F A Lederle, G R Johnson, S E Wilson, E P Chute, R J Hye, M S Makaroun, G W Barone, D Bandyk, G L Moneta, R G Makhoul
The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.
Arch Intern Med. 2000 May 22;160(10):1425-30.
Abstract/Text
BACKGROUND: We previously reported the prevalence and associations of abdominal aortic aneurysm (AAA) in 73451 veterans aged 50 to 79 years who underwent ultrasound screening.
OBJECTIVE: To understand the prevalence of and principal positive and negative risk factors for AAA, and to assess reproducibility of our previous findings.
METHODS: In the new cohort of veterans undergoing screening, 52 745 subjects aged 50 to 79 without history of AAA underwent successful ultrasound screening for AAA, after completing a questionnaire on demographics and potential risk factors.
RESULTS: We detected AAA of 4.0 cm or larger in 613 participants (1.2%; compared with 1.4% in the earlier cohort). The direction and magnitude of the important associations reported in the first cohort were confirmed. Respective odds ratios for the major associations with AAA for the second and for the combined cohorts were as follows: 1.81 and 1.71 for age (per 7 years), 0.12 and 0. 18 for female sex, 0.59 and 0.53 for black race, 1.94 and 1.94 for family history of AAA, 4.45 and 5.07 for smoking, 0.50 and 0.52 for diabetes, and 1.60 and 1.66 for atherosclerotic diseases. The excess prevalence associated with smoking accounted for 75% of all AAAs of 4.0 cm or larger in the total population of 126 196. Associations for AAA of 3.0 to 3.9 cm were similar but tended to be somewhat weaker.
CONCLUSIONS: Our findings confirm our previous cohort findings. Age, smoking, family history of AAA, and atherosclerotic diseases remained the principal positive associations with AAA, and female sex, diabetes, and black race remained the principal negative associations.
Rachel H Bhak, Michael Wininger, Gary R Johnson, Frank A Lederle, Louis M Messina, David J Ballard, Samuel E Wilson, Aneurysm Detection and Management (ADAM) Study Group
Factors associated with small abdominal aortic aneurysm expansion rate.
JAMA Surg. 2015 Jan;150(1):44-50. doi: 10.1001/jamasurg.2014.2025.
Abstract/Text
IMPORTANCE: Because of the high mortality rate after rupture of small abdominal aortic aneurysms (AAAs), surveillance is recommended to detect aneurysm expansion; however, the effects of clinical risk factors on long-term patterns of AAA expansion are poorly characterized.
OBJECTIVE: To identify significant clinical risk factors associated with the AAA expansion rate for both constant and accelerated expansion trajectories.
DESIGN, SETTING, AND PARTICIPANTS: A multivariate mixed-effects model was established to identify clinical risk factors associated with the AAA expansion rate. Separate shape factor analysis was used to characterize steady vs accelerated expansion over time. Five hundred sixty-seven patients hospitalized at Veterans Affairs medical centers were randomized to the surveillance arm of the Aneurysm Detection and Management (ADAM) study conducted by the Veterans Affairs Cooperative Studies Program from 1992 to 2000. The patients had an AAA with a maximum diameter from 3.0 to 5.4 cm, which was monitored until a 5.5-cm maximum diameter was reached or the aneurysm became symptomatic. Thirty-three participants were not included in this analysis owing to missing or extraneous values in key predictor variables. The mean (SD) follow-up time was 3.7 (2.0) years.
MAIN OUTCOMES AND MEASURES: The primary outcome measure was the AAA expansion rate, determined by measurement of the maximum diameter by ultrasonography at regular intervals. The objective to assess the association of clinical variables with the expansion of the AAA was formulated after data collection.
RESULTS: The mean (SD) linear expansion rate of AAAs was 0.26 (0.01) cm/y. Current smoking was associated with a 0.05 (0.01)-cm/y increase in the linear expansion rate (95% CI, 0.25-0.28; P < .001), diastolic blood pressure with a 0.02 (0.01)-cm/y increase per 10 mm Hg (95% CI, 0.01-0.04; P = .001), and diabetes mellitus with a 0.11 (0.02)-cm/y decrease (95% CI, 0.07-0.16; P < .001). Diastolic blood pressure and baseline AAA diameter were associated with accelerated AAA expansion (P = .001 and P < .001, respectively).
CONCLUSIONS AND RELEVANCE: Smoking cessation and control of diastolic blood pressure are direct actions that should be taken to reduce the rate of AAA expansion. Other clinical risk factors, except for diabetes, were not associated with the AAA expansion rate. This study also provides evidence of differing trajectories in AAA expansion over time, a finding that merits further investigation.
Carlos Iribarren, Jeanne A Darbinian, Alan S Go, Bruce H Fireman, Chong D Lee, Douglas P Grey
Traditional and novel risk factors for clinically diagnosed abdominal aortic aneurysm: the Kaiser multiphasic health checkup cohort study.
Ann Epidemiol. 2007 Sep;17(9):669-78. doi: 10.1016/j.annepidem.2007.02.004. Epub 2007 May 18.
Abstract/Text
BACKGROUND: Identification of risk factors for and early diagnosis of clinically significant abdominal aortic aneurysm (AAA) before rupture is vital to optimize outcomes in these patients. Our aim was to examine traditional and three novel potential risk factors (abdominal obesity, white blood cell count, and kidney function) for abdominal aortic aneurysm (AAA, comprising discharge diagnosis or surgical repair) in a large multiethnic population.
METHODS: Cohort study (N =104,813) conducted at an integrated health care delivery system in northern California.
RESULTS: After a median of 13 years, 605 AAA events (490 in men and 115 in women; 91 [15%] fatal) were observed. In multivariable analysis, factors significantly associated with risk of clinically detected AAA included male gender, older age, black race (inversely), low educational attainment, cigarette smoking (with dose-response relation), height, treated and untreated hypertension, high total serum cholesterol, elevated white blood cell count, known coronary artery disease, history of intermittent claudication, and reduced kidney function. A significant Asian race by gender interaction was found such that Asian race had a (borderline significant) protective association with AAA in men but not in women.
CONCLUSIONS: Our findings confirm that major atherosclerotic risk factors, except for diabetes and obesity, are also prospectively related to AAA and suggest that elevated white blood cell count and reduced kidney function may improve risk stratification for clinically relevant AAA.
P De Rango, L Farchioni, B Fiorucci, M Lenti
Diabetes and abdominal aortic aneurysms.
Eur J Vasc Endovasc Surg. 2014 Mar;47(3):243-61. doi: 10.1016/j.ejvs.2013.12.007. Epub 2014 Jan 18.
Abstract/Text
Epidemiologic evidence suggests that patients with diabetes may have a lower incidence of abdominal aortic aneurysm (AAA); however, the link between diabetes and AAA development and expansion is unclear. The aim of this review is to analyze updated evidence to better understand the impact of diabetes on prevalence, incidence, clinical outcome, and expansion rate of AAA. A systematic review of literature published in the last 20 years using the PubMed and Cochrane databases was undertaken. Studies reporting appropriate data were identified and a meta-analysis performed using the generic inverse variance method. Sixty-four studies were identified. Methodological quality was "fair" in 16 and "good" in 44 studies according to a formal assessment checklist (Newcastle-Ottawa). In 17 large population prevalence studies there was a significant inverse association between diabetes and AAA: pooled odds ratio (OR) 0.80; 95% confidence intervals (CI) 0.70-0.90 (p = .0009). An inverse association was also confirmed by pooled analysis of data from smaller prevalence studies on selected populations (OR 0.59; 95% CI 0.35-0.99; p = .05), while no significant results were provided by case-control studies. A significant lower pooled incidence of new AAA in diabetics was found over six prospective studies: OR 0.54; 95% CI 0.31-0.91; p = .03. Diabetic patients showed increased operative (30-day/in-hospital) mortality after AAA repair: pooled OR 1.26; 95% CI 1.10-1.44; p = .0008. The increased operative risk was more evident in studies with 30-day assessment. In the long-term, diabetics showed lower survival rates at 2-5 years, while there was general evidence of lower growth rates of small AAA in patients with diabetes compared to non-diabetics. There is currently evidence to support an inverse relationship between diabetes and AAA development and enlargement, even though fair methodological quality or unclear risk of bias in many available studies decreases the strength of the finding. At the same time, operative and long-term survival is lower in diabetic patients, suggesting increased cardiovascular burden. The higher mortality in diabetics raises the question as to whether AAA repair should be individualized in selected diabetic populations at higher AAA rupture risk.
Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
F A Lederle, D L Simel
The rational clinical examination. Does this patient have abdominal aortic aneurysm? .
JAMA. 1999 Jan 6;281(1):77-82.
Abstract/Text
In the physical examination of abdominal aortic aneurysm (AAA), the only maneuver of demonstrated value is abdominal palpation to detect abnormal widening of the aortic pulsation. Palpation of AAA appears to be safe and has not been reported to precipitate rupture. The best evidence on the accuracy of abdominal palpation comes from 15 studies of patients not previously known to have AAA who were screened with both abdominal palpation and ultrasound. When results from these studies are pooled, the sensitivity of abdominal palpation increases significantly with AAA diameter (P<.001), ranging from 29% for AAAs of 3.0 to 3.9 cm to 50% for AAAs of 4.0 to 4.9 cm and 76% for AAAs of 5.0 cm or greater. Positive and negative likelihood ratios with 95% confidence intervals (CIs) using a cutoff point for AAAs of 3.0 cm or greater are 12.0 (95% CI, 7.4-19.5) and 0.72 (95% CI, 0.65-0.81), respectively, and for AAAs of 4.0 cm or greater are 15.6 (95% CI, 8.6-28.5) and 0.51 (95% CI, 0.38-0.67). The positive predictive value of palpation for AAA of 3.0 cm or greater in these studies was 43%. Limited data suggest that abdominal obesity decreases the sensitivity of palpation. Abdominal palpation specifically directed at measuring aortic width has moderate sensitivity for detecting an AAA that would be large enough to be referred for surgery but cannot be relied on to exclude AAA, especially if rupture is a possibility.
Anthony R Brady, Simon G Thompson, F Gerald R Fowkes, Roger M Greenhalgh, Janet T Powell, UK Small Aneurysm Trial Participants
Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance.
Circulation. 2004 Jul 6;110(1):16-21. doi: 10.1161/01.CIR.0000133279.07468.9F. Epub 2004 Jun 21.
Abstract/Text
BACKGROUND: Intervention to reduce abdominal aortic aneurysm (AAA) expansion and optimization of screening intervals would improve current surveillance programs. The aim of this study was to characterize AAA growth in a national cohort of patients with AAA both overall and by cardiovascular risk factors.
METHODS AND RESULTS: In this study, 1743 patients were monitored for changes in AAA diameter by ultrasonography over a mean follow-up of 1.9 years. Mean initial AAA diameter and growth rate were 43 mm (range 28 to 85 mm) and 2.6 mm/year (95% range, -1.0 to 6.1 mm/year), respectively. Baseline diameter was strongly associated with growth, suggesting that AAA growth accelerates as the aneurysm enlarges. AAA growth rate was lower in those with low ankle/brachial pressure index and diabetes but higher for current smokers (all P<0.001). No other factor (including lipids and blood pressure) was associated with AAA growth. Intervals of 36, 24, 12, and 3 months for aneurysms of 35, 40, 45, and 50 mm, respectively, would restrict the probability of breaching the 55-mm limit at rescreening to below 1%.
CONCLUSIONS: Annual, or less frequent, surveillance intervals are safe for all AAAs < or =45 mm in diameter. Smoking increases AAA growth, but atherosclerosis plays a minor role.
Ryaz B Chagpar, Jeremy R Harris, D Kirk Lawlor, Guy DeRose, Thomas L Forbes
Early mortality following endovascular versus open repair of ruptured abdominal aortic aneurysms.
Vasc Endovascular Surg. 2010 Nov;44(8):645-9. doi: 10.1177/1538574410376603. Epub 2010 Jul 30.
Abstract/Text
PURPOSE: To determine whether endovascular repair (EVAR) offers a survival advantage over open repair (OAR) with ruptured abdominal aortic aneurysms (RAAA).
METHODS: Retrospective analysis of RAAA patients treated between 2003 and 2008. Univariate and multivariate analyses were performed.
RESULTS: 167 patients presented with RAAA (OAR = 135, 80.8%, EVAR = 32, 19.2%). On univariate analysis, EVAR was associated with a decreased mortality relative to OAR, (15.6% vs 43.7%, P = .004). Patients who survived were younger (P < .0005), had a higher blood pressure (P < .0005), level of consciousness (P < .0005), and hemoglobin (P = .018), and a lower urea (P = .005) and international normalized ratio (INR; P = .001). On multivariate analysis, type of repair remained an independent predictor of 30-day mortality (OR: 0.121; 95% CI: 0.021-0.682, P = .017).
CONCLUSION: Controlling for preoperative factors, EVAR is an independent predictor of lower 30 day mortality relative to open repair after RAAA. This supports the wider use of endovascular repair in all patients with RAAA.
M J Bown, A J Sutton, P R F Bell, R D Sayers
A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair.
Br J Surg. 2002 Jun;89(6):714-30. doi: 10.1046/j.1365-2168.2002.02122.x.
Abstract/Text
BACKGROUND: Operative repair of ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate but reported figures vary widely. The aim of this study was to estimate the operative mortality of RAAA repair and determine how it has changed over time.
METHODS: A meta-analysis of all English language literature quoting figures for operative mortality of RAAA repair.
RESULTS: The pooled estimate for the overall operative mortality rate of RAAA repair from 1955 to 1998 was 48 (95 per cent confidence interval 46 to 50) per cent. Meta-regression analysis of operative mortality over time demonstrated a constant reduction of approximately 3.5 per cent per decade (1954-1997) with an operative mortality rate estimate for the year 2000 of 41 per cent. Seventy-seven studies reported intraoperative mortality but, while this appears to have remained constant over time, there was evidence of the presence of publication bias in the subgroup of papers reporting this outcome. There was no evidence of publication bias for the overall operative mortality outcome.
CONCLUSION: Contrary to the conclusion of recent studies, this paper demonstrates a gradual reduction with time in the operative mortality rate of RAAA repair.
L L Hoornweg, M N Storm-Versloot, D T Ubbink, M J W Koelemay, D A Legemate, R Balm
Meta analysis on mortality of ruptured abdominal aortic aneurysms.
Eur J Vasc Endovasc Surg. 2008 May;35(5):558-70. doi: 10.1016/j.ejvs.2007.11.019. Epub 2008 Jan 15.
Abstract/Text
OBJECTIVES: To assess the mortality of patients with ruptured abdominal aortic aneurysms undergoing open surgery and examine changes in mortality over time.
METHODS: Literature databases were searched for relevant articles published between 1991 and 2006. Two reviewers independently performed study inclusion and data extraction. Primary outcome measure was 30 day or in-hospital mortality. Subgroup analyses were performed examining the effect of population- and hospital-based studies, hospital volume and type of surgeon.
RESULTS: From a total of 1419 identified studies, 145 observational studies met the inclusion criteria of which 116 were included in the systematic review comprising 60,822 patients. Overall mortality was 48.5% (95% CI: 48.1-48.9%) and did not change significantly over the years. Age increased over the years. For overall mortality a trend was seen in favour of high-volume hospitals.
CONCLUSIONS: This meta-analysis suggests that mortality of patients with RAAA treated by open surgery has not changed over the past 15 years. This could be explained by increased age of patients undergoing RAAA repair.
H Bengtsson, D Bergqvist
Ruptured abdominal aortic aneurysm: a population-based study.
J Vasc Surg. 1993 Jul;18(1):74-80. doi: 10.1067/mva.1993.42107.
Abstract/Text
PURPOSE: The purpose of this study was to make an analysis of all ruptured abdominal aortic aneurysms in a defined population.
METHODS: An epidemiologic analysis of ruptured abdominal aortic aneurysms (AAAs) was made in an urban population during a 16-year period. The study was retrospective and covered a demographically defined population of 230,000 inhabitants in the city of Malmö, Sweden. Reports of all identified ruptured AAAs in Malmö from 1971 to 1986 were analyzed. The autopsy rate in the city was 85% during this period.
RESULTS: Ruptured AAAs were found in 5.6 of 100,000 persons (8.4/100,000 men and 3.0/100,000 women). No increase was found during the study period after age and sex standardization. The age-specific incidence was highest (113/100,000) in men 81 to 90 years old and (68/100,000) in women older than 90. The number of surgical interventions increased among men but not among women and the surgical mortality rate decreased from 86% to 43%. The overall mortality rate for ruptured AAA was 88%. The most common symptoms were abdominal pain and loss of consciousness.
CONCLUSIONS: The validity of the study was based on a high autopsy rate. The incidence of aneurysm rupture was not low compared with other Scandinavian studies, but was low in comparison with studies from the United Kingdom. No increase in standardized rupture incidence was found. To substantially decrease the total mortality caused by rupture, operation must be performed before rupture.
Jae-Sung Cho, Taeyoung Park, Jang Yong Kim, Rabih A Chaer, Robert Y Rhee, Michel S Makaroun
Prior endovascular abdominal aortic aneurysm repair provides no survival benefits when the aneurysm ruptures.
J Vasc Surg. 2010 Nov;52(5):1127-34. doi: 10.1016/j.jvs.2010.05.099. Epub 2010 Jul 31.
Abstract/Text
OBJECTIVE: It has been proposed that prior endovascular abdominal aortic aneurysm (AAA) repair (EVAR) confers protective effects in the setting of ruptured AAA (rAAA). This study was conducted to compare outcomes of rAAA repairs in patients with and without prior EVAR.
METHODS: A retrospective review identified 18 patients with (group 1) and 233 patients without (group 2) antecedent EVAR who presented with rAAA from January 2001 to December 2008. Patient characteristics and perioperative variables were noted and the outcomes were compared. Multiple logistic regression was used to identify factors contributing to morbidity and mortality and Kaplan-Meier analyses to estimate late survival rates.
RESULTS: Baseline characteristics were similar between groups. Mean age was 78 years in group 1 and 74.8 years in group 2 (P=.17). Men comprised 83.3% of patients in group 1 and 77.3% in group 2 (P=.77). Hemodynamic instability at rAAA was noted with similar frequency between groups, 55.6% vs 52.6%, respectively (P=.99). Mean time from EVAR to rAAA was 4.0 years and from last follow-up computed tomography (CT) 1.2 years. The devices involved were Ancure (Guidant, Menlo Park, Calif) (9), AneuRx (Medtronic, Minneapolis, Minn) (5), Zenith (Cook Medical Inc, Bloomington, Ind) (3), and Excluder (W.L Gore, Flagstaff, Ariz) (1). Mean preoperative AAA size was 6.4 cm in group 1. All but 1 patient had an endoleak at the time of rupture. Of 14 patients with CT follow-up, only 3 patients had a known increase in size (≥5 mm) and only 3 were known to have an endoleak. Fifteen patients were treated by a single intervention, whereas 3 patients underwent multiple procedures. In group 2, open repair was performed in 218 patients and EVAR in 15. Morbidity (66.7% vs 56.7%) and in-hospital mortality (38.9% vs 36.9%) were nearly identical between groups. One-year survival rates (27.8% vs 48.2%; P=.15) were also similar. The mortality rates for EVAR for primary rAAA was 20% as compared to 38.1% for open repair for rAAAs (P=.27).
CONCLUSION: rAAA remains a lethal problem in patients with and without prior EVAR alike. An existing endograft provides neither acute nor 1-year survival benefits after rAAA repairs. Prediction of patients at risk for rupture post-EVAR is difficult, as only a minority of patients had a known prior endoleak or sac enlargement.
Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Felix J V Schlösser, Ilonca Vaartjes, Geert J M G van der Heijden, Frans L Moll, Hence J M Verhagen, Bart E Muhs, Gert J de Borst, Andreas T Tiel Groenestege, Jan W P F Kardaun, Johannes B Reitsma, Yolanda van der Graaf, Michiel L Bots
Mortality after hospital admission for ruptured abdominal aortic aneurysm.
Ann Vasc Surg. 2010 Nov;24(8):1125-32. doi: 10.1016/j.avsg.2010.07.010.
Abstract/Text
BACKGROUND: The purpose of this study is to quantify age- and gender-specific mortality risks for patients hospitalized for ruptured abdominal aortic aneurysm (rAAA).
METHODS: The mortality risks for 28-day, 1-year, and 5-year were derived from a retrospective nation-wide cohort study of patients who were first hospitalized for rAAA in 1997 or 2000, formed through linkage of the Hospital Discharge Register with the Dutch population register. The Hospital Discharge Register contains a record for each hospital admission, giving information about patient demographics and diagnosis. The population register contains information on patient demographics and the mortality status of all registered persons in The Netherlands. Relations between gender and mortality within specific age groups were assessed with chi-square tests. Associations between age, gender, comorbidities, and mortality were studied in multivariate analysis with Cox regression.
RESULTS: A total of 1,463 patients hospitalized for rAAA were identified (86% males). Mean age was higher in women than in men (79 vs. 72 years; 95% CI of difference: 5.0-7.4). Mortality risks at 28-day, 1-year, and 5-year increased significantly with age (28-day: from 36 to 91% in men and 59 to 92% in women; 5-year: from 51 to 97% in men and 79 to 96% in women). In patients aged <80 years, mortality risks were significantly higher in women than in men. Age (HR: 1.04; 95% CI: 1.03-1.05), previous hospitalization for congestive heart failure (HR: 1.55; 95% CI: 1.06-2.26), and cerebrovascular disease (HR: 1.60; 95% CI: 1.16-2.21) were significant predictors of short- and long-term mortality.
CONCLUSIONS: Mortality risks after hospitalization for rAAA clearly increase by age and are higher in women than in men in patients aged <80 years. Because of the major effect of age and gender, future studies should consider reporting absolute mortality risks stratified by age and gender, instead of simply presenting overall mortality risks.
Copyright © 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.
Fausto Biancari, Maria Alessandra Mazziotti, Rosalba Paone, Sani Laukontaus, Maarit Venermo, Mauri Lepäntalo
Outcome after open repair of ruptured abdominal aortic aneurysm in patients>80 years old: a systematic review and meta-analysis.
World J Surg. 2011 Jul;35(7):1662-70. doi: 10.1007/s00268-011-1103-x.
Abstract/Text
BACKGROUND: The role of open repair in the management of ruptured abdominal aortic aneurysm (RAAA) in patients>80 years old is questioned by the perceived high operative risk of these patients. This issue has been investigated in the present meta-analysis of observational studies.
METHODS: Studies on open repair of RAAA in patients>80 years old were identified in July 2010. The immediate and intermediate results were expressed as pooled proportions with 95% confidence interval (95% CI). Linear regression and meta-regression were performed to evaluate the impact of variables on the immediate postoperative mortality.
RESULTS: Pooled analysis of 29 studies showed that the risk of immediate postoperative mortality in patients>80 years old was significantly higher than in younger patients (risk ratio 1.440, 95%CI 1.365-1.519, I2 36.8%, P=0.002; risk difference 19.4%, 95% CI 16.4-22.4%, I2 38.8%, P=0.019). Pooled analysis of 36 studies showed an immediate postoperative mortality rate of 59.2% (95% CI 55.7-62.5, I2 35.62). Immediate postoperative mortality in patients<80 years old positively correlated with that of patients>80 years old (rho: 0.686, P<0.0001). Intermediate survival data of 111 operative survivors were available from six studies, and their pooled survival rates at 1-, 2-, and 3-year were 82.4, 75.6, and 68.7%, respectively.
CONCLUSIONS: Immediate and intermediate survival rates of patients>80 years old after open repair of RAAA are acceptable. These findings suggest a more confident approach toward emergency repair of RAAA in the very elderly.
EVAR trial participants
Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial.
Lancet. 2005 Jun 25-Jul 1;365(9478):2187-92. doi: 10.1016/S0140-6736(05)66628-7.
Abstract/Text
BACKGROUND: Endovascular aneurysm repair (EVAR) to exclude abdominal aortic aneurysm (AAA) was introduced for patients of poor health status considered unfit for major surgery. We instigated EVAR trial 2 to identify whether EVAR improves survival compared with no intervention in patients unfit for open repair of aortic aneurysm.
METHODS: We did a randomised controlled trial of 338 patients aged 60 years or older who had aneurysms of at least 5.5 cm in diameter and who had been referred to one of 31 hospitals in the UK. We assigned patients to receive either EVAR (n=166) or no intervention (n=172). Our primary endpoint was all-cause mortality, with secondary endpoints of aneurysm-related mortality, health-related quality of life (HRQL), postoperative complications, and hospital costs. Analyses were by intention to treat.
FINDINGS: 197 patients underwent aneurysm repair (47 assigned no intervention) and 80% of patients adhered to protocol. The 30-day operative mortality in the EVAR group was 9% (13 of 150, 95% CI 5-15) and the no intervention group had a rupture rate of 9.0 per 100 person years (95% CI 6.0-13.5). By end of follow up 142 patients had died, 42 of aneurysm-related factors; overall mortality after 4 years was 64%. There was no significant difference between the EVAR group and the no intervention group for all-cause mortality (hazard ratio 1.21, 95% CI 0.87-1.69, p=0.25). There was no difference in aneurysm-related mortality. The mean hospital costs per patient over 4 years were UK pound sterling 13,632 in the EVAR group and pound sterling 4983 in the no intervention group (mean difference pound sterling 8649, SE 1248), with no difference in HRQL scores.
INTERPRETATION: EVAR had a considerable 30-day operative mortality in patients already unfit for open repair of their aneurysm. EVAR did not improve survival over no intervention and was associated with a need for continued surveillance and reinterventions, at substantially increased cost. Ongoing follow-up and improved fitness of these patients is a priority.
Daniel G Hackam, Deva Thiruchelvam, Donald A Redelmeier
Angiotensin-converting enzyme inhibitors and aortic rupture: a population-based case-control study.
Lancet. 2006 Aug 19;368(9536):659-65. doi: 10.1016/S0140-6736(06)69250-7.
Abstract/Text
BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors prevent the expansion and rupture of aortic aneurysms in animals. We investigated the association between ACE inhibitors and rupture in patients with abdominal aortic aneurysms.
METHODS: We did a population-based case-control study of linked administrative databases in Ontario, Canada. The sample included consecutive patients older than 65 (n=15,326) admitted to hospital with a primary diagnosis of ruptured or intact abdominal aortic aneurysm between April 1, 1992, and April 1, 2002.
FINDINGS: Patients who received ACE inhibitors before admission were significantly less likely to present with ruptured aneurysm (odds ratio [OR] 0.82, 95% CI 0.74-0.90) than those who did not receive ACE inhibitors. Adjustment for demographic characteristics, risk factors for rupture, comorbidities, contraindications to ACE inhibitors, measures of health-care use, and aneurysm screening yielded similar results (0.83, 0.73-0.95). Consistent findings were noted in subgroups at high risk of rupture, including patients older than 75 years and those with a history of hypertension. Conversely, such protective associations were not observed for beta blockers (1.02, 0.89-1.17), calcium channel blockers (1.01, 0.89-1.14), alpha blockers (1.15, 0.86-1.54), angiotensin receptor blockers (1.24, 0.71-2.18), or thiazide diuretics (0.91, 0.78-1.07).
INTERPRETATION: ACE inhibitors are associated with a reduced risk of ruptured abdominal aortic aneurysm, unlike other antihypertensive agents. Randomised trials of ACE inhibitors for prevention of aortic rupture might be warranted.
日本循環器学会/日本心臓血管外科学会/日本胸部外科学会/日本血管外科学会合同ガイドライン：2020年改訂版 大動脈瘤・大動脈解離診療ガイドライン、2020.
Frank A Lederle, Samuel E Wilson, Gary R Johnson, Donovan B Reinke, Fred N Littooy, Charles W Acher, David J Ballard, Louis M Messina, Ian L Gordon, Edmund P Chute, William C Krupski, Steven J Busuttil, Gary W Barone, Steven Sparks, Linda M Graham, Joseph H Rapp, Michel S Makaroun, Gregory L Moneta, Robert A Cambria, Raymond G Makhoul, Darwin Eton, Howard J Ansel, Julie A Freischlag, Dennis Bandyk, Aneurysm Detection and Management Veterans Affairs Cooperative Study Group
Immediate repair compared with surveillance of small abdominal aortic aneurysms.
N Engl J Med. 2002 May 9;346(19):1437-44. doi: 10.1056/NEJMoa012573.
Abstract/Text
BACKGROUND: Whether elective surgical repair of small abdominal aortic aneurysms improves survival remains controversial.
METHODS: We randomly assigned patients 50 to 79 years old with abdominal aortic aneurysms of 4.0 to 5.4 cm in diameter who did not have high surgical risk to undergo immediate open surgical repair of the aneurysm or to undergo surveillance by means of ultrasonography or computed tomography every six months with repair reserved for aneurysms that became symptomatic or enlarged to 5.5 cm. Follow-up ranged from 3.5 to 8.0 years (mean, 4.9).
RESULTS: A total of 569 patients were randomly assigned to immediate repair and 567 to surveillance. By the end of the study, aneurysm repair had been performed in 92.6 percent of the patients in the immediate-repair group and 61.6 percent of those in the surveillance group. The rate of death from any cause, the primary outcome, was not significantly different in the two groups (relative risk in the immediate-repair group as compared with the surveillance group, 1.21; 95 percent confidence interval, 0.95 to 1.54). Trends in survival did not favor immediate repair in any of the prespecified subgroups defined by age or diameter of aneurysm at entry. These findings were obtained despite a low total operative mortality of 2.7 percent in the immediate-repair group. There was also no reduction in the rate of death related to abdominal aortic aneurysm in the immediate-repair group (3.0 percent) as compared with the surveillance group (2.6 percent). Eleven patients in the surveillance group had rupture of abdominal aortic aneurysms (0.6 percent per year), resulting in seven deaths. The rate of hospitalization related to abdominal aortic aneurysm was 39 percent lower in the surveillance group.
CONCLUSIONS: Survival is not improved by elective repair of abdominal aortic aneurysms smaller than 5.5 cm, even when operative mortality is low.
Monique Prinssen, Eric L G Verhoeven, Jaap Buth, Philippe W M Cuypers, Marc R H M van Sambeek, Ron Balm, Erik Buskens, Diederick E Grobbee, Jan D Blankensteijn, Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group
A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
N Engl J Med. 2004 Oct 14;351(16):1607-18. doi: 10.1056/NEJMoa042002.
Abstract/Text
BACKGROUND: Although the initial results of endovascular repair of abdominal aortic aneurysms were promising, current evidence from controlled studies does not convincingly show a reduction in 30-day mortality relative to that achieved with open repair.
METHODS: We conducted a multicenter, randomized trial comparing open repair with endovascular repair in 345 patients who had received a diagnosis of abdominal aortic aneurysm of at least 5 cm in diameter and who were considered suitable candidates for both techniques. The outcome events analyzed were operative (30-day) mortality and two composite end points of operative mortality and severe complications and operative mortality and moderate or severe complications.
RESULTS: The operative mortality rate was 4.6 percent in the open-repair group (8 of 174 patients; 95 percent confidence interval, 2.0 to 8.9 percent) and 1.2 percent in the endovascular-repair group (2 of 171 patients; 95 percent confidence interval, 0.1 to 4.2 percent), resulting in a risk ratio of 3.9 (95 percent confidence interval, 0.9 to 32.9). The combined rate of operative mortality and severe complications was 9.8 percent in the open-repair group (17 of 174 patients; 95 percent confidence interval, 5.8 to 15.2 percent) and 4.7 percent in the endovascular-repair group (8 of 171 patients; 95 percent confidence interval, 2.0 to 9.0 percent), resulting in a risk ratio of 2.1 (95 percent confidence interval, 0.9 to 5.4).
CONCLUSIONS: On the basis of the overall results of this trial, endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter. Long-term follow-up is needed to determine whether this advantage is sustained.
Copyright 2004 Massachusetts Medical Society.
I M Nordon, A Karthikesalingam, R J Hinchliffe, P J Holt, I M Loftus, M M Thompson
Secondary interventions following endovascular aneurysm repair (EVAR) and the enduring value of graft surveillance.
Eur J Vasc Endovasc Surg. 2010 May;39(5):547-54. doi: 10.1016/j.ejvs.2009.11.002. Epub 2009 Nov 25.
Abstract/Text
OBJECTIVE: Lifelong imaging surveillance is currently recommended for all patients following endovascular aortic aneurysm repair (EVR). The modality, timing and overall necessity of surveillance has recently been brought into question. This review reports contemporary secondary intervention rates and explores surveillance imaging pick-up rates and reports the evidence supporting modified EVR surveillance programs.
DESIGN: Systematic review of literature (2002-2009) and meta-analysis of Kaplan-Meier re-intervention-free survival estimates.
RESULTS: 32 Papers were included in final analysis. 17,987 EVR cases were reported. Crude annual secondary intervention rates from the US population registries were 3.7%/year (range 1.7-4.3%). Combined re-intervention-free survival estimates, from 14 series (10,365 cases), demonstrated a linear progression with 89.9%, 86.9% and 81.5% of grafts without secondary procedures at 2, 3 and 5 years respectively. 3 Reports (1249 cases) differentiated between interventions directed by surveillance or outside surveillance protocols. Surveillance imaging alone initiated the secondary interventions in 1.4-9% of cases; >90% of EVR cases received no benefits from surveillance scans.
DISCUSSION: Some format of surveillance following EVR probably remains necessary despite a reduction in secondary interventions with modern stent-grafts. Surveillance should be targeted at those stent-grafts and patients at high risk of complications. Further work is justified to identify this group.
Copyright (c) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
United Kingdom EVAR Trial Investigators, Roger M Greenhalgh, Louise C Brown, Janet T Powell, Simon G Thompson, David Epstein
Endovascular repair of aortic aneurysm in patients physically ineligible for open repair.
N Engl J Med. 2010 May 20;362(20):1872-80. doi: 10.1056/NEJMoa0911056. Epub 2010 Apr 11.
Abstract/Text
BACKGROUND: Endovascular repair of abdominal aortic aneurysm was originally developed for patients who were considered to be physically ineligible for open surgical repair. Data are lacking on the question of whether endovascular repair reduces the rate of death among these patients.
METHODS: From 1999 through 2004 at 33 hospitals in the United Kingdom, we randomly assigned 404 patients with large abdominal aortic aneurysms (> or = 5.5 cm in diameter) who were considered to be physically ineligible for open repair to undergo either endovascular repair or no repair; 197 patients were assigned to undergo endovascular repair, and 207 were assigned to have no intervention. Patients were followed for rates of death, graft-related complications and reinterventions, and costs until the end of 2009. Cox regression was used to compare outcomes in the two groups.
RESULTS: The 30-day operative mortality was 7.3% in the endovascular-repair group. The overall rate of aneurysm rupture in the no-intervention group was 12.4 (95% confidence interval [CI], 9.6 to 16.2) per 100 person-years. Aneurysm-related mortality was lower in the endovascular-repair group (adjusted hazard ratio, 0.53; 95% CI, 0.32 to 0.89; P=0.02). This advantage did not result in any benefit in terms of total mortality (adjusted hazard ratio, 0.99; 95% CI, 0.78 to 1.27; P=0.97). A total of 48% of patients who survived endovascular repair had graft-related complications, and 27% required reintervention within the first 6 years. During 8 years of follow-up, endovascular repair was considerably more expensive than no repair (cost difference, 9,826 pounds sterling [U.S. $14,867]; 95% CI, 7,638 to 12,013 [11,556 to 18,176]).
CONCLUSIONS: In this randomized trial involving patients who were physically ineligible for open repair, endovascular repair of abdominal aortic aneurysm was associated with a significantly lower rate of aneurysm-related mortality than no repair. However, endovascular repair was not associated with a reduction in the rate of death from any cause. The rates of graft-related complications and reinterventions were higher with endovascular repair, and it was more costly. (Current Controlled Trials number, ISRCTN55703451.)
2010 Massachusetts Medical Society
L C Brown, R M Greenhalgh, J T Powell, S G Thompson, EVAR Trial Participants
Use of baseline factors to predict complications and reinterventions after endovascular repair of abdominal aortic aneurysm.
Br J Surg. 2010 Aug;97(8):1207-17. doi: 10.1002/bjs.7104.
Abstract/Text
BACKGROUND: It is uncertain which baseline factors are associated with graft-related complications and reinterventions after endovascular aneurysm repair (EVAR) in patients with a large abdominal aortic aneurysm.
METHODS: Patients randomized to elective EVAR in EVAR Trial 1 or 2 were followed for serious graft-related complications (type 2 endoleaks excluded) and reinterventions. Cox regression analysis was used to investigate whether any prespecified baseline factors were associated with time to first serious complication or reintervention.
RESULTS: A total of 756 patients who had elective EVAR were followed for a mean of 3.7 years, by which time there were 179 serious graft complications (rate 6.5 per 100 person years) and 114 reinterventions (rate 3.8 per 100 person years). The highest rate was during the first 6 months, with an apparent increase again after 2 years. Multivariable analysis indicated that graft-related complications increased significantly with larger initial aneurysm diameter (P < 0.001) and older age (P = 0.040). There was also evidence that patients with larger common iliac diameters experienced higher complication rates (P = 0.011).
CONCLUSION: Graft-related complication and reintervention rates were common after EVAR in patients with a large aneurysm. Younger patients and those with aneurysms closer to the 5.5-cm threshold for intervention experienced lower rates.
Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
A Karthikesalingam, P J E Holt, R J Hinchliffe, I M Nordon, I M Loftus, M M Thompson
Risk of reintervention after endovascular aortic aneurysm repair.
Br J Surg. 2010 May;97(5):657-63. doi: 10.1002/bjs.6991.
Abstract/Text
BACKGROUND: The role of symptomatic presentation in directing reintervention after endovascular aortic aneurysm repair (EVAR) was investigated.
METHODS: All patients undergoing infrarenal EVAR between 2001 and 2009 were studied. Those needing reintervention were divided into symptomatic and asymptomatic presentations. Kaplan-Meier survival curves were used to calculate freedom from reintervention, and log rank tests for subgroup analyses. Multivariable analysis identified risk factors for reintervention.
RESULTS: The study included 553 patients with a mean(s.d.) age of 75(7) years and aneurysm diameter of 65(13) mm. The 30-day mortality rate was 2.5 per cent. Median follow-up was 31 (range 1-97) months. There were 86 reinterventions in 69 (12.5 per cent) of 553 patients; 41 presented with symptoms and 28 were asymptomatic. Reintervention-free survival rates at 1, 3 and 5 years were 90.1, 85.3 and 81.2 per cent. The reintervention rate was higher in patients who needed an intraoperative adjunct during the index procedure (P = 0.014) and in those who did not have intraoperative computed tomography angiography (P = 0.024). Intraoperative adjuncts were an independent risk factor for future reintervention (hazard ratio 2.62, 95 per cent confidence interval 1.18 to 3.76; P = 0.012).
CONCLUSION: Most patients requiring reintervention presented symptomatically. A high-risk subgroup may be identifiable to rationalize a postoperative surveillance programme.
Copyright 2010 British Journal of Surgery Society Ltd.
Jonathan Golledge, Adam Parr, Margaret Boult, Guy Maddern, Robert Fitridge
The outcome of endovascular repair of small abdominal aortic aneurysms.
Ann Surg. 2007 Feb;245(2):326-33. doi: 10.1097/01.sla.0000253965.95368.52.
Abstract/Text
OBJECTIVE: To assess the outcome of endovascular repair (EVAR) of small abdominal aortic aneurysms (AAA, SUMMARY BACKGROUND DATA: Randomized trials have suggested that small AAAs should not be treated by open surgery. EVAR is associated with less perioperative mortality than open surgery for large AAAs. We assessed the outcome of EVAR of small AAAs as part of a national audit.
METHODS: ASERNIP-S carried out a prospective audit of EVAR performed between November 1999 and May 2001 in Australia. A total of 478 of the 961 patients entered underwent treatment of a small AAA. Data were collected regarding preoperative characteristics, procedural outcome, and intermediate success. Median follow-up was 3.2 years. Data were analyzed using Kaplan-Meier and Cox proportional hazard analyses.
RESULTS: The 30-day mortality and technical success rates were 1.1% and 98%, respectively. Postoperative complications occurred in 29%. Survival was 84% and 52% at 3 and 5 years, respectively. Primary, assisted primary, and secondary clinical success rates were 72%, 79%, and 82%, respectively, at 3 years. Reintervention rate was 11% at 3 years; however, 15% of patients continued to have significant aortic sac enlargement. Survival was reduced in patients considered unfit for general anesthesia (odds ratio = 2.6; 95% confidence interval, 1.4-4.8, P = 0.002) or those who had elevated preoperative serum creatinine (odds ratio = 2.0; 95% confidence interval, 1.3-3.0, P = 0.001).
CONCLUSIONS: EVAR can be carried with good perioperative outcome in patients with small AAA; however, intermediate success is hampered by the need for reintervention and continued aortic sac enlargement. At present, widespread treatment of small AAAs by EVAR would appear inappropriate.
D Drury, J A Michaels, L Jones, L Ayiku
Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm.
Br J Surg. 2005 Aug;92(8):937-46. doi: 10.1002/bjs.5123.
Abstract/Text
BACKGROUND: Conventional management of abdominal aortic aneurysm (AAA) is by open repair and is associated with a mortality rate of 2-6 per cent. Endovascular aneurysm repair (EVAR) is an alternative technique first introduced in 1991. A systematic review was undertaken of the evidence for the safety and efficacy of elective EVAR in the management of asymptomatic infrarenal AAA.
METHODS: Thirteen electronic bibliographical databases were searched, covering biomedical, health-related, science and social science literature. Outcomes were assessed with respect to efficacy (successful deployment, technical success, conversion rates and secondary intervention rates) and safety (30-day mortality rate, procedure morbidity rates and technical issues-endoleaks, graft thrombosis, stenosis and migration).
RESULTS: Of 606 reports identified, 61 met the inclusion criteria (three randomized and 15 non-randomized controlled trials, and 43 uncontrolled studies). There were 29 059 participants in total; 19,804 underwent EVAR. Deployment was successful in 97.6 per cent of cases. Technical success (complete aneurysm exclusion) was 81.9 per cent at discharge and 88.8 per cent at 30 days. Secondary intervention to treat endoleak or maintain graft patency was required in 16.2 per cent of patients. Mean stay in the intensive care unit and mean hospital stay were significantly shorter following EVAR. The 30-day mortality rate for EVAR was 1.6 per cent (randomized controlled trials) and 2.0 per cent in nonrandomized trials and case series. Technical complications comprised stent migration (4.0 per cent), graft limb thrombosis (3.9 per cent), endoleak (type I, 6.8 per cent; type II, 10.3 per cent; type III, 4.2 per cent) and access artery injury (4.8 per cent).
DISCUSSION: EVAR is technically effective and safe, with lower short-term morbidity and mortality rates than open surgery. However, there is a need for extended follow-up as the long-term success of EVAR in preventing aneurysm-related deaths is not yet known.
Michael L LeFevre, U.S. Preventive Services Task Force
Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med. 2014 Aug 19;161(4):281-90. doi: 10.7326/M14-1204. Epub 2014 Jun 24.
Abstract/Text
DESCRIPTION: Update of the 2005 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for abdominal aortic aneurysm (AAA).
METHODS: The USPSTF commissioned a systematic review that assessed the evidence on the benefits and harms of screening for AAA and strategies for managing small (3.0 to 5.4 cm) screen-detected AAAs.
POPULATION: These recommendations apply to asymptomatic adults aged 50 years or older.
RECOMMENDATION: The USPSTF recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked. (B recommendation). The USPSTF recommends that clinicians selectively offer screening for AAA in men aged 65 to 75 years who have never smoked. (C recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women aged 65 to 75 years who have ever smoked. (I statement). The USPSTF recommends against routine screening for AAA in women who have never smoked. (D recommendation).
P A Cosford, G C Leng
Screening for abdominal aortic aneurysm.
Cochrane Database Syst Rev. 2007 Apr 18;(2):CD002945. doi: 10.1002/14651858.CD002945.pub2. Epub 2007 Apr 18.
Abstract/Text
BACKGROUND: Abdominal aortic aneurysm (AAA) is found in 5% to 10% of men aged 65 to 79 years. The major complication is rupture which presents as a surgical emergency. The mortality after rupture is high, 80% for patients reaching hospital and 50% for those undergoing surgery for emergency repair. Currently elective surgical repair is recommended for aneurysms discovered to be larger than 5.5 cm to prevent rupture. There is interest in population screening to detect, monitor and repair abdominal aortic aneurysms before rupture.
OBJECTIVES: To determine the effects of screening asymptomatic individuals for AAA on mortality, subsequent treatment, quality of life and cost effectiveness of screening.
SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Trials Register (last searched 26 January 2007) and CENTRAL (last searched Issue 1, 2007).
SELECTION CRITERIA: Randomised controlled trials of population screening for AAA.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed trials and extracted data.
MAIN RESULTS: Four studies involving 127,891 men and 9,342 women were included in this review. Only one study included women. Results for men and women were analysed separately. Three to five years after screening there was no significant difference in all-cause mortality between screened and unscreened groups for men or women (men, odds ratio (OR) 0.95; 95% Confidence interval (CI) 0.85 to 1.07; for women OR 1.06; 95% CI 0.93 to 1.21). There was a significant decrease in mortality from AAA in men (OR 0.60; 95% CI 0.47 to 0.78), but not for women (OR 1.99; 95% CI 0.36 to 10.88). In this analysis mortality includes death from rupture and from emergency or elective surgery for aneurysm repair. There was also a decreased incidence of ruptured aneurysm in men (OR 0.45; 95% CI 0.21 to 0.99) but not in women (OR 1.49; 95% CI 0.25 to 8.94). There was a significant increase in surgery for AAA in men (OR 2.03; 95% CI 1.59 to 2.59). This was not reported in women. There were no data on life expectancy, complications of surgery or subjective quality of life.
AUTHORS' CONCLUSIONS: There is evidence of a significant reduction in mortality from AAA in men aged 65 to 79 years who undergo ultrasound screening. There is insufficient evidence to demonstrate benefit in women. The cost effectiveness may be acceptable, but needs further expert analysis. These findings need careful consideration in judging whether a co-ordinated population-based screening programme should be introduced.
