addressed in the design of future screening programmes.
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Affiliation(s)
- Marie Dahl
- Cardiovascular Research Centre, Regional Hospital Central Denmark, Heibergs Allé 4, 8800, Viborg, Denmark. .,Department of Clinical Medicine, Aarhus University, 8000, Aarhus, Denmark.
| | - Lars Frost
- Cardiovascular Research Centre, Regional Hospital Central Denmark, Heibergs Allé 4, 8800, Viborg, Denmark
| | - Rikke Søgaard
- Department of Public Health and Department of Clinical Medicine, Aarhus University, 8000, Aarhus, Denmark
| | - Ib Christian Klausen
- Cardiovascular Research Centre, Regional Hospital Central Denmark, Heibergs Allé 4, 8800, Viborg, Denmark
| | - Vibeke Lorentzen
- Cardiovascular Research Centre, Regional Hospital Central Denmark, Heibergs Allé 4, 8800, Viborg, Denmark.,Centre for Research in Clinical Nursing, Viborg, Denmark
| | - Jes Lindholt
- Cardiovascular Research Centre, Regional Hospital Central Denmark, Heibergs Allé 4, 8800, Viborg, Denmark.,Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, 5000 , Odense, Denmark
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21
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Badger S, Forster R, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. Cochrane Database Syst Rev 2017; 5:CD005261. [PMID: 28548204 PMCID: PMC6481849 DOI: 10.1002/14651858.cd005261.pub4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) is a condition that can occur as a person ages. It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. Endovascular aneurysm repair (EVAR), a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition. This is an update of the review first published in 2006. OBJECTIVES To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality, major complication rates, aneurysm exclusion (specifically endoleaks in the eEVAR treatment group), and late complications. SEARCH METHODS For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched June 2016), CENTRAL (2016, Issue 5), and trials registries. We also checked reference lists of relevant publications. SELECTION CRITERIA Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment. Disagreements were resolved through discussion. We performed meta-analysis using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data. MAIN RESULTS We included four randomised controlled trials in this review. A total of 868 participants with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias, and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for 30-day (or in-hospital) mortality (OR 0.88, 95% CI 0.66 to 1.16; moderate-quality evidence). There were a total of 44 endoleak events in 128 participants from three studies (low-quality evidence). Thirty-day complication outcomes (myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation, and respiratory failure) were reported in between one and three studies, therefore we were unable to draw a robust conclusion. We downgraded the quality of the evidence for myocardial infarction, renal complications, and respiratory failure due to imprecision, inconsistency, and risk of bias. Odds ratios for complications outcomes were OR 2.38 (95% CI 0.34 to 16.53; 139 participants; 2 studies; low-quality evidence) for myocardial infarction; OR 1.07 (95% CI 0.21 to 5.42; 255 participants; 3 studies; low-quality evidence) for renal complications; and OR 3.62 (95% CI 0.14 to 95.78; 32 participants; 1 study; low-quality evidence) for respiratory failure. There was low-quality evidence of a reduction in bowel ischaemia in the eEVAR treatment group, but very few events were reported (OR 0.37, 95% CI 0.14 to 0.94), and we downgraded the evidence due to imprecision and risk of bias. Six-month and one-year outcomes were evaluated in three studies, but only results from a single study could be used for each outcome, which showed no clear evidence of a difference between the interventions. We rated six-month mortality evidence as of moderate quality due to imprecision (OR 0.89, 95% CI 0.40 to 1.98; 116 participants). AUTHORS' CONCLUSIONS The conclusions of this review are currently limited by the paucity of data. We found from the data available moderate-quality evidence suggesting there is no difference in 30-day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.
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Affiliation(s)
- Stephen Badger
- Mater Misericordiae University HospitalDepartment of Vascular SurgeryEccles StreetDublinIreland
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Paul H Blair
- Royal Victoria HospitalBelfast Vascular CentreBelfast Health & Social Care TrustBelfastNorthern IrelandUKBT12 6BA
| | - Peter Ellis
- Royal Victoria HospitalBelfast Vascular CentreBelfast Health & Social Care TrustBelfastNorthern IrelandUKBT12 6BA
| | - Frank Kee
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastUniversity RoadBelfastNorthern IrelandUK
| | - Denis W Harkin
- Royal Victoria HospitalBelfast Vascular CentreBelfast Health & Social Care TrustBelfastNorthern IrelandUKBT12 6BA
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22
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Kvist TV, Lindholt JS, Rasmussen LM, Søgaard R, Lambrechtsen J, Steffensen FH, Frost L, Olsen MH, Mickley H, Hallas J, Urbonaviciene G, Busk M, Egstrup K, Diederichsen ACP. The DanCavas Pilot Study of Multifaceted Screening for Subclinical Cardiovascular Disease in Men and Women Aged 65-74 Years. Eur J Vasc Endovasc Surg 2016; 53:123-131. [PMID: 27890524 DOI: 10.1016/j.ejvs.2016.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 10/14/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE/BACKGROUND This pilot study of a large population based randomised screening trial investigated feasibility, acceptability, and relevance (prevalence of clinical and subclinical cardiovascular disease [CVD] and proportion receiving insufficient prevention) of a multifaceted screening for CVD. METHODS In total, 2060 randomly selected Danish men and women aged 65-74 years were offered (i) low dose non-contrast computed tomography to detect coronary artery calcification (CAC) and aortic/iliac aneurysms; (ii) detection of atrial fibrillation (AF); (iii) brachial and ankle blood pressure measurements; and (iv) blood levels of cholesterol and hemoglobin A1c. Web based self booking and data management was used to reduce the administrative burden. RESULTS Attendance rates were 64.9% (n = 678) and 63.0% (n = 640) for men and women, respectively. In total, 39.7% received a recommendation for medical preventive actions. Prevalence of aneurysms was 12.4% (95% confidence interval [CI] 9.9-14.9) in men and 1.1% (95% CI 0.3-1.9) in women, respectively (p < .001). A CAC score > 400 was found in 37.8% of men and 11.3% of women (p < .001), along with a significant increase in median CAC score with age (p = .03). Peripheral arterial disease was more prevalent in men (18.8%, 95% CI 15.8-21.8) than in women (11.2%, 95% CI 8.7-13.6). No significant differences between the sexes were found with regard to newly discovered AF (men 1.3%, women 0.5%), potential hypertension (men 9.7%, women 11.5%), hypercholesterolemia (men 0.9%, women 1.1%) or diabetes mellitus (men 2.1%, women 1.3%). CONCLUSION Owing to the higher prevalence of severe conditions, such as aneurysms and CAC ≥ 400, screening for CVD seemed more prudent in men than women. The attendance rates were acceptable compared with other screening programs and the logistical structure of the screening program proved successful.
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Affiliation(s)
- T V Kvist
- Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Odense, Denmark.
| | - J S Lindholt
- Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Odense, Denmark; Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - L M Rasmussen
- Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Odense, Denmark
| | - R Søgaard
- Department of Public Health and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - J Lambrechtsen
- Department of Cardiology, University Hospital Odense Svendborg, Svendborg, Denmark
| | - F H Steffensen
- Department of Cardiology, Vejle Hospital, Vejle, Denmark
| | - L Frost
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark
| | - M H Olsen
- Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Odense, Denmark
| | - H Mickley
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
| | - J Hallas
- Institute of Pharmacology, University of Southern Denmark, Odense C, Denmark
| | - G Urbonaviciene
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark
| | - M Busk
- Department of Cardiology, Vejle Hospital, Vejle, Denmark
| | - K Egstrup
- Department of Cardiology, University Hospital Odense Svendborg, Svendborg, Denmark
| | - A C P Diederichsen
- Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Odense, Denmark; Department of Cardiology, Odense University Hospital, Odense C, Denmark
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23
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Makrygiannis G, Labalue P, Erpicum M, Schlitz M, Seidel L, El Hachemi M, Gangolf M, Albert A, Defraigne JO, Lindholt JS, Sakalihasan N. Extending Abdominal Aortic Aneurysm Detection to Older Age Groups: Preliminary Results from the Liège Screening Programme. Ann Vasc Surg 2016; 36:55-63. [DOI: 10.1016/j.avsg.2016.02.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 11/01/2015] [Accepted: 02/17/2016] [Indexed: 12/28/2022]
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24
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Chabok M, Nicolaides A, Aslam M, Farahmandfar M, Humphries K, Kermani NZ, Coltart J, Standfield N. Risk factors associated with increased prevalence of abdominal aortic aneurysm in women. Br J Surg 2016; 103:1132-8. [DOI: 10.1002/bjs.10179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/23/2015] [Accepted: 03/02/2016] [Indexed: 02/04/2023]
Abstract
Abstract
Background
Four randomized trials of men aged 65–80 years showed that aneurysm-related mortality was reduced by 40 per cent by ultrasound screening. Screening is considered economically viable when the prevalence of abdominal aortic aneurysm (AAA) is 1·0 per cent or higher. This is not the case for women, in whom the prevalence of AAA is less than 1 per cent. The aim of the present investigation was to determine the prevalence of AAA 3·0 cm or larger in women screened with ultrasound imaging, the risk factors associated with AAA in this population, and whether high-risk groups can be identified with an AAA prevalence of 1 per cent or greater.
Methods
Demographic data and risk factors were collected from the first 50 000 women who attended for private cardiovascular screening in the UK. Tests included ultrasound screening for AAA, ankle : brachial pressure index (ABPI), carotid duplex imaging for carotid atherosclerosis, and electrocardiography for atrial fibrillation.
Results
AAA was detected in 82 of 50 000 women screened; these aneurysms were rare below the age of 66 years (7 of 24 499). In the 66–85-years age group there were 72 AAAs in 25 170 women (0·29 per cent). Univariable analysis demonstrated that a history of stroke/transient ischaemic attack (TIA), hypertension, smoking, atrial fibrillation, ABPI of less than 0·9 and internal carotid artery stenosis of at least 50 per cent were associated with an increased prevalence of AAA (P < 0·001). In multivariable linear logistic regression of risk factors, age 76 years or more, history of stroke/TIA, hypertension and smoking were independent predictors of AAA. This model had an area under the receiver operating characteristic (ROC) curve (AUC) of 0·711 (95 per cent c.i. 0·649 to 0·772) and could identify 2235 women who had 22 AAAs (prevalence 0·98 per cent). By adding ABPI, atrial fibrillation and carotid stenosis, the prediction improved to an AUC of 0·775 (0·724 to 0·826). This model could identify 3701 women who had 58 AAAs (prevalence 1·57 per cent).
Conclusion
This report should stimulate consideration of a targeted AAA screening programme for women aged over 65 years.
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Affiliation(s)
- M Chabok
- Department of Surgery and Cancer, Imperial College, London, UK
- Department of Vascular Surgery, Imperial College, London, UK
| | - A Nicolaides
- Department of Surgery, Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - M Aslam
- Department of Surgery and Cancer, Imperial College, London, UK
- Department of Vascular Surgery, Imperial College, London, UK
| | - M Farahmandfar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - K Humphries
- Wessex Scientific Medical Ultrasound Consultancy, Southampton, UK
| | - N Z Kermani
- Department of Surgery and Cancer, Imperial College, London, UK
| | - J Coltart
- Department of Cardiology, Guy's and St Thomas' Hospital, London, UK
| | - N Standfield
- Department of Surgery and Cancer, Imperial College, London, UK
- Department of Vascular Surgery, Imperial College, London, UK
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25
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Alvarez J, Prada A, Bermúdez C, García R, Ruiz E, Urbano J. [Abdominal aneurism screening in Primary Care]. Semergen 2016; 43:13-19. [PMID: 27117909 DOI: 10.1016/j.semerg.2016.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/13/2015] [Accepted: 03/03/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To obtain the percentage of abdominal aortic aneurism (AAA) determined in men between 65-74 years old in a health centre using ultrasound, and to describe the distribution of risk factors in the whole sample and in patients with aneurism, as well as determining how many AAA are confirmed at the hospital and those cases of uncertain diagnosis. PATIENTS AND METHOD A cross-sectional study conducted on patients included from September 2014 to February 2015. From a total of 212 randomised patients, a clinical interview and abdominal ultrasound were performed on 115 men, aged 65 to 74, telephone-recruited from a total of 171 that fulfilled inclusion criteria. RESULTS An infra-renal AAA was found in 2.6% of the sample (95% CI 0.54-7.4). Just over half (51.3%) of the sample had arterial hypertension, and 76.1% were smokers or former smokers. The 3 AAA found, one of which had an initial doubtful diagnosis, were confirmed by the Hospital Universitario Fundación Jiménez Díaz. There were no losses. All of the patients with AAA were active smokers and had at least one other risk factor. CONCLUSION The percentage of infra-renal AAA in the sample was lower than expected, but higher than the percentage found in other studies that did not consider smoking in the inclusion criteria.
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Affiliation(s)
- J Alvarez
- Medicina de Familia, Centro de Salud Palacio de Segovia, Madrid, España.
| | - A Prada
- Medicina de Familia, Centro de Salud Palacio de Segovia, Madrid, España
| | - C Bermúdez
- Residencia de cuarto año de Medicina Familiar y Comunitaria, Centro de Salud Palacio de Segovia, Madrid, España
| | - R García
- Residencia de cuarto año de Medicina Familiar y Comunitaria, Centro de Salud Palacio de Segovia, Madrid, España
| | - E Ruiz
- Medicina de Familia, Centro de Salud Palacio de Segovia, Madrid, España
| | - J Urbano
- Unidad de Radiología Vascular e Intervencionista, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
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26
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Zarrouk M, Lundqvist A, Holst J, Troëng T, Gottsäter A. Cost-effectiveness of Screening for Abdominal Aortic Aneurysm in Combination with Medical Intervention in Patients with Small Aneurysms. Eur J Vasc Endovasc Surg 2016; 51:766-73. [PMID: 26952345 DOI: 10.1016/j.ejvs.2015.12.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 12/31/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Screening for abdominal aortic aneurysm (AAA) among 65 year old men has been proven cost-effective, but nowadays is conducted partly under new conditions. The prevalence of AAA has decreased, and endovascular aneurysm repair (EVAR) has become the predominant surgical method for AAA repair in many centers. At the Malmö Vascular Center pharmacological secondary prevention with statins, antiplatelet therapy, and blood pressure reduction is initiated and given to all patients with AAA. This study evaluates the cost-effectiveness of AAA screening under the above mentioned conditions. METHODS This was a Markov cohort simulation. A total of 4,300 65 year old men were invited to annual AAA screening; the attendance rate was 78.3% and AAA prevalence was 1.8%. A Markov model with 11 health states was used to evaluate cost-effectiveness of AAA screening. Background data on rupture risks, costs, and effectiveness of surgical interventions were obtained from the participating unit, the national Swedvasc Registry, and from the scientific literature. RESULTS The additional costs of the screening strategy compared with no screening were €169 per person and year. The incremental health gain per subject in the screened cohort was 0.011 additional quality adjusted life years (QALYs), corresponding to an incremental cost-effectiveness ratio (ICER) of €15710 per QALY. Assuming a 10% reduction of all cause mortality, the incremental cost of screening was €175 per person and year. The gain per subject in the screened cohort was 0.013 additional QALYs, corresponding to an ICER of €13922 per QALY CONCLUSIONS: AAA screening remains cost-effective according to both the Swedish recommendations and the UK National Institute for Health and Care Excellence recommendations in the new era of lower AAA prevalence, EVAR as the predominant surgical method, and secondary prevention for all AAA patients.
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Affiliation(s)
- M Zarrouk
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden.
| | - A Lundqvist
- Swedish Institute for Health Economics, IHE, Lund, Sweden
| | - J Holst
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
| | - T Troëng
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - A Gottsäter
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
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27
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Lo RC, Schermerhorn ML. Abdominal aortic aneurysms in women. J Vasc Surg 2016; 63:839-44. [PMID: 26747679 PMCID: PMC4769685 DOI: 10.1016/j.jvs.2015.10.087] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/16/2015] [Indexed: 01/15/2023]
Abstract
Abdominal aortic aneurysm (AAA) has long been recognized as a condition predominantly affecting males, with sex-associated differences described for almost every aspect of the disease from pathophysiology and epidemiology to morbidity and mortality. Women are generally spared from AAA formation by the immunomodulating effects of estrogen, but once they develop, the natural history of AAAs in women appears to be more aggressive, with more rapid expansion, a higher tendency to rupture at smaller diameters, and higher mortality following rupture. However, simply repairing AAAs at smaller diameters in women is a debatable solution, as even elective endovascular AAA repair is fraught with higher morbidity and mortality in women compared to men. The goal of this review is to summarize what is currently known about the effect of gender on AAA presentation, treatment, and outcomes. Additionally, we aim to review current controversies over screening recommendations and threshold for repair in women.
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Affiliation(s)
- Ruby C Lo
- Beth Israel Deaconess Medical Center, Boston, Mass
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28
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Diederichsen ACP, Rasmussen LM, Søgaard R, Lambrechtsen J, Steffensen FH, Frost L, Egstrup K, Urbonaviciene G, Busk M, Olsen MH, Mickley H, Hallas J, Lindholt JS. The Danish Cardiovascular Screening Trial (DANCAVAS): study protocol for a randomized controlled trial. Trials 2015; 16:554. [PMID: 26637993 PMCID: PMC4670524 DOI: 10.1186/s13063-015-1082-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 11/24/2015] [Indexed: 12/28/2022] Open
Abstract
Background The significant increase in the average life expectancy has increased the societal challenge of managing serious age-related diseases, especially cancer and cardiovascular diseases. A routine check by a general practitioner is not sufficient to detect incipient cardiovascular disease. Design Population-based randomized clinically controlled screening trial. Methods Participants: 45,000 Danish men aged 65–74 years living on the Island of Funen, or in the surrounding communities of Vejle and Silkeborg. No exclusion criteria are used. Interventions: One-third will be invited to cardiovascular seven-faceted screening examinations at one of four locations. The screening will include: (1) low-dose non-contrast CT scan to detect coronary artery calcification and aortic/iliac aneurysms, (2) brachial and ankle blood pressure index to detect peripheral arterial disease and hypertension, (3) a telemetric assessment of the heart rhythm, and (4) a measurement of the cholesterol and plasma glucose levels. Up-to-date cardiovascular preventive treatment is recommended in case of positive findings. Objective: To investigate whether advanced cardiovascular screening will prevent death and cardiovascular events, and whether the possible health benefits are cost effective. Outcome: Registry-based follow-up on all cause death (primary outcome), and costs after 3, 5 and 10 years (secondary outcome). Randomization: Each of the 45,000 individuals is, by EPIDATA, given a random number from 1–100. Those numbered 67+ will be offered screening; the others will act as a control group. Blinding: Only those randomized to the screening will be invited to the examination;the remaining participants will not. Numbers randomized: A total of 45,000 men will be randomized 1:2. Recruitment: Enrollment started October 2014. Outcome: A 5 % reduction in overall mortality (HR = 0.95), with the risk for a type 1 error = 5 % and the risk for a type II error = 80 %, is expected. We expect a 2-year enrollment, a 10-year follow-up, and a median survival of 15 years among the controls. The attendance to screening is assumed to be 70 %. Discussion The primary aim of this so far stand-alone population-based, randomized trial will be to evaluate the health benefits and costeffectiveness of using non-contrast full truncus computer tomography (CT) scans (to measure coronary artery calcification (CAC) and identify aortic/iliac aneurysms) and measurements of the ankle brachial blood pressure index (ABI) as part of a multifocal screening and intervention program for CVD in men aged 65–74. Attendance rate and compliance to initiated preventive actions must be expected to become of major importance. Trial registration Current Controlled Trials: ISRCTN12157806 (21 March 2015).
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Affiliation(s)
- Axel Cosmus Pyndt Diederichsen
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Cardiology, University Hospital Odense, Odense, Denmark.
| | - Lars Melholt Rasmussen
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Clinical Biochemistry and Pharmacology, University Hospital Odense, Odense, Denmark.
| | - Rikke Søgaard
- Department of Public Health and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Jess Lambrechtsen
- Department of Cardiology, University Hospital Odense, Svendborg, Denmark.
| | | | - Lars Frost
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark.
| | - Kenneth Egstrup
- Department of Cardiology, University Hospital Odense, Svendborg, Denmark.
| | - Grazina Urbonaviciene
- Department of Cardiology, Diagnostic Centre, Regional Hospital Silkeborg, Silkeborg, Denmark.
| | - Martin Busk
- Department of Cardiology, Vejle Hospital, Vejle, Denmark.
| | - Michael Hecht Olsen
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Endocrinology, University Hospital Odense, Odense, Denmark.
| | - Hans Mickley
- Department of Cardiology, University Hospital Odense, Odense, Denmark.
| | - Jesper Hallas
- Institute of Pharmacology, University of Southern Denmark, Odense, Denmark.
| | - Jes Sanddal Lindholt
- Elitary Research Centre of Individualized Medicine in Arterial Disease (CIMA), Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
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29
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Rueda Martínez de Santos JR. [Economic evaluation studies in diagnostic imaging: justification and critical reading]. RADIOLOGIA 2015; 57 Suppl 2:10-22. [PMID: 26563613 DOI: 10.1016/j.rx.2015.09.003] [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: 03/16/2015] [Revised: 08/19/2015] [Accepted: 09/14/2015] [Indexed: 10/22/2022]
Abstract
First, this article describes the concepts and tools most widely used for economic evaluation in healthcare. Second, it discusses some elements that must be taken into account in the social decision about how much we are willing to spend to prolong a person's life by one year. Third, it describes the criteria recommended for the critical analysis of publications that evaluate the economic aspects of health interventions. Finally, several studies about ultrasound screening for aneurysms of the abdominal aorta are used as illustrative examples to show how these elements and criteria can be applied.
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30
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Lindholt JS. Unfit for Repair After Screening for Abdominal Aortic Aneurysm: Do We Fail to Fulfil the Basic WHO Criterion of an Available Treatment? Eur J Vasc Endovasc Surg 2015; 50:737. [PMID: 26432260 DOI: 10.1016/j.ejvs.2015.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 08/24/2015] [Indexed: 11/16/2022]
Affiliation(s)
- J S Lindholt
- Elitary Research Centre of Individualised Medicine of Arterial Disease (CIMA), Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark.
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31
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Laroche JP, Becker F, Baud JM, Miserey G, Jaussent A, Picot MC, Bura-Rivière A, Quéré I. [Ultrasound screening of abdominal aortic aneurysm: Lessons from Vesale 2013]. ACTA ACUST UNITED AC 2015; 40:340-9. [PMID: 26371387 DOI: 10.1016/j.jmv.2015.07.104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 07/10/2015] [Indexed: 01/16/2023]
Abstract
Although aneurysm of the abdominal infra-renal aorta (AAA) meets criteria warranting B mode ultrasound screening, the advantages of mass screening versus selective targeted opportunistic screening remain a subject of debate. In France, the French Society of Vascular Medicine (SFMV) and the Health Authority (HAS) published recommendations for targeted opportunistic screening in 2006 and 2013 respectively. The SFMV held a mainstream communication day on November 21, 2013 in France involving participants from metropolitan France and overseas departments that led to a proposal for free AAA ultrasound screening: the Vesalius operation. Being a consumer operation, the selection criteria were limited to age (men and women between 60 and 75 years); the age limit was lowered to 50 years in case of direct family history of AAA. More than 7000 people (as many women as men) were screened in 83 centers with a 1.70% prevalence of AAA in the age-based target population (3.12% for men, 0.27% for women). The median diameter of detected AAA was 33 mm (range 20 to 74 mm). The prevalence of AAA was 1.7% in this population. Vesalius data are consistent with those of the literature both in terms of prevalence and for cardiovascular risk factors with the important role of smoking. Lessons from Vesalius to take into consideration are: screening is warranted in men 60 years and over, especially smokers, and in female smokers. Screening beyond 75 years should be discussed. Given the importance of screening, the SFMV set up a year of national screening for AAA (Vesalius operation 2014/2015) in order to increase public and physician awareness about AAA detection, therapeutic management, and monitoring. AAA is a serious, common, disease that kills 6000 people each year. The goal of screening is cost-effective reduction in the death toll.
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Affiliation(s)
- J P Laroche
- Médecine interne et médecine vasculaire, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France.
| | - F Becker
- 40, chemin des Favrands, 74400 Chamonix-Mont-Blanc, France
| | - J M Baud
- Centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - G Miserey
- 55, rue Gambetta, 78120 Rambouillet, France
| | - A Jaussent
- Unité de recherche clinique et épidémiologie, CHRU de Montpellier, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - M C Picot
- Unité de recherche clinique et épidémiologie, CHRU de Montpellier, 191, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - A Bura-Rivière
- Médecine vasculaire, hôpital Rangueil, CHRU de Toulouse, 1, avenue Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France
| | - I Quéré
- Médecine interne et médecine vasculaire, hôpital Saint-Éloi, CHRU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
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32
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Grøndal N, Søgaard R, Lindholt JS. Baseline prevalence of abdominal aortic aneurysm, peripheral arterial disease and hypertension in men aged 65–74 years from a population screening study (VIVA trial). Br J Surg 2015; 102:902-6. [DOI: 10.1002/bjs.9825] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/10/2014] [Accepted: 03/09/2015] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Abdominal aortic aneurysm (AAA) screening has been introduced into some health systems and could easily be supplemented with broader vascular screening. The aim of this study was to evaluate the screening set-up and investigate combined screening for AAA, peripheral arterial disease (PAD) and possible hypertension (HT), and detection rates.
Methods
This observational study was based on the intervention arm of a screening trial in 25 083 Danish men aged 65–74 years. A combined screening programme for AAA, PAD and HT was offered at local hospitals. Participants with positive test results were offered secondary prophylaxis and/or referred to their general practitioner. The programme set-up included decentralized screening by three mobile teams at 14 venues. Diagnostic criteria were: aortic diameter at least 30 mm for AAA, ankle : brachial pressure index below 0·9 or above 1·4 for PAD, and BP exceeding 160/100 mmHg for HT.
Results
Overall, 18 749 men (uptake 74·7 per cent) attended the screening. An AAA was diagnosed in 3·3 (95 per cent c.i. 3·0 to 3·6) per cent, PAD in 10·9 (10·5 to 11·4) per cent and HT in 10·5 (10·0 to 10·9) per cent. Lipid-lowering and/or antiplatelet treatment was initiated in 34·8 per cent of the participants.
Conclusion
Preventive actions were started in one-third of the attenders. The long-term effect of this on morbidity and mortality is an important part of future analysis. The trial confirms that the prevalence of AAA in Denmark has decreased only slightly in the past decade, from 4·0 to 3·3 per cent, in contrast to other nations.
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Affiliation(s)
- N Grøndal
- Vascular Research Unit, Department of Vascular Surgery, Viborg Hospital, Viborg, Denmark
| | - R Søgaard
- Health Economics, Department for Public Health and Department for Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - J S Lindholt
- Vascular Research Unit, Department of Vascular Surgery, Viborg Hospital, Viborg, Denmark
- Department of Thoracic, Heart and Vascular Surgery, Odense University Hospital, Odense, Denmark
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Søgaard R, Lindholt JS. Screening for abdominal aortic aneurysm in a modern context and issues for the future. Eur J Vasc Endovasc Surg 2014; 48:668. [PMID: 25445727 DOI: 10.1016/j.ejvs.2014.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/21/2014] [Indexed: 12/01/2022]
Affiliation(s)
- R Søgaard
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - J S Lindholt
- Elitary Research Centre of Individualised Medicine in Arterial Diseases (CIMA), Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Sdr Boulevard 20, DK-500, Odense C, Denmark.
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Svensjö S, Björck M, Wanhainen A. Update on Screening for Abdominal Aortic Aneurysm: A Topical Review. Eur J Vasc Endovasc Surg 2014; 48:659-67. [DOI: 10.1016/j.ejvs.2014.08.029] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 08/31/2014] [Indexed: 11/30/2022]
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Ploug T, Holm S, Brodersen J. Scientific second-order 'nudging' or lobbying by interest groups: the battle over abdominal aortic aneurysm screening programmes. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2014; 17:641-650. [PMID: 24807744 DOI: 10.1007/s11019-014-9566-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The idea that it is acceptable to 'nudge' people to opt for the 'healthy choice' is gaining currency in health care policy circles. This article investigates whether researchers evaluating Abdominal Aortic Aneurysm Screening Programmes (AAASP) attempt to influence decision makers in ways that are similar to popular 'nudging' techniques. Comparing two papers on the health economics of AAASP both published in the BMJ within the last 3 years, it is shown that the values chosen for the health economics modelling are not representative of the literature and consistently favour the conclusions of the articles. It is argued (1) that this and other features of these articles may be justified within a Libertarian Paternalist framework as 'nudging' like ways of influencing decision makers, but also (2) that these ways of influencing decision makers raise significant ethical issues in the context of democratic decision making.
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Affiliation(s)
- Thomas Ploug
- Department of Communication and Psychology, Centre for Applied Ethics and Philosophy of Science, Aalborg University Copenhagen, A. C. Meyers Vænge 15, 2450, Copenhagen SV, Denmark,
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Earnshaw J. The National Health Service Abdominal Aortic Aneurysm Screening Programme in England. GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00772-014-1331-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Badger S, Bedenis R, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. Cochrane Database Syst Rev 2014:CD005261. [PMID: 25042123 DOI: 10.1002/14651858.cd005261.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular aneurysm repair (EVAR), has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. Emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition. OBJECTIVES To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by the effect on short-term mortality, major complication rates, aneurysm exclusion, and late complications when compared with the effects in patients who have had conventional open repair of RAAA. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 2). Reference lists of relevant publications were also checked. SELECTION CRITERIA Randomised controlled trials in which patients with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. DATA COLLECTION AND ANALYSIS Studies identified for potential inclusion were independently assessed for eligibility by at least two review authors. Data extraction and quality assessment were also completed independently by two review authors. Disagreements were resolved through discussion. Meta-analysis was performed using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data. MAIN RESULTS Three randomised controlled trials were included in this review. A total of 761 patients with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low but one study did not adequately report random sequence generation, putting it at risk of selection bias, two studies did not report on outcomes identified in their protocol, indicating reporting bias, and one study was underpowered. There was no clear evidence to support a difference between the two interventions on 30-day (or in-hospital) mortality, OR of 0.91 (95% CI 0.67 to 1.22; P = 0.52). The 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, re-operation, amputation, and respiratory failure. Individual complication outcomes were reported in only one or two studies and therefore no robust conclusion can currently be drawn. For complication outcomes that did include at least two studies in the meta-analysis there was no clear evidence to support a difference between eEVAR and open repair. Six-month outcomes were evaluated in only a single study, which included mortality and re-operation, with no clear evidence of a difference between the interventions and no overall association. Cost per patient was only evaluated in a single study and therefore no overall associations can currently be derived. AUTHORS' CONCLUSIONS The conclusions of this review are currently limited by the paucity of data. From the data available there is no difference in the outcomes evaluated in this review between eEVAR and open repair, specifically 30-day mortality. Not enough information was provided for complications in order to make a well informed conclusion at this time. Long-term data are lacking for both survival and late complications. More high quality, randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed in order to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.
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Affiliation(s)
- Stephen Badger
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
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Stackelberg O, Björck M, Larsson SC, Orsini N, Wolk A. Sex differences in the association between smoking and abdominal aortic aneurysm. Br J Surg 2014; 101:1230-7. [DOI: 10.1002/bjs.9526] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 12/12/2022]
Abstract
Abstract
Background
It is unclear whether recommendations about ultrasound screening programmes for abdominal aortic aneurysm (AAA) among men should be extended to include women who smoke. The aim was to examine sex-specific dose–response associations between AAA risk and smoking status, pack-years smoked and time since smoking cessation.
Methods
Women in the Swedish Mammography Cohort and men in the Cohort of Swedish Men were followed up from 1998 to 2011. AAA was identified through linkage of the cohorts to the Swedish Inpatient Register and the Swedish National Register for Vascular Surgery (Swedvasc), and not through general ultrasound screening. Associations were estimated with Cox proportional hazards models.
Results
The cohorts included 35 550 women and 42 596 men, aged 46–84 years. During follow-up, AAA was identified in 199 women and 958 men. The incidence of AAA per 100 000 person-years was 76 among men who never smoked and 136 among women who currently smoke. Regarding AAA risk, women were more sensitive to current smoking (Pinteraction= 0·002). Compared with never smokers, the hazard ratio (HR) for AAA in current smokers with more than 20 pack-years was 10·97 (95 per cent confidence interval 7·41 to 16·26) among women and 6·55 (5·36 to 7·99) among men. Following smoking cessation, women had a more rapid decline in excess risk (Pinteraction < 0·001). The risk was halved after 11 years (HR 0·51, 0·32 to 0·81) among women and after 23 years (HR 0·50, 0·42 to 0·60) among men.
Conclusion
There were sex differences in the associations between smoking status and AAA risk. These data support further investigation of targeted AAA screening among women who smoke.
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Affiliation(s)
- O Stackelberg
- Units of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - S C Larsson
- Units of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - N Orsini
- Units of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - A Wolk
- Units of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Glover MJ, Kim LG, Sweeting MJ, Thompson SG, Buxton MJ. Cost-effectiveness of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. Br J Surg 2014; 101:976-82. [PMID: 24862963 PMCID: PMC4231222 DOI: 10.1002/bjs.9528] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Implementation of the National Health Service abdominal aortic aneurysm (AAA) screening programme (NAAASP) for men aged 65 years began in England in 2009. An important element of the evidence base supporting its introduction was the economic modelling of the long-term cost-effectiveness of screening, which was based mainly on 4-year follow-up data from the Multicentre Aneurysm Screening Study (MASS) randomized trial. Concern has been expressed about whether this conclusion of cost-effectiveness still holds, given the early performance parameters, particularly the lower prevalence of AAA observed in NAAASP. METHODS The existing published model was adjusted and updated to reflect the current best evidence. It was recalibrated to mirror the 10-year follow-up data from MASS; the main cost parameters were re-estimated to reflect current practice; and more robust estimates of AAA growth and rupture rates from recent meta-analyses were incorporated, as were key parameters as observed in NAAASP (attendance rates, AAA prevalence and size distributions). RESULTS The revised and updated model produced estimates of the long-term incremental cost-effectiveness of £5758 (95 per cent confidence interval £4285 to £7410) per life-year gained, or £7370 (£5467 to £9443) per quality-adjusted life-year (QALY) gained. CONCLUSION Although the updated parameters, particularly the increased costs and lower AAA prevalence, have increased the cost per QALY, the latest modelling provides evidence that AAA screening as now being implemented in England is still highly cost-effective.
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Affiliation(s)
- M J Glover
- Health Economics Research Group, Brunel University, London, UK
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Svensjö S, Mani K, Björck M, Lundkvist J, Wanhainen A. Screening for Abdominal Aortic Aneurysm in 65-Year-old Men Remains Cost-effective with Contemporary Epidemiology and Management. Eur J Vasc Endovasc Surg 2014; 47:357-65. [DOI: 10.1016/j.ejvs.2013.12.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
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Intact cost-effectiveness of screening for abdominal aortic aneurysms in Sweden. Eur J Vasc Endovasc Surg 2014; 47:366. [PMID: 24440203 DOI: 10.1016/j.ejvs.2013.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022]
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Martufi G, Christian Gasser T. Review: the role of biomechanical modeling in the rupture risk assessment for abdominal aortic aneurysms. J Biomech Eng 2013; 135:021010. [PMID: 23445055 DOI: 10.1115/1.4023254] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AAA disease is a serious condition and a multidisciplinary approach including biomechanics is needed to better understand and more effectively treat this disease. A rupture risk assessment is central to the management of AAA patients, and biomechanical simulation is a powerful tool to assist clinical decisions. Central to such a simulation approach is a need for robust and physiologically relevant models. Vascular tissue senses and responds actively to changes in its mechanical environment, a crucial tissue property that might also improve the biomechanical AAA rupture risk assessment. Specifically, constitutive modeling should not only focus on the (passive) interaction of structural components within the vascular wall, but also how cells dynamically maintain such a structure. In this article, after specifying the objectives of an AAA rupture risk assessment, the histology and mechanical properties of AAA tissue, with emphasis on the wall, are reviewed. Then a histomechanical constitutive description of the AAA wall is introduced that specifically accounts for collagen turnover. A test case simulation clearly emphasizes the need for constitutive descriptions that remodels with respect to the mechanical loading state. Finally, remarks regarding modeling of realistic clinical problems and possible future trends conclude the article.
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Affiliation(s)
- Giampaolo Martufi
- Department of Solid Mechanics, School of Engineering Sciences, Royal Institute of Technology (KTH), Osquars Backe 1, SE-100 44 Stockholm, Sweden.
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Davis M, Harris M, Earnshaw JJ. Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Program in England. J Vasc Surg 2013; 57:1440-5. [DOI: 10.1016/j.jvs.2012.10.114] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/23/2012] [Accepted: 10/25/2012] [Indexed: 01/16/2023]
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Stather P, Dattani N, Bown M, Earnshaw J, Lees T. International Variations in AAA Screening. Eur J Vasc Endovasc Surg 2013; 45:231-4. [DOI: 10.1016/j.ejvs.2012.12.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 12/20/2012] [Indexed: 01/08/2023]
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Mureddu GF, Brandimarte F, Faggiano P, Rigo F, Nixdorff U. Between risk charts and imaging: how should we stratify cardiovascular risk in clinical practice? Eur Heart J Cardiovasc Imaging 2013; 14:401-16. [DOI: 10.1093/ehjci/jes297] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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