Infrarenal Aortic Diameter Predicts All-Cause Mortality

Association of aortic diameters and mortality in the general population-an MRI-based study

BACKGROUND

Increased diameters of the aorta are associated with increased mortality risk. In the present analyses, we assessed whether aortic diameters are associated with cardiovascular and all-cause mortality in community-dwelling individuals free of known cardiovascular disease (CVD).

METHODS

MRI-derived vascular parameters of the thoracic and abdominal aorta from 2668 participants (median age = 53 years; 51.1% women) of the population-based SHIP-START-2 and SHIP-TREND-0 cohorts without CVD were analyzed. Age- and sex-adjusted, as well as multivariable-adjusted Cox-proportional hazard models, were used to estimate associations of diameters of six different aortic segments to mortality.

RESULTS

Over a median follow-up time of 10.6 years (IQR: 8.7; 12.4), a total of 188 participants (126 men and 62 women) died, of which 38 deaths were due to CVD. In unadjusted models, mortality rates were higher in participants with aortic diameters above the median compared to below the median for all investigated aortic sections (all log-rank p < 0.001). In multivariable-adjusted models, the diameters of the ascending thoracic aorta (HR = 1.34 95% CI: 1.04; 1.72, p = 0.022) and of the infrarenal aorta (HR = 3.75 95% CI: 1.06; 13.3, p = 0.040), modeled continuously, were associated with greater cardiovascular mortality. The diameter of the subphrenic aorta was associated with higher cardiovascular mortality only in the age and sex-adjusted model (HR = 3.65 95% CI: 1.01; 13.3, p = 0.049). None of the investigated aortic segments were associated with all-cause mortality.

CONCLUSION

Non-indexed diameters of the ascending thoracic and infrarenal aorta were associated with higher cardiovascular mortality but not with all-cause mortality in a population sample free of clinically overt CVD at baseline.

CLINICAL RELEVANCE STATEMENT

Increased aortic diameter is associated with cardiovascular mortality and can help to identify high-risk patients.

KEY POINTS

Increased aortic diameter is associated with mortality. Non-indexed diameters of the ascending and infrarenal aorta are associated with cardiovascular mortality but not all-cause mortality. Aortic diameter measurements support the estimate of cardiovascular mortality.

Abdominal aortic calcium and geometry in patients with essential hypertension

PURPOSE

Abdominal aorta calcium (AAC) burden and dilatation are associated with an increased risk of mortality. The purpose of this study was to investigate determinants of AAC and abdominal aorta size in patients with essential hypertension.

MATERIALS AND METHODS

Patients with uncomplicated essential hypertension who had undergone non-enhanced abdominal CT to rule out secondary hypertension in addition to biological test were recruited between 2010 and 2018. A semi-automatic system was designed to estimate the aortic size (diameter, length, volume) and quantify the AAC from mesenteric artery to bifurcation using the Agatston score. Determinants of aortic size and those related to AAC were searched for using uni- and multivariables analyses.

RESULTS

Among 293 randomly selected patients with hypertension (age 52 ± 11 [SD] years) included, 23% had resistant hypertension. Mean abdominal aorta diameter was 20.1 ± 2.1 (SD) mm. Eight (3%) patients had abdominal aorta aneurysm ≥ 30 mm and 58 (20%) had dilated abdominal aorta ≥ 27 mm. Median AAC score was 38 and calcifications were detected in the infra- and supra-renal abdominal aortic portions in 59% and 26% of the patients, respectively. After adjustment for age, male sex and body surface area, abdominal aorta diameter was positively associated with diastolic blood pressure (P = 0.0019). Smoking was the single variable associated with calcified abdominal aorta (P < 0.001) after adjustment for cofactors. In patients with calcifications of abdominal aorta, the score increased with smoking history (P < 0.001), statins treatment (P < 0.01), greater number of anti-hypertensive drugs (P < 0.01), larger abdominal aorta (P < 0.05) and greater systolic blood pressure (P < 0.05). Patients with resistant hypertension had more AAC in the supra-renal abdominal aorta portion than those without resistant hypertension (P < 0.01).

CONCLUSION

In patients with essential hypertension, abdominal aorta dilation is related with diastolic blood pressure while AAC is associated with smoking history and resistant hypertension when located to the supra-renal abdominal aorta portion.

Magnetic Resonance Imaging and Computed Tomography for the Noninvasive Assessment of Arterial Aging: A Review by the VascAgeNet COST Action

Magnetic resonance imaging and computed tomography allow the characterization of arterial state and function with high confidence and thus play a key role in the understanding of arterial aging and its translation into the clinic. Decades of research into the development of innovative imaging sequences and image analysis techniques have led to the identification of a large number of potential biomarkers, some bringing improvement in basic science, others in clinical practice. Nonetheless, the complexity of some of these biomarkers and the image analysis techniques required for their computation hamper their widespread use. In this narrative review, current biomarkers related to aging of the aorta, their founding principles, the sequence, and postprocessing required, and their predictive values for cardiovascular events are summarized. For each biomarker a summary of reference values and reproducibility studies and limitations is provided. The present review, developed in the COST Action VascAgeNet, aims to guide clinicians and technical researchers in the critical understanding of the possibilities offered by these advanced imaging modalities for studying the state and function of the aorta, and their possible clinically relevant relationships with aging.

Editor's Choice - Systematic Review and Meta-Analysis of Normal Infrarenal Aortic Diameter in the General Worldwide Population and Changes in Recent Decades

OBJECTIVE

To analyse the characteristics of normal infrarenal aortic diameter (AD) in the general worldwide population, to examine changes over time, and to investigate geographical differences.

DATA SOURCES

PubMed, Cochrane Library, and Web of Science.

REVIEW METHODS

This was a systematic review and meta-analysis of studies published up to October 2020 describing infrarenal AD measured by ultrasound in the general adult population. The study was conducted in accordance with the PRISMA statement and placed no restrictions on geographical location or year of publication. Studies of individuals pre-selected for certain diseases or risk factors and opportunistic screening were excluded. A random effects model was used to estimate pooled mean AD, and meta-regression analysis was used to study the effects of determinants of AD.

RESULTS

Thirty-two studies were included, reporting data for 941 144 individuals (98% were men). The pooled mean AD was 19.4 mm (95% confidence interval [CI] 18.8 - 20.1), being 20.1 mm (95% CI 19.4 - 20.8) in men and 17.8 mm (95% CI 16.5 - 19.1) in women (p < .001). Outer edge to outer edge (OTO) caliper placement method (p = .015) and body surface area (BSA; p = .010) were significantly associated with larger AD. In men, the largest mean AD was observed in Oceania (p < .001) and the smallest in Asia (p < .020). As none of the studies collected data between 2002 and 2007, the studies were divided into two periods: 2001 and before, and 2008 and after. All recent studies were European, with the diameters being significantly smaller (p = .003) in the latter period (18.3 mm [95% CI 17.5 - 19.1] vs. 20.7 mm [95% CI 19.1 - 22.3]). In the meta-regression models, the reduction in AD over time remained significant after adjustment for potential effect modifiers such as sex, age, geographical area, body size, cardiovascular risk factors, and ultrasound method.

CONCLUSION

Mean infrarenal AD in older European adults has decreased significantly in recent decades. Male sex, BSA, and OTO ultrasound measurement method are associated with larger AD, and geographical differences were observed in men.

Potential influencing factors of aortic diameter at specific segments in population with cardiovascular risk

Background

Aortic diameter is a critical parameter for the diagnosis of aortic dilated diseases. Aortic dilation has some common risk factors with cardiovascular diseases. This study aimed to investigate potential influence of traditional cardiovascular risk factors and the measures of subclinical atherosclerosis on aortic diameter of specific segments among adults.

Methods

Four hundred and eight patients with cardiovascular risk factors were prospectively recruited in the observational study. Comprehensive transthoracic M-mode, 2-dimensional Doppler echocardiographic studies were performed using commercial and clinical diagnostic ultrasonography techniques. The aortic dimensions were assessed at different levels: (1) the annulus, (2) the mid-point of the sinuses of Valsalva, (3) the sinotubular junction, (4) the ascending aorta at the level of its largest diameter, (5) the transverse arch (including proximal arch, mid arch, distal arch), (6) the descending aorta posterior to the left atrium, and (7) the abdominal aorta just distal to the origin of the renal arteries. Multivariable linear regression analysis was used for evaluating aortic diameter-related risk factors, including common cardiovascular risk factors, co-morbidities, subclinical atherosclerosis, lipid profile, and hematological parameters.

Results

Significant univariate relations were found between aortic diameter of different levels and most traditional cardiovascular risk factors. Carotid intima-media thickness was significantly correlated with diameter of descending and abdominal aorta. Multivariate linear regression showed potential effects of age, sex, body surface area and some other cardiovascular risk factors on aortic diameter enlargement. Among them, high-density lipoprotein cholesterol had a significantly positive effect on the diameter of ascending and abdominal aorta. Diastolic blood pressure was observed for the positive associations with diameters of five thoracic aortic segments, while systolic blood pressure was only independently related to mid arch diameter.

Conclusion

Aortic segmental diameters were associated with diastolic blood pressure, high-density lipoprotein cholesterol, atherosclerosis diseases and other traditional cardiovascular risk factors, and some determinants still need to be clarified for a better understanding of aortic dilation diseases.

Editor's Choice - Cohort Study Examining the Association Between Abdominal Aortic Size and Major Adverse Cardiovascular Events in Patients with Aortic and Peripheral Occlusive and Aneurysmal Disease

OBJECTIVE

The aim of this study was to examine whether there were independent associations between abdominal aortic diameter, size index, and height index and the risk of major adverse events in patients referred for treatment of various types of aortic and peripheral occlusive and aneurysmal disease (APOAD).

METHODS

In total, 1 752 participants with a variety of APOADs were prospectively recruited between 2002 and 2020 and had a maximum abdominal aortic diameter, aortic size index (aortic diameter relative to body surface area), and aortic height index (aortic diameter relative to height) measured by ultrasound at recruitment. Participants were followed for a median of 4.6 years (interquartile range 2.0 - 8.0 years) to record outcome events, including major adverse cardiovascular events (MACE), peripheral artery surgery, abdominal aortic aneurysm (AAA) events (rupture or repair), and all cause mortality. The association between aortic size and events was assessed using Cox proportional hazard analysis. The ability of aortic size to improve risk of events classification was assessed using the net reclassification index (NRI).

RESULTS

After adjusting for other risk factors, larger aortic diameter was associated with an increased risk of MACE (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.05 - 1.31), requirement for peripheral artery surgery (HR 2.05, 95% CI 1.90 - 2.22), AAA events (HR 3.01, 95% CI 2.77 - 3.26), and all cause mortality (HR 1.20, 95% CI 1.08 - 1.32). Findings were similar for aortic size and aortic height indices. According to the NRI, all three aortic size measures significantly improved classification of risk of peripheral artery surgery and AAA events but not MACE. Aortic size index, but not aortic diameter or aortic height index, significantly improved the classification of all cause mortality risk.

CONCLUSION

Larger abdominal aortic diameter, size index, and height index are all independently associated with an increased risk of major adverse events in patients with established vascular disease.

Sex-specific normal values and determinants of infrarenal abdominal aortic diameter among non-aneurysmal elderly population

To establish age- and sex-specific distribution of the infrarenal abdominal aortic diameters (IAD) among non-aneurysmal elderly population and to investigate the associations between traditional cardiovascular risk factors and IAD in men and women. We included 4032 participants (mean age 67.2 years; 60.4% women) from the population-based Rotterdam Study, free of cardiovascular disease, who underwent IAD ultrasound assessment between 2009-2014. Linear regression analysis was used to identify determinants of IAD. The medians (inter-quartile range) of absolute IAD and body surface area (BSA)-adjusted IAD were 17.0 (15.0-18.0) mm and 9.3 (8.5-10.2) mm for women and 19.0 (18.0-21.0) mm and 9.4 (8.6-10.3) mm for men, respectively. There was a non-linear relationship between age and IAD. IAD increased steeply with advancing age and up to 70 years. After around 75 years of age, the diameter values reached a plateau. Waist circumference and diastolic blood pressure were associated with larger diameters in both sexes. Body mass index [Effect estimate (95% CI): 0.04 (0.00 to 0.08)], systolic blood pressure [- 0.01(- 0.02 to 0.00)], current smoking [0.35 (0.06 to 0.65)], total cholesterol levels [- 0.21 (- 0.31 to - 0.11)], and lipid-lowering medication [- 0.43 (- 0.67 to - 0.19)] were significantly associated with IAD in women. Sex differences in IAD values diminished after taking BSA into account. The increase in diameters was attenuated after 70 years. Differences were observed in the associations of several cardiovascular risk factors with IAD among men and women.

Systematic review of genome-wide association studies of abdominal aortic aneurysm

BACKGROUND AND AIMS

Abdominal aortic aneurysm (AAA) is an important cause of death worldwide and has an estimated heritability between 70 and 77%. Genome-wide association studies (GWAS) are an established way to discover genetic risk variants. The aim of this study was to systematically review the findings and quality of previous AAA GWAS.

METHODS

The Medline, PubMed, Web of Science and relevant genetic databases were searched to identify previous AAA GWAS. A framework was developed to grade the methodological quality of the GWAS. Data from included studies were extracted to assess methods and findings.

RESULTS

Eight case-control studies were included. Thirty-three of the 38 total single nucleotide polymorphisms (SNPs) previously reported were associated with AAA diagnosis at genome-wide significance (p < 5.0 × 10^-8). The CDKN2B antisense RNA-1 gene had the most significant association with AAA diagnosis (p = 6.94 × 10^-29 and p = 1.54 × 10^-33 for rs4007642 and rs10757274 respectively). Age, sex and smoking history were not reported for the complete cohort in any of the included studies, although five of the eight studies adjusted or matched for at least two confounding variables. All included studies had important design limitations including lack of sample size estimation, inconsistent case and control ascertainment and limited phenotyping of the AAAs. AAA growth was assessed in one GWAS, however, no significant associations with the reported SNPs were found.

CONCLUSIONS

This systematic review identified 33 SNPs associated with AAA diagnosis at genome-wide significance previously validated in multiple cohorts. The association between SNPs and AAA growth was not adequately examined. Previous GWAS have a number of design limitations.

Editor's Choice - Infra-Renal Aortic Diameter and Cardiovascular Risk: Making Better Use of Abdominal Aortic Aneurysm Screening Outcomes

OBJECTIVE

Aortic diameter (AD), used traditionally for abdominal aortic aneurysm (AAA) screening may have a role in assessing cardiovascular risk. Unfortunately, AD estimates for those without AAA are underutilised, whilst cardiovascular risk is sub-optimally managed in those with AAA. Our objective was to examine the association between AD measurements and future cardiovascular risk.

METHODS

Retrospective analysis of three databases of male participants screened for aortic aneurysm disease. Imaging and clinical data were obtained from three independent sources: 1) the Multi-centre Aneurysm Screening Study (MASS) trial (n = 26 882 men); 2) the 2013/14 cohort of the English NHS AAA Screening Programme (NAAASP) (n = 237 441 men) linked with NHS hospital admission and death registry data; and 3) the Framingham Heart Study (FHS) offspring cohort (n = 649). Associations between maximal aortic diameter, as measured on ultrasound or computed tomography, and cardiovascular outcomes were examined.

RESULTS

Cardiovascular mortality in the MASS trial, was higher in men with AAA at 13 years of follow up, compared to those without (Hazard Ratio [HR] 2.22, 95% CI 1.97-2.50, p < .001). Contemporary risk of major adverse cardiovascular events in the NAAASP was highest in those with an AAA (HR 2.91, 95% CI 2.00-4.25), whilst, extremes of aortic diameter were associated with increased risk for cardiovascular events. Aortic diameter was an independent risk factor for cardiovascular events in the FHS dataset.

CONCLUSION

Irrespective of the diagnosis of AAA, men attending for AAA screening who are found to have an abnormal aortic diameter are at high risk of future cardiovascular events. This currently unutilised data from AAA screening programmes has the potential to improve preventative management of cardiovascular risk.

Both Small and Large Infrarenal Aortic Size is Associated with an Increased Prevalence of Ischaemic Heart Disease

OBJECTIVE

Past studies have suggested a potential "J shaped" relationship between infrarenal aortic diameter and both cardiovascular disease (CVD) prevalence and all cause mortality. However, screening programmes have focused primarily on large (aneurysmal) aortas. In addition, aortic diameter is rarely adjusted for body size, which is particularly important for women. This study aimed to investigate specifically the relationship between body size adjusted infrarenal aortic diameter and baseline prevalence of CVD.

METHODS

A retrospective analysis was performed on a total of 4882 elderly (>50 years) participants (mean age 69.4 ± 8.9 years) for whom duplex ultrasound to assess infrarenal abdominal aortic diameters had been performed. History of CVDs, including ischaemic heart disease (IHD), and associated risk factors were collected at the time of assessment. A derivation cohort of 1668 participants was used to select cut offs at the lower and upper 12.5% tails of the aortic size distributions (aortic size index of <0.84 and >1.2, respectively), which was then tested in a separate cohort.

RESULTS

A significantly elevated prevalence of CVD, and specifically IHD, was observed in participants with both small and large aortas. These associations remained significant following adjustment for age, sex, diabetes, hypertension, dyslipidaemia, obesity (body mass index), and smoking.

CONCLUSION

The largest and smallest infrarenal aortic sizes were both associated with prevalence of IHD. In addition to identifying those with aneurysmal disease, it is hypothesised that screening programmes examining infrarenal aortic size may also have the potential to improve global CVD risk prediction by identifying those with small aortas.

Analysing The Cross-Section of The Abdominal Aortic Aneurysm Neck and Its Effects on Stent Deployment

Stent graft devices for the treatment of abdominal aortic aneurysms (AAAs) are being increasingly used worldwide. Yet, during modelling and optimization of these devices, as well as in clinical practice, vascular sections are idealized, possibly compromising the effectiveness of the intervention. In this study, we challenge the commonly used approximation of the circular cross-section of the aorta and identify the implications of this approximation to the mechanical assessment of stent grafts. Using computed tomography angiography (CTA) data from 258 AAA patients, the lumen of the aneurysmal neck was analysed. The cross-section of the aortic neck was found to be an independent variable, uncorrelated to other geometrical aspects of the region, and its shape was non-circular reaching elliptical ratios as low as 0.77. These results were used to design a finite element analysis (FEA) study for the assessment of a ring stent bundle deployed under a variety of aortic cross-sections. Results showed that the most common clinical approximations of the vascular cross-section can be a source of significant error when calculating the maximum stent strains (underestimated by up to 69%) and radial forces (overestimated by up to 13%). Nevertheless, a less frequently used average approximation was shown to yield satisfactory results (5% and 2% of divergence respectively).

Increased Aortic Diameters on Multidetector Computed Tomographic Scan Are Independent Predictors of Incident Adverse Cardiovascular Events: The Framingham Heart Study

BACKGROUND

Adverse aortic remodeling, such as dilation, is associated with multiple cardiovascular disease (CVD) risk factors. We sought to determine whether measures of enlarged aortic diameters improve prediction of incident adverse CVD events above standard CVD risk factors in a community-dwelling cohort.

METHODS AND RESULTS

Participants from the Framingham Offspring and Third Generation Cohorts (n=3318; aged 48.9±10.3 years), who underwent noncontrast thoracic and abdominal multidetector computed tomography during 2002 to 2005, had complete risk factor profiles, and were free of clinical CVD, were included in this study. Diameters were measured at 4 anatomically defined locations: the ascending thoracic aorta, descending thoracic aorta, the infrarenal abdominal aorta, and lower abdominal aorta. Adverse events comprised CVD death, myocardial infarction, coronary insufficiency, index admission for heart failure, and stroke. Each aortic segment was dichotomized as enlarged (diameter ≥upper 90th percentile for age, sex, and body surface area) or not enlarged; the hazard of an adverse event for an enlarged segment was determined using multivariable-adjusted Cox proportional hazards models. Over a mean 8.8±2.0 years of follow-up, there were 177 incident adverse CVD events. In models adjusted for traditional CVD risk factors, enlarged infrarenal abdominal aorta (hazard ratio=1.57; 95% confidence interval=1.06 to 2.32) and lower abdominal aorta (hazard ratio=1.53; 95% confidence interval=1.00 to 2.34) were associated with an increased hazard of CVD events. Enlarged ascending thoracic aorta and descending thoracic aorta were not significantly associated with CVD events.

CONCLUSIONS

Among community-dwelling adults initially free of clinical CVD, enlarged infrarenal abdominal aorta and lower abdominal aorta, on noncontrast multidetector computed tomography scans, are independent predictors of incident adverse CVD events above traditional risk factors alone.

Small infrarenal aortic diameter associated with lower-extremity peripheral artery disease in Chinese hypertensive adults

Several studies suggest that infrarenal aortic diameter is associated with lower-extremity peripheral artery disease (LE-PAD). However, data regarding the associations between infrarenal aortic diameter and LE-PAD are limited, especially in large sample populations and Asian or Chinese populations. Our analysis included 17279 Chinese hypertensive adults comprising 6590 men and 10689 women with a mean age of 64.74 ± 7.41 years. Participants were selected from 22693 candidates from two large population-based cohort-studies. The primary noninvasive test for diagnosis of LE-PAD is the ankle–brachial index (ABI) at rest and typically an ABI ≤ 0.90 is used to define LE-PAD. The prevalence of LE-PAD was found to significantly decrease as the aortic diameter increased according to the tertile of the aortic diameter. LE-PAD was significantly more prevalent in the lowest tertile (OR = 1.58, 95% CI = 1.29–1.94, p < 0.001) and similarly prevalent in the highest tertile (OR = 0.92, 95% CI = 0.73–1.16, p = 0.49) when compared with the median tertile. No significant interactions between the aortic diameter and any of the stratified variables were found (all p > 0.05). In conclusion, Small aortic diameter (as opposed to large aortic diameter) is significantly associated with LE-PAD in Chinese hypertensive adults.

Meta-analysis of the association between alcohol consumption and abdominal aortic aneurysm

Background

Alcohol is a possible risk factor for abdominal aortic aneurysm (AAA), but evidence from individual studies is weak and inconsistent. Existing narrative reviews suggest the possibility of non-linear associations. The aim here was to quantify any association using a systematic literature review, followed by dose–response meta-analysis of prospective studies.

Methods

MEDLINE, Embase and Web of Science were searched systematically to January 2017 for relevant prospective studies of alcohol consumption and AAA risk. Summary estimates of highest versus lowest levels of consumption, and linear and non-linear dose–response curves were quantified using random-effects models.

Results

Eleven relevant cohorts were identified describing results from 3580 individuals with among 473 092 participants. Data were extracted from ten cohorts for meta-analyses of high versus low levels of alcohol consumption (risk ratio for AAA 0·93, 95 per cent c.i. 0·78 to 1·11; P = 0·4, I2 = 47 per cent). The linear dose–response risk ratio for AAA, derived from 11 cohorts, was 1·00 (0·97 to 1·04) per 8 g alcohol per day (P = 0·9, I2 = 73 per cent). Non-linear dose–response results showed a tick-shaped curve with lower risk up to 2 units/day, but increasing risk beyond that (P = 0·05). The increase in risk beyond 2 units/day was stronger in men than in women.

Conclusion

Although the linear dose–response analysis revealed little evidence of an association between alcohol consumption and AAA risk, a tick-shaped trend in the association was observed. This non-linear dose–response analysis revealed reduced risks for alcohol consumption below 2 units/day, masking increased risks for 2 or more units/day.

Does the diameter of abdominal aortic aneurysm influence late survival following abdominal aortic aneurysm repair? A systematic review and meta-analysis

Background

Studies reporting the influence of preoperative abdominal aortic aneurysm diameter on late survival following abdominal aortic aneurysm repair have not been consistent. Aim: To report the influence of abdominal aortic aneurysm diameter on overall long-term survival following abdominal aortic aneurysm repair.

Methods

Embase, Medline and the Cochrane electronic databases were searched to identify articles reporting the influence of abdominal aortic aneurysm diameter on late survival following open aneurysm repair and endovascular aneurysm repair published up to April 2015. Data were extracted from multivariate analysis; estimated risks were expressed as hazard ratio.

Results

A total of 2167 titles/abstracts were retrieved, of which 76 studies were fully assessed; 19 studies reporting on 22,104 patients were included. Preoperative larger abdominal aortic aneurysm size was associated with a worse survival compared to smaller aneurysms with a pooled hazard ratio of 1.14 (95% CI: 1.09–1.18), per 1 cm increase in abdominal aortic aneurysm diameter. Subgroup analysis of the different types of repair was performed and the hazard ratio (95% CI), for open aneurysm repair and endovascular aneurysm repair were 1.08 (1.03–1.12) and 1.20 (1.15–1.25), respectively, per 1 cm increase. There was a significant difference between the groups p < 0.02.

Conclusions

This meta-analysis suggests that preoperative large abdominal aortic aneurysm independently influences overall late survival following abdominal aortic aneurysm repair, and this association was greater in abdominal aortic aneurysm repaired with endovascular aneurysm repair.

Systematic review of cardiovascular disease and cardiovascular death in patients with a small abdominal aortic aneurysm

Background

Screening for abdominal aortic aneurysm (AAA) has reduced the rate of AAA rupture. However, cardiovascular disease is still a major cause of death in men with an AAA. The aim of this study was to assess cardiovascular risk in patients with a small AAA.

Methods

Standard PRISMA guidelines were followed. Analysis was performed of studies reporting cardiovascular outcomes in patients with a small AAA (30–54 mm). Weighted metaregression was performed for cardiovascular death in patients with a small AAA, and the prevalence of cardiovascular disease was reviewed.

Results

Twenty-one articles were identified describing patients with an AAA, and the prevalence of, and death from, cardiovascular disease. Ten of these reported cardiovascular death rates in patients with a small AAA. Some 2323 patients with a small AAA were identified; 335 cardiovascular deaths occurred, of which 37 were due to AAA rupture. Metaregression demonstrated that the risk of cardiovascular death was 3·0 (95 per cent c.i. 1·7 to 4·3) per cent per year in patients with a small AAA (R2 = 0·902, P &lt; 0·001). The prevalence of ischaemic heart disease (44·9 per cent), myocardial infarction (26·8 per cent), heart failure (4·4 per cent) and stroke (14·0 per cent) was also high in these patients.

Conclusion

The risk of cardiovascular death in patients with a small AAA is high and increases by approximately 3 per cent each year after diagnosis. Patients with a small AAA have a high prevalence of cardiovascular disease. Patients a small AAA should be considered for lifestyle modifications and secondary cardiovascular protection.

Task force on: 'Early markers of atherosclerosis: influence of age and sex'

Atherosclerosis and its complications are the most important causes of death all over the world, especially in Western countries. Diet habits, modern stress life, smoking, sedentary way of life and an involvement of genetic pattern of individuals lead to a sure degeneration of quality of life increasing the risk of atherosclerosis development. For this reason, the main purpose of actual medicine is to identify all the markers that could allow the physicians to evaluate the first moments of the development of this dangerous pathological process. The aim is to reduce the speed of its evolution, trying to delay indefinitely the risk coming from the morphological alterations of the vessels. 'Endothelium function' could allow physicians to detect the first moment of the natural history of atherosclerosis process. Its impairment is the first step in the degeneration of vascular structures. Many methods [flow-mediated vasodilatation (FMD); antero-posterior abdominal aorta diameter (APAO); intima-media thickness of the common carotid artery (CCA-IMT); arterial stiffness; and so on] try to evaluate its function, but many limitations come from general population characteristics. A standardization of the methods should take into account individuals' peculiarities. Two elements, not modifiable, should be taken into account for vascular evaluation: age and sex. The aim of this review is to outline the linkage among age, sex and instrumental evaluation of patients considered for a noninvasive assessment of their cardiovascular risk profile.

Value of volume measurements in evaluating abdominal aortic aneurysms growth rate and need for surgical treatment

PURPOSE

To examine whether indices other than the traditionally used abdominal aortic aneurysm (AAA) maximum diameter, such as AAA volume, intraluminal thrombus (ILT) thickness and ILT volume, may be superior to evaluate aneurismal enlargement.

MATERIALS AND METHODS

Thirty-four small AAAs (initially presenting a maximum diameter <5.5cm which is the threshold for surgical repair) with an initial and a follow-up CT were examined. Median increase and percentile annual change of these variables was calculated. Correlation between growth rates as determined by the new indices under evaluation and those of maximum diameter were assessed. AAAs were divided according to outcome (surveillance vs. elective repair after follow-up which is based on the maximum diameter criterion) and according to growth rate (high vs. low) based on four indices. Contingency between groups of high/low growth rate regarding each of the four indices on one hand and those regarding need for surgical repair on the other was assessed.

RESULTS

A strong correlation between growth rates of maximum diameter and those of AAA and ILT volumes could be established. Evaluation of contingency between groups of outcome and those of growth rate revealed significant associations only for AAA and ILT volumes. Subsequently AAAs with a rapid volumetric increase over time had a likelihood ratio of 10 to be operated compared to those with a slower enlargement. Regarding increase of maximum diameter, likelihood ratio between AAAs with rapid and those with slow expansion was only 3.

CONCLUSION

Growth rate of aneurysms regarding 3Dimensional indices of AAA and ILT volumes is significantly associated with the need for surgical intervention while the same does not hold for growth rates determined by 2Dimensional indices of maximum diameter and ILT thickness.

Positional relationships of abdominal aorta landmarks for angiography: observations from the intravascular space

PURPOSE

To clarify the positional relationships of abdominal aorta (Ao) landmarks by way of observations from the intravascular space to facilitate angiography.

METHODS

A total of 95 donated Japanese cadavers were observed. We excluded 32 cadavers with anatomical variation at the celiac trunk (CT) or superior mesenteric artery (SMA), with flexure exceeding 5° in the aorta located cranially to the renal artery (RA), and with flexure exceeding 60° in the aorta located caudal to the RA. The maximum longitudinal diameter of the left (Lt.) RA was measured and the Ao was incised by frontal section to acquire photographs of the intravascular space. The inner diameter of the Ao at the Lt. RA level was investigated. The distances between the inferior borders of the CT, SMA, and Lt. RA were also used as the hypotenuse of a right-angled triangle. Lines parallel to the longitudinal diameter of the Ao and those parallel to the transverse diameter of the right-angled triangle were measured by a computer, and expressed as relative distance indexes using the transverse diameter of the aorta at the Lt. RA level as a reference point. The angle between the transverse axis of the Ao and the line connecting the CT to the SMA was also investigated.

RESULTS

The mean diameter of the aorta was 20.6 ± 2.0 mm. The indexes between each blood vessel (longitudinal/transverse) were as follows: Lt. RA to CT 1.69/0.41, Lt. RA to SMA 0.86/0.51, and CT to SMA 0.82/0.13. The mean angle between the transverse axis of the Ao and CT to SMA was 81.9° ± 9.5°.

CONCLUSION

These indexes should contribute to improving skills for workers new to angiography, and may reduce patient risk.

On the prediction of monocyte deposition in abdominal aortic aneurysms using computational fluid dynamics

In abdominal aortic aneurysm disease, the aortic wall is exposed to intense biological activity involving inflammation and matrix metalloproteinase–mediated degradation of the extracellular matrix. These processes are orchestrated by monocytes and rather than affecting the aorta uniformly, damage and weaken focal areas of the wall leaving it vulnerable to rupture. This study attempts to model numerically the deposition of monocytes using large eddy simulation, discrete phase modelling and near-wall particle residence time. The model was first applied to idealised aneurysms and then to three patient-specific lumen geometries using three-component inlet velocities derived from phase-contrast magnetic resonance imaging. The use of a novel, variable wall shear stress-limiter based on previous experimental data significantly improved the results. Simulations identified a critical diameter (1.8 times the inlet diameter) beyond which significant monocyte deposition is expected to occur. Monocyte adhesion occurred proximally in smaller abdominal aortic aneurysms and distally as the sac expands. The near-wall particle residence time observed in each of the patient-specific models was markedly different. Discrete hotspots of monocyte residence time were detected, suggesting that the monocyte infiltration responsible for the breakdown of the abdominal aortic aneurysm wall occurs heterogeneously. Peak monocyte residence time was found to increase with aneurysm sac size. Further work addressing certain limitations is needed in a larger cohort to determine clinical significance.

Is hypovitaminosis D associated with abdominal aortic aneurysm, and is there a dose-response relationship?

OBJECTIVE

This study aims to investigate the association between plasma 25-hydroxyvitamin D (25(OH)D) concentrations with the presence of abdominal aortic aneurysm (AAA) and aortic diameter.

DESIGN

An observational study of 4233 community-dwelling men aged 70-88 years, who participated in a randomised controlled trial of screening for AAA.

METHODS

Infrarenal aortic diameter measured by ultrasound and 25(OH)D by immunoassay.

RESULTS

A total of 311 men (7.4%) with AAA (defined as aortic diameter ≥ 30 mm) comprised the study. Multivariable models were adjusted for age, smoking, cardiovascular disease, hypertension, diabetes, dyslipidaemia, body mass index and serum creatinine concentration. Amongst men with the lowest 25(OH)D quartile of values compared with the highest quartile, the adjusted odds ratio of having an AAA increased in a graded fashion from 1.23 (95% confidence interval (CI) 0.87-1.73) for AAA ≥ 30 mm to 5.42 (95% CI 1.85-15.88) for AAA ≥ 40 mm. Similarly, there was a dose-response relationship between 25(OH)D concentrations and the size of the AAA: every 10-nmol l(-1) decrease in 25(OH)D levels was associated with 0.49 mm (95% CI 0.11-0.87) increase in mean aortic diameter.

CONCLUSIONS

Low vitamin D status is associated with the presence of larger AAA in older men, and there is a graded inverse relationship between 25(OH)D concentrations and AAA diameter. Further research is needed to clarify the mechanisms underlying these associations.

Associations of IGF1 and its binding proteins with abdominal aortic aneurysm and aortic diameter in older men

OBJECTIVE

Abdominal aortic aneurysm (AAA) is most prevalent in older men. GH secretion declines with age resulting in reduced IGF1 levels. IGF1 and its binding proteins (IGFBPs) are expressed in vasculature, and lower IGF1 levels have been associated with cardiovascular risk factors and disease. However, the relationship of the IGF1 system with aortic dilation and AAA is unclear. We tested the hypothesis that circulating IGF1 and IGFBPs are associated with AAA and aortic diameter in older men.

DESIGN

A cross-sectional analysis involving 3981 community-dwelling men aged 70-89 years was performed.

METHODS

Abdominal aortic diameter was measured by ultrasound. Plasma total IGF1, IGFBP1 and IGFBP3 were measured by immunoassays.

RESULTS

After adjustment for age, body mass index, waist:hip ratio, smoking, hypertension, dyslipidemia, diabetes, coronary heart disease and serum creatinine, a higher IGF1 level was associated with AAA (odds ratio (OR)/1 s.d. increase 1.18, 95% confidence interval (CI) 1.05-1.33, P=0.006), as was the ratio of IGF1/IGFBP3 (OR=1.22, 95% CI 1.10-1.35, P<0.001). Highest IGF1 concentrations compared with lowest quintile were significantly associated with AAA (quintile (Q) 5 vs Q1: OR=1.80, 95% CI 1.20-2.70, P=0.004) as were IGF1/IGFBP3 ratios (Q5 vs Q1: OR=2.52, 95% CI 1.59-4.02, P<0.001). IGF1 and IGFBP1 were independently associated with aortic diameter (β=0.200, 95% CI 0.043-0.357, P=0.012 and β=0.274, 95% CI 0.098-0.449, P=0.002 respectively).

CONCLUSIONS

In older men, higher IGF1 and an increased ratio of IGF1/IGFBP3 are associated with AAA, while IGFBP1 is independently associated with increased aortic diameter. Components of the IGF1 system may contribute to, or be a marker for, aortic dilation in ageing men.

Genomic research to identify novel pathways in the development of abdominal aortic aneurysm

Abdominal aortic aneurysm (AAA) is a common disease with a large heritable component. There is a need to improve our understanding of AAA pathogenesis in order to develop novel treatment paradigms. Genomewide association studies have revolutionized research into the genetic variants that underpin the development of many complex diseases including AAA. This article reviews the progress that has been made to date in this regard, including mechanisms by which loci identified by GWAS may contribute to the development of AAA. It also highlights potential post-GWAS analytical strategies to improve our understanding of the disease further.

Socioeconomic position, comorbidity, and mortality in aortic aneurysms: a 13-year prospective cohort study

BACKGROUND

To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register.

METHODS

We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA.

RESULTS

We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA.

CONCLUSIONS

Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA.

Genome wide association studies of abdominal aortic aneurysms-biological insights and potential translation applications

Abdominal aortic aneurysm (AAA) is a complex disease with important environmental risk factors and a heritability of approximately 70%. Genome wide association studies have revolutionised the study of complex disorders and offer the potential for innovative insight into disease pathogenesis and development of individualised therapeutic options. This paper reviews the progress of genome wide association studies in AAA, highlighting novel disease pathways and potential translational applications of genomic discoveries.

Thrombus volume is associated with cardiovascular events and aneurysm growth in patients who have abdominal aortic aneurysms

BACKGROUND

Patients with abdominal aortic aneurysms (AAA) are predisposed to cardiovascular events and often experience continual expansion of their aneurysm. Cardiovascular events and expansion rates are positively correlated with aneurysm size. AAA is usually associated with intraluminal thrombus, which has previously been implicated in AAA pathogenesis. This study prospectively assessed the association of infrarenal abdominal aortic thrombus volume with cardiovascular events and AAA growth.

METHODS

Ninety-eight patients with AAAs underwent computed tomography angiography (CTA). The volume of infrarenal aorta thrombus was measured by a previously validated technique. Patients were monitored prospectively for a median of 3 years (interquartile range [IQR], 2.0-3.6 years), and cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, coronary revascularization, amputation, and cardiovascular death) were recorded. Of the original patients, 39 underwent repeat CTA a median of 1.5 years (IQR, 1.1-3.3 years) after entry to the study. Kaplan-Meier and Cox proportional analysis were used to examine the association of aortic thrombus with cardiovascular events and average weighted AAA growth.

RESULTS

There were 28 cardiovascular events during follow-up. The incidence of cardiovascular events was 23.4% and 49.2% for patients with small (smaller than the median) and large (median or larger) volumes of aortic thrombus, respectively, at 4 years (P = .040). AAA thrombus volume of median or larger was associated with increased cardiovascular events (relative risk [RR] 2.8, 95% confidence interval [CI], 1.01-5.24) independent of other risk factors, including initial AAA diameter, but was only of borderline significance when patients were censored at the time of AAA repair (RR, 2.35; 95% CI, 0.98-5.63). In the subset of patients with CTA follow-up, the median annual increase in AAA volume was 5.1 cm³ (IQR, 0.8-10.3 cm³). Annual AAA volume increase was positively correlated with initial AAA diameter (r = 0.44, P = .006) and thrombus volume (r = 0.50, P = .001). Median or larger aortic thrombus volume was associated with rapid AAA volume increase (≥ 5 cm/y), independent of initial aortic diameter (RR, 15.0; 95% CI, 1.9-115.7; P = .009).

CONCLUSION

In this small cohort, infrarenal aortic thrombus volume was associated with the incidence of cardiovascular events and AAA progression. These results need to be confirmed and mechanisms underlying the associations clarified in large further studies.

Population-based observational study of claudication in older men: the Health in Men Study

OBJECTIVES

To assess the prevalence of and risk factors for claudication and its association with subsequent cardiovascular events.

DESIGN, SETTING AND PARTICIPANTS

Observational cohort study of 12 203 Western Australian men aged 65 years and over, recruited from 1996 to 1999, and followed up from 2001 to 2004.

MAIN OUTCOME MEASURES

Prevalence of claudication and incidence of peripheral arterial disease (PAD); risk factors for claudication and its association with subsequent cardiovascular events.

RESULTS

The prevalence of claudication was 5.3% (638 of 11 970 men). At follow-up, after exclusion of 148 men with claudication at baseline and 76 with missing data at follow-up, the crude average annual incidence of new PAD (claudication or procedure for PAD) was 0.85% (95% CI, 0.72%-0.96%). The risk factors for prevalent claudication and incident PAD were similar, with age, smoking, hypertension, diabetes and history of cardiovascular disease dominating. Of the men with claudication at baseline, nearly half (47.5%; 303 of 638) were not taking aspirin. At follow-up, 42.5% (82 of 193) of the men with incident PAD were not taking aspirin. Claudication at baseline was associated with twice the risk of cardiovascular death (hazard ratio, 2.00; 95% CI, 1.52-2.64). There was a J-shaped relationship between aortic diameter, and both prevalent claudication and subsequent cardiovascular events.

CONCLUSIONS

Among older men, claudication is prevalent and is associated with factors that can still be modified in older age, including smoking, exercise and diet. Relatively few men with claudication or at risk of PAD use aspirin. Claudication is a significant predictor of cardiovascular outcome.

Relation of infra-renal abdominal aortic calcific deposits and cardiovascular events in patients with peripheral artery disease

In patients with peripheral artery disease, aortic calcific deposits are a common finding. The aim of this study was to assess the association of infrarenal abdominal aortic calcific deposits with prospective cardiovascular events in patients with peripheral artery disease. A consecutive series of 213 patients who presented for investigation of abdominal aortic aneurysm or intermittent claudication were assessed using computed tomographic angiography. Infrarenal abdominal aortic calcific deposits were estimated using a previously defined highly reproducible semiautomated program. Patients were followed prospectively for a median of 2.8 years (interquartile range 1.7 to 3.6), and cardiovascular events were recorded. Kaplan-Meier and Cox proportional-hazards analysis were used to examine the association of calcific deposits with cardiovascular events. A total of 45 cardiovascular events occurred during follow-up, including nonfatal myocardial infarction (n = 23), coronary revascularization (n = 6), stroke (n = 3), below-knee amputation (n = 2), and cardiovascular death (n = 11). The incidence of cardiovascular events was 21.7%, 33.0%, and 36.9% for patients with mild (<400 mm(3)), intermediate (400 to 1,700 mm(3)), and severe (>1,700 mm(3)) abdominal aortic calcific deposits, respectively (p = 0.039). Calcific deposit volume >400 mm(3) (relative risk 2.8, 95% confidence interval 1.2 to 6.6) and coronary artery disease (relative risk 2.8, 95% confidence interval 1.4 to 5.6) were independently associated with increased cardiovascular events during follow-up. In conclusion, abdominal aortic calcific deposits are prognostic for cardiovascular events in patients with peripheral artery disease.

Comparison of volume and diameter measurement in assessing small abdominal aortic aneurysm expansion examined using computed tomographic angiography

AIM

First we aimed to assess the reproducibility of a computer tomography angiography (CTA) based technique for measuring infra-renal aortic volume and diameter. Second we sought to investigate whether changes in aortic volume and diameter were similar during follow-up.

MATERIALS AND METHODS

A prospective series of 57 patients, with aortic diameter initially measuring between 25 and 55 mm, were assessed with 2 CTAs a median of 14 months apart. Aortic volume and maximum diameter (both axial and orthogonal) were measured by a semi-automated workstation protocol based on previously defined techniques. Intra- and inter-observer reproducibility were assessed by repeat assessment of the initial CTA images of the first 33 patients included in the study, in order to estimate the 95% limits of agreements. Changes in aortic dimensions between the first and follow-up CTA, were defined for volume and diameter separately as changes greater than their respective 95% limits of agreement.

RESULTS

Reproducibility of aortic volume and diameter was excellent with an average coefficient of variation <4%. The median (inter-quartile range) increases in total volume, orthogonal and axial diameters were 4.9 cm(3) (0.01-14.18), 1.2mm (0.40-3.50) and 1.4mm (-0.15 to 3.55) respectively. Forty-two percent of patients who had increased aortic volume above the 95% limit of agreement did not display corresponding axial or orthogonal diameter changes.

CONCLUSIONS

Infra-renal total aortic volume, axial and orthogonal diameter can all be measured reproducibly from CTA. Aortic volume changes are not always reflected by similar changes in diameter and therefore provide complementary information when assessing AAA expansion over time.

Abdominal aortic aneurysms, or a relatively large diameter of non-aneurysmal aortas, increase total and cardiovascular mortality: the Tromsø study

BACKGROUND

In a population-based study in Tromsø, Norway, the authors assessed whether an abdominal aortic aneurysm (AAA) or the maximal infrarenal aortic diameter in a non-aneurismal aorta influence total and cardiovascular disease (CVD) mortality.

METHODS

A total of 6640 men and women, aged 25-84 years, were included in a 10-year mortality follow-up: 345 subjects with a diagnosed AAA and 6295 subjects with a non-aneurismal aorta. Non-aneurismal aortic diameter and prevalent AAAs were categorized into seven groups.

RESULTS

In subjects without an AAA, an aortic diameter > or =30 mm increased age- and sex-adjusted total mortality [mortality rate ratio (MRR) = 3.73, 95% confidence interval (CI) 1.77-7.89] and CVD mortality (MRR = 9.24, 95% CI 4.07-20.97) compared with subjects with aortic diameter of 21-23 mm. An AAA at screening was strongly associated with deaths from aortic aneurysm and was associated with total (MRR = 1.60, 95% CI 1.31-1.96) and CVD mortality (MRR = 2.41, 95% CI 1.81-3.21). This was not explained by deaths due to an AAA. Adjustments for CVD risk factors could fully explain the increased total, but not CVD mortality in subjects with an AAA.

CONCLUSIONS

An AAA increases total and CVD mortality. In the large majority of subjects with a non-aneurysmal aorta, the diameter does not influence total or CVD mortality. However, in individuals with a maximal diameter >26 mm (2% of the population), a positive relationship is found.

Relationship of heavy drinking, lipoprotein (a) and lipid profile to infrarenal aortic diameter

Abstract

The objective of this study was to examine the association of alcohol drinking and lipid profile with infrarenal aortic dimension. The diameter of the infrarenal aorta was measured using ultrasound in 395 individuals (mean 66.6 ± 10.3 years) with atherosclerotic diseases or risk factors. The associations between heavy drinking, serum lipoprotein (a) levels, lipid profile and infrarenal aorta diameters were examined. Heavy drinking and lipoprotein (a) were positively related with infrarenal aortic dimension, while low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C), LDL-C and total cholesterol (TC)/HDL-C were negatively associated with infrarenal aortic diameter ( p < 0.05). In addition, there were negative associations of LDL-C/HDL-C, TC/HDL-C and positive associations of HDL-C and apolipoprotein AI (Apo AI) with heavy drinking ( p < 0.05). In conclusion, there was a positive association between infrarenal aortic diameters and heavy drinking, as well as lipoprotein (a) levels. Furthermore, the novel and unexpected inverse association between LDL-C/HDL-C, LDL-C, TC/HDL-C and abdominal aortic diameter may suggest a possible role for anti-atherogenic lipid profile (characterized by a higher level of HDL-C and lower level of LDL-C) in aortic dilatation processes, which need to be clarified by further studies.

Haemostatic and fibrinolytic factors in men with a small abdominal aortic aneurysm

BACKGROUND

: The presence of an abdominal aortic aneurysm (AAA) independently predicts cardiovascular disease (CVD) and its complications. Levels of plasma markers of fibrin turnover are raised in men with a large AAA (at least 5.5 cm) and predict CVD risk in healthy subjects. This study examined fibrin turnover in men with a small AAA.

METHODS

: Seventy-five men with a small AAA (30-55 mm) were compared with 90 controls matched for age, sex and race. Haemostatic and fibrinolytic parameters were assessed.

RESULTS

: Men with a small AAA had higher mean levels of fibrinogen (2.92 versus 2.59 g/l; P = 0.019), thrombin-antithrombin (TAT) complex (4.57 versus 1.89 ng/ml; P < 0.001), prothrombin F1 + 2 (1.13 versus 0.82 ng/ml; P = 0.004) and D-dimer (346.7 versus 120.2 ng/ml; P < 0.001). All markers correlated with maximum aortic diameter determined by ultrasonography. On multivariable regression the association between presence of an AAA and fibrinogen, TAT complex, prothrombin F1 + 2 and D-dimer levels remained significant after adjustment for confounding influences.

CONCLUSION

: Fibrin turnover was increased in these men with a small AAA, independently of concomitant CVD, conventional risk factors and inflammatory markers. Enhanced fibrin turnover may contribute to the risk of cardiac complications in this group.

Idiopathic retroperitoneal fibrosis: prospective evaluation of incidence and clinicoradiologic presentation

Retroperitoneal fibrosis (RPF) is a rare disorder of unknown etiology. Its incidence is unknown, and the insidious and nonspecific nature of symptoms may contribute to considerable diagnostic delay. We conducted the current study to assess the incidence and clinicoradiologic characteristics of idiopathic RPF. For this, we evaluated prospectively 53 consecutive patients with a diagnosis of idiopathic RPF at our tertiary care referral center from April 1998 through January 2008.Calculated annual incidence of RPF was 1.3/100,000 inhabitants. Mean age was 64 +/- 11.1 (SD) yr; male-female ratio was 3.3:1.0. Median duration of symptoms was 6.0 mo (IQR 3.0-12.0). Abdominal, flank, and/or back pain and discomfort were the major symptoms, with visual analogue scale scores of 49 +/- 27.2 mm and 43 +/- 29.4 mm for pain and discomfort, respectively. Female patients had higher erythrocyte sedimentation rate (ESR), higher white blood cell count, and lower hemoglobin content than male patients at presentation. Computed tomography-documented maximal mass thickness amounted to 35 +/- 16.6 mm; craniocaudal length amounted to 137 +/- 48.8 mm. RPF mass extension up to or above the level of the renal vessels was noted in 3 patients (6%). Six patients (11%) presented with atypical RPF localization and/or bulky mass. Localized lymphadenopathy adjacent to the RPF mass was observed frequently (25%). Patients with hydronephrosis (56%) presented earlier than patients without hydronephrosis, with higher creatinine and greater mass thickness but similar pain severity. Patients were typically at high cardiovascular risk with increased-often aneurysmal-infrarenal aortic diameter (25.0 mm, IQR 22.0-30.0). RPF mass distribution was similar in patients with or without aneurysmal dilation. Occupational asbestos exposure (20%) and asbestos-related pleural changes (17%) were frequent among males. Previous or concurrent chronic inflammatory disease and/or autoimmune disease was noted in 8 patients (15%). Multivariate analysis revealed an independent association of ESR values with severity of pain and discomfort. Smoking was independently associated with infrarenal aortic diameter.In summary, annual RPF incidence is higher than previously assumed. Age at diagnosis and male-female ratio seem to have changed over time. RPF typically affects patients at high cardiovascular risk, including increased aortic diameter. Clinical presentation is influenced by sex, severity of inflammation and presence of hydronephrosis. Prolonged asbestos exposure and asbestos-related pleural changes were frequent among males. Localized lymphadenopathy adjacent to the RPF mass occurs frequently and should not confuse RPF diagnosis.