Screening of siblings to patients with abdominal aortic aneurysms in Sweden

Objective. The prevalence of Abdominal Aortic Aneurysm (AAA) is higher for First Degree Relatives to AAA-patients compared to the general population, regardless of sex. The prevalence of AAA is also higher in the North of Sweden compared to the Mid and South. A regional strong hereditary trait has been suggested as an explanation to this. The aim of this study was to investigate if siblings to AAA-patients in the North have a higher prevalence of AAA compared to siblings in the Mid-region. Design. Cohort study. Materials and Methods. All patients treated for AAA in a northern region (Norrbotten county, North) were screened for siblings. Consenting siblings, age 40–80, were examined (n?=?379) with ultrasound. The results were compared to the previously published results of 150 ultrasound-screened siblings in the Mid-region (Stockholm county). Results. The male/female ratio in the sibling cohort was 48% vs 52%. The prevalence of AAA in siblings in the North was 37/379 (brothers 14%, sisters 6%). This was not different from the prevalence among the Mid-region siblings 16/150 (brothers 17%, sisters 6% (p?=?0.75). The distribution of risk factors was similar in the two regions. Conclusion. The results reinforce the importance of a more systematic approach towards selective screening of all siblings to AAA patients. Ultrasound should be performed in all eligible siblings, since the distribution of AAA is similar over regions. A correlation between the familial distribution and the reported high prevalence of AAA in general population in the North could not be shown.     

Anaesthesia for open abdominal aortic surgery

The prevalence of abdominal aortic aneurysm (AAA) has declined in recent years and according to the annual National Vascular Registry reports (2016–20) the number of patients undergoing aneurysm repair has been steadily decreasing over the last five years. The UK has worked tirelessly to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement programme. Reducing death from ruptured aortic aneurysm has been the focus of the national screening programme. The short-term benefits of EVAR when compared to open repair are well described, however, the long-term survival benefits, freedom form re-intervention and cost effectiveness of EVAR have been demonstrated to be dominated by open surgery. That is that people with intact AAA should be offered open surgery if medically suitable. The choice of technique for emergency AAA repair is less contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options in those who are anatomically suitable for EVAR. Technical analysis by NICE has consistently reported favourable outcomes with EVAR in the emergency setting and that it is a cost-effective treatment. In this article we provide an overview of the evidence supporting the different treatment options, outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management.     

Risk of developing an abdominal aortic aneurysm after ectatic aorta detection from initial screening

ObjectiveCurrent abdominal aortic aneurysm (AAA) surveillance guidelines lack any follow-up recommendations after initial abdominal aortic screening diameter of less than 3.0 cm. Some reports have demonstrated patients with late AAA formation and late ruptures after initial ultrasound screening detection of patients with an aortic diameter of 2.5 to 2.9 cm (ectatic aorta). The purpose of this study was to determine ectatic aorta prevalence, AAA development, rupture risk, and risk factor profile in patients with detected ectatic aortas in a AAA screening program.MethodsA retrospective chart review of all patients screened for AAA from January 1, 2007, to December 31, 2016, within a regional health care system was conducted. Screening criteria were men 65 to 75 years of age that smoked a minimum of 100 cigarettes in their lifetime. An ectatic aorta was defined as a maximum aortic diameter from 2.5 to 2.9 cm. An AAA was defined as an aortic diameter of 3 cm or greater. Patients screened with ectatic aortas who had subsequent follow-up imaging of the aorta with a minimum of 1-year follow-up were analyzed for associated clinical and cardiovascular risk factors. All data were collected through December 3,/2018. A logistic regression of statistically significant variables from univariate and χ² analyses were performed to identify risks associated with the development of AAA from an initially diagnosed ectatic aorta. A Cox proportional hazard model was used to assess survival data. A P value of less than .05 was considered statistically significant.ResultsFrom a screening pool of 19,649 patients, 3205 (16.3%) with a mean age of 72.1 ± 5.3 years were identified to have an ectatic aorta from January 1, 2007, to December 31, 2016. The average screening ectatic aortic diameter was 2.6 ± 0.1 cm. There were 672 patients (21.0%) with a mean age of 73.0 ± 5.7 years who received subsequent imaging for other clinical indications and 193 of these patients (28.7%) with ectatic aortas developed an AAA from the last follow-up scan (4.2 ± 2.5 years). The average observation length of all patients was 6.4 ± 2.9 years. No ruptures were reported, but 27.8% of deaths were of unknown cause. One patient had aortic growth to 5.5 cm or greater (0.15%). Larger initial screening diameter (P < .01), presence of chronic obstructive pulmonary disease (P < .01), and active smoking (P = .01) were associated with AAA development.ConclusionsPatients with diagnosed ectatic aortas from screening who are active smokers or have chronic obstructive pulmonary disease are likely to develop an AAA.     

Screening for abdominal aortic aneurysm with electronic clinical reminders

Background

Based on randomized, population-based screening protocols, a single ultrasound examination reduces mortality from an abdominal aortic aneurysm (AAA) by facilitating elective surgical intervention before rupture. Ultrasound screening is accurate, noninvasive, inexpensive, and cost effective. By using a comprehensive electronic medical record, we inquired whether an age-prompted clinical reminder would facilitate the detection of AAA.

Methods

The AAA risk screen was installed in May 2007 via a computerized patient record system prompt for male veterans ages 65 to 75 who ever smoked. This abbreviated ultrasound examination uses a 3.5- to 4-MHz scan head, measures anteroposterior and transverse planes, and reports the largest infrarenal aortic diameter.

Results

Of 1437 examinations there were 73 AAAs of 3.0-cm diameter or larger (5.1%); 33 AAAs of 4.0-cm diameter or larger (2.3%); 15 AAAs of 5.0-cm diameter or larger (1.0%); and 11 AAAs of 5.5-cm diameter or larger (.77%). Fifty (68%) received counseling for abnormal findings.

Conclusions

Recognition of newly diagnosed AAA compared favorably with that of previous screening studies. Electronic clinical reminders identify undiagnosed, life-threatening AAAs before rupture. Immediate counseling is available in the vascular setting.     

Real-world cost analysis of endovascular repair versus open repair in patients with nonruptured abdominal aortic aneurysms

BackgroundThe aim of this study was to provide a nationwide, all-payer, real-world cost analysis of endovascular aortic aneurysm repair (EVAR) versus open aortic aneurysm repair (OAR) in patients with nonruptured abdominal aortic aneurysms (non-rAAA).MethodsAll non-rAAA patients registered between July 2009 and March 2015 in the Premier Healthcare Database were analyzed. The Student t-test and the χ² test were used for continuous and categorical variables, respectively; median value comparisons were done with the Wilcoxon-Mann-Whitney rank-sum test. The in-hospital absolute mean total cost (sum of fixed cost and variable cost) and subcategories were analyzed after adjustment for inflation at July 2015. Fixed costs included all overhead costs while variables costs included in-hospital services including procedures, room and board, services provided by hospital staff, and pharmacy costs. Total cost was stratified based on admission type (emergency vs nonemergency), 75th percentile of length of hospital stay among individual procedures (expected vs extended stay), mortality, and complications. Student t-test and Fisher's analysis of variance were used for comparing mean cost. Year-wise comparison of mean cost was done with analysis of variance to look for a trend over time.ResultsOur study cohort included 38,809 non-rAAA patients (33,171 EVAR and 5638 OAR). The mean total cost of index admission was lower in EVAR in comparison with OAR ($32,052 vs $36,091; P < .001), with lower fixed costs ($11,309 vs $16,818; P < .001) and higher variable costs ($20,743 vs $19,272; P < .001). Cost of pharmacy, labor, operating room, room and board and other costs were significantly higher with OAR, whereas the supply cost was higher with EVAR. The expected hospital length of stay of patients who underwent EVAR was associated with a higher total cost ($27,271 vs $25,680; P < .001) and a higher variable cost ($18,186 vs $13,671; P < .001) than OAR patients. However, the extended hospital stay of patients who underwent EVAR had lower costs in all categories compared with the extended length of stay of those who underwent OAR. Mortality associated with EVAR was costlier than OAR associated mortality (mean $72,483 vs $59,804; P = .017). From 2009 to 2014, the mean total cost of EVAR increased significantly by 18.5% ($28,745 vs $34,049; P < .001) owing to a 7.8% increase in fixed costs ($10,931 vs $11,789; P < .001) and a 25.0% increase in variable costs ($17,804 vs $22,257; P < .001). The mean total cost OAR remained stable over time.ConclusionsOverall hospitalization costs associated with EVAR of non-rAAA was lower than the hospitalization cost of OAR. Interestingly, we found that, among patients who had an expected hospital length of stay, the hospitalization cost after OAR was significantly lower than after EVAR. The average hospitalization cost of OAR was stable during the 5 years study period, whereas the hospitalization cost of EVAR increased significantly over time. Further studies are required to identify reasons for increased costs associated with EVAR.     

Screening for clinically unsuspected abdominal aortic aneurysms in patients with peripheral vascular disease

In patients with abdominal aortic aneurysms, most fatalities occur from rupture before the patient can be brought to hospital. Even when seen in hospital the mortality is still approximately 50% in contrast to elective repair which has a substantially reduced mortality of less than 5%. In order to reduce the number of patients dying from rupture, they must be diagnosed early to allow elective intervention, hence there has been considerable renewed interest in screening for abdominal aortic aneurysms. We have studied a consecutive series of 104 patients with either claudication or ischaemic rest pain in the lower limbs to determine the incidence of aortic aneurysms in this type of patient.     

Importance of cardiovascular interventions before surgery for abdominal aortic aneurysms

Preoperative screening, and interventional and surgical therapy of cardiovascular diseases are of pivotal importance for successful outcome after abdominal aortic aneurysm surgery. In a retrospective study, all patients who underwent surgery for abdominal aortic aneurysm were reevaluated by preoperative diagnostic and therapeutic interventions for cardiovascular disease. Two study periods (1980-1989 and 1990-1996) were compared. Of 603 patients operated upon for abdominal aortic aneurysm between 1980 and 1996, 449 had surgery on an elective basis and 154 as an emergency. Preoperative diagnostic studies for coronary artery disease were performed on elective patients and were positive in 76.8% (1980-1989, 76.1%, 1990-1996, 77.5%). Coronary angiography was performed in 108 patients (29.6%). Medical therapy of coronary artery disease declined by 2.3%, and interventional procedures by 18.8%. In contrast, myocardial revascularization with subsequent aneurysm resection increased by 26.6% and 12 patients (16%) required urgent simultaneous cardiac and aortic surgery. Early mortality after abdominal aortic aneurysm surgery decreased from 4.2 to 2.9%, and the frequency of primary cardiac failure as the cause of death was reduced from 33.3 to 22.2% (P < 0.05). It was concluded that 42.6% more cardiac surgical procedures were performed before abdominal aortic aneurysm surgery since 1990 compared with the period 1980-1989. In contrast, the number of interventional procedures fell by 18.8%. Surgical therapy of cardiac disease reduces early mortality after elective abdominal aortic aneurysm surgery.     

Anaesthesia for open abdominal aortic surgery

The prevalence of abdominal aortic aneurysm (AAA) and the number of patients undergoing aneurysm repair is increasing. The UK has worked tirelessly to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement programme. Reducing death from ruptured aortic aneurysm has been the focus of the national screening programme. Despite the increased prevalence of disease and intervention, the popularity of open repair has diminished since the advent of endovascular repair (EVAR). The short-term benefits of EVAR when compared to open repair are well described; however, the long-term survival benefits, freedom form re-intervention and cost effectiveness of EVAR are not proven. The choice of technique for emergency AAA repair is contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options. In this article we provide an overview of the evidence supporting the different treatment options, outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management.     

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

Background: The Asian population is believed to have lower incidence of abdominal aortic aneurysm (AAA), and hence, the benefit of screening is uncertain. The size of native aorta in Asians, which shall affect the definition of AAA, has also never been reported. Our study investigated the prevalence of AAA and the infra‐renal aortic diameter (AD) in Chinese patients with severe coronary artery disease. Methods: This is a prospective observational study of infra‐renal aortic size for patients who had coronary artery bypass surgery by ultrasound. The patients' demographics, important co‐morbidities and maximum AD were recorded. Results: The study included 624 consecutive Chinese patients (mean age = 63.2 years). The mean maximum infra‐renal AD was 17.5 mm for men and 14.8 mm for women. The presence of AAA was defined as maximum AD greater than 30 mm. The result was also compared with an alternate definition that defines AAA as maximum AD of greater than 1.5 times of the group's mean. Eleven patients had an AD greater than 30 mm, and the prevalence of AAA was only 1.8%. With AAA defined as maximum AD of 1.5 times greater than the group's mean, 19 patients had AAA. The prevalence of AAA in this high‐risk group would become 3% overall. Conclusion: The prevalence of AAA in Chinese patients was low, and the result did not support routine screening. The smaller mean infra‐renal AD in Chinese merits validation by large‐scale study and consideration when deciding threshold for small AAA repair in our locality.     

Screening for abdominal aortic aneurysms does not increase psychological morbidity.

Screening can lead to harmful psychological effects in the screened population--an argument used against abdominal aortic aneurysm (AAA) screening. However, there is no evidence for this in AAA screening. We applied the Hospital Anxiety and Depression Scale (HADS) to a group of men undergoing screening for AAA. The HADS questionnaire was completed by subjects found not to have AAA, subjects with known small aneurysms attending for follow-up scans, subjects with known AAA on waiting lists for surgery, and controls not involved in the screening programme. The groups were well matched for age and the number of additional diseases. There was no significant difference in the distribution of patients for anxiety and depression according to the HADS questionnaire (chi 2 test, P > 0.1). The results from this study suggest that AAA screening does not increase anxiety or depression in the screened subjects--contrary to the argument put forward against screening for this condition.     

Abdominal aortic aneurysms: screening,epidemiology and open surgical repair

Abdominal Aortic Aneurysm (AAA) is a dilatation of the infra-renal abdominal aorta to greater than 3 cm. Population screening is offered to men in their 65th year in the UK. Patients with small AAAs (<5.5 cm) are entered into surveillance programs and should have cardiovascular risk factors managed aggressively. An AAA with ≥5.5 cm diameter should be considered for surgical repair to prevent rupture. Open surgical repair has proven to be a durable treatment for AAA and while less often performed than endovascular aneurysm repair (EVAR) it remains a common approach in the surgical management of AAA. While associated with higher short-term risks than EVAR, the long-term outcomes are similar and many younger patients have a preference for open repair as routine follow-up is not required.     

Malignant neoplasia in patients with abdominal aortic aneurysms

Thirty-eight percent of 69 patients with abdominal aortic aneurysms were on record for having malignant neoplasms with the Connecticut State Tumor Registry five to ten years following aneurysm repair. Thirteen percent of 61 patients with atherosclerotic occlusive disease were on record for having malignant neoplasms as a contemporaneous case-control group. The crude and adjusted odds-ratios for this difference in patients with aneurysms v patients with atherosclerotic disease were statistically significant. There are several theoretical explanations for these observations, spanning the gamut from possible immunologic mechanisms to hypothetical disturbances in the relationship of epithelia to connective-tissue matrix in the patients with aneurysms.     

Repair of abdominal aortic aneurysms in high-risk patients

Today, repair of an abdominal aortic aneurysm with interposition prosthetic graft replacement is the only reliable method of preventing aneurysm rupture. The Mayo experience demonstrates that this repair also can be accomplished in high-risk patients with very acceptable morbidity and low mortality rates. However, it must be emphasized that these results are related not only to the surgical procedure itself but also to vigorous perioperative medical support, including intraoperative pharmacologic enhancement of cardiac function, intra-aortic balloon counterpulsation if necessary, and intensive postoperative pulmonary management. When resources are available for intensive intraoperative and postoperative support, direct graft repair is the treatment of choice for high-risk patients with abdominal aortic aneurysms.