Outcome after abdominal aortic aneurysm repair. Difference between men and women.

OBJECTIVES: To evaluate short- and long-term outcome after open repair for ruptured and non-ruptured abdominal aortic aneurysm (AAA) with special emphasis on the difference between men and women. DESIGN: Single center retrospective study. Time and cause of death were determined from hospital charts, the National Bureau of Statistics and the Department for National Health and Welfare. Materials. Eight hundred and forty-six patients were followed-up, 597 were operated on for non-ruptured and 249 for ruptured aneurysms. METHODS: Case fatality was analyzed by multiple logistic regression considering year of surgery, age at surgery, and gender as covariates. The mortality rate for patients surviving 60 days after surgery was compared with the mortality in the general population by calculating the standardised mortality ratio (SMR). Mortality was also stratified according to gender and type of surgery. RESULTS: The SMR for patients surviving 60 days after surgery was significantly increased. SMR was significantly higher for women than for men. There was no statistically significant difference in SMR between patients operated for rupture compared to those operated for non-ruptured aneurysms. CONCLUSIONS: Women with AAA have a poorer outcome than women in the general population. This finding may relate to the large number of risk factors present in this patient sub-group.     

The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004

INTRODUCTION: The elective repair of abdominal aortic aneurysms (AAA) may decrease a patient's risk of rupture and confers a significantly lower in-hospital mortality rate than emergency repair. Previous works have shown that AAA rupture rates are higher in women compared to men, and that women have higher associated in-hospital mortality rates. This study was performed to evaluate, currently, to what extent patient gender influences presentation and treatment of AAA and the associated outcomes in the United States. METHODS: The Nationwide Inpatient Sample was used, with pertinent ICD-9 codes, to identify all patient-discharges that occurred with the primary diagnosis of intact (iAAA) or ruptured/dissecting (rAAA) abdominal aortic aneurysms between the years 2001 and 2004. Univariate and multiple logistic regression analyses of variables were performed. RESULTS: An estimated 220,403 AAA patient-discharges were identified during the study period. 37,016 (17%) patients presented with rAAA. A higher percentage of women with AAA presented with rupture compared to men (21% vs 16%; odds ratio [OR] 1.40, 95% confidence interval [CI], 1.27-1.54). This rupture rate did not significantly change from 2001 to 2004 (P = .85 for trend). For iAAA, women had higher odds of in-hospital mortality than men (OR 1.60; 95% CI, 1.24-2.07). Compared to men, in-hospital mortality rates for women with iAAA were higher for both endovascular (2.1% vs 0.83%, P < .0001) and open repairs (6.1% vs 4.0%, P < .0001). For iAAA, fewer women underwent endovascular repair (32.4% vs 46.7%, P < .0001; O.R. 0.59, 95% CI, 0.52-0.67). For patients who presented with rAAA, women were less likely to undergo surgical intervention compared to men (59% vs 70%, P < .0001). For those that underwent repair, women had higher in-hospital mortality rates than men (43% vs 36%, P < .0001; OR 1.49, 95% CI, 1.16-1.91). CONCLUSION: A higher percentage of women currently present with aneurysm rupture. They have higher in-hospital mortality rates for both iAAA and rAAA. This gender difference in the outcomes following repair of abdominal aortic aneurysm has persisted over time, the cause of which is not explained by these or previous data, a fact that warrants further investigation.     

Peroperative factors influencing the outcome of elective abdominal aorta aneurysm repair.

PURPOSE: To identify perioperative variables which may influence mortality of elective abdominal aneurysm repair (AAA). METHOD: prospective study of patients undergoing elective AAA repair between 1986 and 1997. RESULTS: Four hundred and seventy patients (438 men, 32 females) with a mean age of 69.4+/-13 years and aneurysms with a diameter of 60+/-3 mm were operated on with a 1-month mortality rate of 5.3%. Multivariate analysis identified the following independent risk factors for mortality: age >70 (p<0.0001), a past history of myocardial infarction (p<0.0001), preoperative renal insufficiency (p<0.0001), reoperation (p<0.0001), colonic necrosis (p<0.0001), and severe postoperative medical complications (p<0.0001). CONCLUSION: Intra- and postoperative events affect the outcome of AAA repair, independently of preoperative factors, and should be described when presenting the results of AAA repair.     

Influence of gender on outcome from ruptured abdominal aortic aneurysm

BACKGROUND: The aim of the present study was to compare outcomes following ruptured abdominal aortic aneurysm (AAA) in men and women. METHODS: Overall mortality from ruptured AAA was compared in men and women using the Western Australia Health Services Research Database. The linked chains of de-identified hospital morbidity and death records were selected using the ICD-9-CM (International Classification of Diseases - Clinical Modification) diagnostic and procedure codes pertaining to AAA. Cases were divided into three groups for analysis: patients who died without admission to hospital, those admitted to hospital with a ruptured AAA but who did not undergo operation, and patients who underwent operation for ruptured AAA. RESULTS: Ruptured AAA occurred in 648 men and 225 women over the age of 55 years during the decade 1985-1994. Only 50 per cent of women, compared with 59 per cent of men, were admitted to hospital. Of those admitted to hospital only 37 per cent of women underwent operation, compared with 63 per cent of men. The overall mortality rate from ruptured AAA was 90 per cent in women and 76 per cent in men (chi2 = 50.34, 1 d.f., P < 0.0001). Although women were, on average, 6 years older than men, this unfavourable pattern occurred across all age groups. CONCLUSION: Women with a ruptured AAA are more likely to die than men. More research is required to identify the causes of this sex difference.     

Relatively high pulmonary and cardiovascular mortality rates in screening-detected aneurysmal patients without previous hospital admissions.

BACKGROUND: Men with abdominal aortic aneurysm (AAA) who are not hospitalised for pulmonary and cardiovascular diseases may have higher mortality due to such disorders. MATERIAL AND METHODS: Previous discharge diagnoses and causes of death were collected for 4,816 men aged 64-73 years attending mass screening for AAA. Of these, 191 (4%) had an AAA. Overall, cardiovascular- and pulmonary-disease-specific mortality was compared for men with and without AAA stratified for earlier pulmonary or cardiovascular hospitalisations by Cox's proportional hazards regression while adjusting for age. Absolute risk differences after five years were calculated by life table analysis. RESULTS: The median observation time was 63 months. 362 men died from cardiovascular causes other than AAA, and 144 died from pulmonary causes. The cardiovascular mortality was significantly higher in aneurysm patients without previous related hospitalisation (HR=4.35, 95% CI: 2.73-6.94, P<0.001) with an absolute mortality difference after 5 years of 16.3% (95% CI: 10.2-22.5%). Pulmonary-cause mortality was higher among men with AAA both with and without previous hospitalisation for pulmonary causes (HR=3.05; 95% CI: 1.19-7.83, P=0.020, and HR=3.29; 95% CI: 1.78-6.08, P<0.001, respectively). CONCLUSIONS: Men with AAA who had not been hospitalised for cardiovascular diseases have more than four times higher cardiovascular mortality. Studies of cohorts being offered relevant prophylaxis may clarify the potential benefits of general preventive actions.     

Differences between women and men in surgical treatment and case fatality rates for ruptured aortic abdominal aneurysm in England

BACKGROUND: Differences between women and men in treatment and outcome after admission with a ruptured abdominal aortic aneurysm (AAA) in England were studied. METHODS: Routinely collected data in Hospital Episode Statistics, linked to death records, for emergency admissions for ruptured AAA in England were analysed. The percentage of patients who underwent surgical repair was calculated, together with 30-day case fatality rates and age-adjusted odds ratios (ORs), comparing women with men. RESULTS: A total of 2463 women and 7615 men were admitted with a primary diagnosis of ruptured AAA (mean age 79.8 and 74.9 years respectively); 39.6 per cent of women and 66.4 per cent of men underwent surgical repair (OR 0.47 (95 per cent confidence interval 0.42 to 0.52)). Overall, 75.6 per cent of women and 61.7 per cent of men died within 30 days of admission (OR 1.36 (1.22 to 1.52)). The death rate for women and men who had surgery was similar (OR 1.01 (0.88 to 1.17)); when no operation was performed the mortality rate was higher in women, but not significantly so (OR 1.14 (0.91 to 1.42)). CONCLUSION: Women with a ruptured AAA were less likely to be treated surgically than men, and their overall mortality rate was higher. Lower rates of surgery in women than in men may contribute to the higher mortality in women, but other explanations are possible.     

Cost-effectiveness of screening women for abdominal aortic aneurysm

BACKGROUND: Women are usually not considered for abdominal aortic aneurysm (AAA) screening because of their lower prevalence of disease. This position may, however, be questioned given the higher risk of rupture and the longer life expectancy among women. The purpose of this study was to assess the cost-effectiveness of screening 65-year-old women for AAA. METHODS: A systematic review of the literature was conducted to obtain data of importance to evaluate the effectiveness of screening women for AAA. Data were entered into a Markov simulation cohort model. RESULTS: The review suggested some main assumptions for women with AAA. Prevalence is 1.1%. In 6.8%, the AAA is of a size that merits surgery, and the patients are fit for a procedure. For patients with an AAA, the yearly risk for elective surgery and the rupture incidence was 3.1% and 2.4%, respectively, in the invited group and 1.1% and 5.7% in the noninvited group. The operative mortality for elective surgery was 3.5%, and the total mortality for ruptured AAA was 86.3%. The long-term mortality for AAA patients was 3.6 times higher than for an age-matched healthy population. Screening reduced the AAA rupture incidence by 33% and the AAA-related death rate by 35%. The cost per life year gained was estimated at $5911. CONCLUSION: The incremental cost-effectiveness ratio was similar to that found for screening men, which reflects the fact that the lower AAA prevalence in women is balanced by a higher rupture rate. Screening women for AAA may be cost-effective, and future evaluations on screening for AAA should include women.     

Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994

Purpose: Little is known about the long-term growth and outcomes of vascular surgery procedures over time. Trends in the use of three major vascular surgery procedures by a general population—lower extremity arterial bypass (LEAB), carotid endarterectomy (CEA), and abdominal aortic aneurysm repair (AAA)—are described. The extent to which these procedures are being performed in low-, moderate-, and high-volume hospitals is examined. Methods: California hospital discharge records for LEAB, CEA, AAA, lower extremity angioplasty, coronary angioplasty, and coronary bypass surgery (CABG) were studied in all non-federal hospitals between 1982 and 1994. The data were age- and sex-adjusted to describe procedure growth. In-hospital mortality rates for LEAB, CEA, and AAA are related to overall hospital procedure volume, using logistic regression to control for risk factors and time trends. Results: Growth in the number of vascular procedures performed in California was modest between 1982 and 1994, with no age-adjusted growth. Lower extremity angioplasty grew considerably in the 1980s and has since plateaued. Annual in-hospital death rates declined for all procedures except ruptured AAA. Comparing the two 5-year periods of 1982–1986 and 1990–1994, in-hospital death rates decreased from 4.2% to 3.3% for LEAB, from 9.2% to 6.2% for unruptured AAA, and from 1.6% to 1.0% for CEA (p < 0.0001). The odds of dying for patients treated in high-volume hospitals for LEAB and CEA procedures compared with patients treated in hospitals performing fewer than 20 procedures in a year were 66.7% (p = < 0.0001) and 66.1% (p < 0.0001), respectively. For patients with ruptured and unruptured AAA procedures, the odds of dying in hospitals with at least 50 AAA procedures in a year were 49.1% (p < 0.0001) and 83.8% (p = 0.016), respectively, compared with the odds of dying in low-volume hospitals. Conclusions: In-hospital mortality rates for CEA, LEAB, and unruptured AAA have been significantly decreasing over time. Mortality is inversely related to hospital volume and directly related to patient age and emergency status. Mortality trends over time for ruptured AAA remains unchanged; however, mortality is less in high-volume hospitals. Coronary angioplasty (PTCA) has not had an impact on rates for LEAB. (J Vasc Surg 1998;28:45-58)     

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE: To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective study. MATERIAL AND METHODS: The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS: At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS: The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.     

Factors associated with development of large abdominal aortic aneurysm in middle-aged men.

OBJECTIVES: To investigate whether any variables in a health-screened population study were associated with later development of large abdominal aortic aneurysms (AAA). SETTING: Malm?, Southern Sweden. MATERIAL AND METHODS: Within the Malm? Preventive Study 22,444 men and 10,982 women were investigated between 1974 and 1991. The mean age at the health screening was 43.7 years. RESULTS: After a median follow-up of 21 years, 126 men and six women (p<0.001) had large AAA that were symptomatic or evaluated for operation (5 cm diameter or more) or had autopsy-verified ruptured AAA. The male group (mean age 47 years) was, because of difference in age (p<0.001) also compared with an age-matched control group. The male patients with AAA showed increased diastolic blood pressure (p<0.007) at the health screening. Smoking predicted the development of AAA (p<0.0001). No difference in forced vital capacity or BMI was seen. Those who were physically inactive (e.g. not walking or cycling to work) had an increased risk of developing AAA (p<0.001). Among the laboratory markers measured, the erythrocyte sedimentation rate did not differ (7.1+/-5.9 vs. 6.4+/-5.7), but cholesterol (6.3+/-1.12 vs. 5.8+/-1.0) (p<0.0001) and triglycerides (1.9+/-0.12 vs. 1.5+/-0.07) (p<0.001) were significantly elevated in these individuals who subsequently developing AAA. The inflammatory proteins alfa-1-antitrypsin, ceruloplasmin, orosmucoid, fibrinogen, and haptoglobulin were increased (p<0.001). CONCLUSION: Male gender, smoking, physical inactivity and cholesterol are significant factors associated with the development of AAA.     

Growth rate and associated factors in small abdominal aortic aneurysms.

OBJECTIVE: To study the growth rate and factors influencing progression of small infrarenal abdominal aortic aneurysms (AAA). DESIGN: Observational, longitudinal, prospective study. PATIENTS AND METHODS: We followed patients with AAA <5 cm in diameter in two groups. Group I (AAA 3-3.9 cm, n = 246) underwent annual ultrasound scans. Group II (AAA 4-4.9 cm, n = 106) underwent 6-monthly CT scans. RESULTS: We included 352 patients (333 men and 19 women) followed for a mean of 55.2+/-37.4 months (6.3-199.8). The mean growth rate was significantly greater in group II (4.72+/-5.93 vs. 2.07+/-3.23 mm/year; p<0.0001). Group II had a greater percentage of patients with rapid aneurysm expansion (>4 mm/year) (36.8 vs. 13.8%; p<0.0001). The classical cardiovascular risk factors did not influence the AAA growth rate in group I. Chronic limb ischemia was associated with slower expansion (< or = 4 mm/year) (OR 0.47; CI 95% 0.22-0.99; p = 0.045). Diabetic patients in group II had a significantly smaller mean AAA growth rate than non-diabetics (1.69+/-3.51 vs. 5.22+/-6.11 mm/year; p = 0.032). CONCLUSIONS: The expansion rate of small AAA increases with the AAA size. AAA with a diameter of 3-3.9 cm expand slowly, and they are very unlikely to require surgical repair in 5 years. Many 4-4.9 cm AAA can be expected to reach a surgical size in the first 2 years of follow-up. Chronic limb ischemia and diabetes are associated with reduced aneurysm growth rates.     

Abdominal aortic aneurysms in aged patients: analysis of risk factors in non-ruptured cases

BACKGROUND AND METHODS: A retrospective analysis of 304 patients (274 males and 30 females) surgically treated for non-ruptured, infrarenal abdominal aortic aneurysm (AAA) to determine the relative contribution of preoperative, operative, and postoperative factors to mortality and to the development of postoperative complications. 1) Risk factors, hospital mortality and long-term survival rate were compared between patients aged 75 or older (- group I; n=79) and those under 75 years of age (group II; n=225). 2) These risk factors were subjected to univariate and multivariate analysis to determine their relative contribution to patient hospital mortality and to the development of major postoperative complications in aged patients. RESULTS: Maximum diameter of AAA, the prevalence of respiratory dysfunction, diabetes mellitus and the total volumes of intraoperative blood loss were significantly different between the two groups. A higher hospital mortality was noted in the aged patients (10.1% versus 3.1%, p<0.05). The majority of deaths in group I resulted from organ dysfunctions, especially involved with respiratory failure. The long term survival rate at 3 and 5 years was not different between operative survivors in the two groups. Incremental risk factors for hospital death in aged patients included the presence of symptomatic AAA, the maximum diameter of AAA, the postoperative development of myocardial infarction, respiratory complications and gastrointestinal bleeding. Operation time and the volumes of intraoperative blood loss significantly correlated with the postoperative development of respiratory failure, renal failure and multiple organ failure. CONCLUSIONS: 1) A higher operative mortality and higher prevalence of postoperative complications were noted in aged patients with AAA. 2) To reduce operation time and the volumes of intraoperative blood loss would be essential to improve surgical results of AAA in aged patients.     

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS: The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs. MATERIAL AND METHODS: 110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model. RESULTS: Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard). CONCLUSIONS: Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.     

Endovascular repair or surveillance of patients with small AAA.

OBJECTIVE: To compare the outcome of patients with small abdominal aortic aneurysms (AAA) treated in a prospective trial of endovascular aneurysm repair (EVAR) to patients randomized to the surveillance arm of the UK Small Aneurysm Trial. METHOD: All patients with small AAA (< or = 5.5 cm diameter) treated with a stent graft (EVARsmall) in the multicenter AneuRx clinical trial from 1997 to 1999 were reviewed with follow up through 2003. A subgroup of patients (EVARmatch) who met the age (60-76 years) and aneurysm size (4.0-5.5 cm diameter) inclusion criteria of the UK Small Aneurysm Trial were compared to the published results of the surveillance patient cohort (UKsurveil) of the UK Small Aneurysm Trial (NEJM 346:1445, 2002). Endpoints of comparison were aneurysm rupture, fatal aneurysm rupture, operative mortality, aneurysm related death and overall mortality. The total patient years of follow-up for EVAR patients was 1369 years and for UK patients was 3048 years. Statistical comparisons of EVARmatch and UKsurveil patients were made for rates per 100 patient years of follow up (/100 years) to adjust for differences in follow-up time. RESULTS: The EVARsmall group of 478 patients comprised 40% of the total number of patients treated during the course of the AneuRx clinical trial. The EVARmatch group of 312 patients excluded 151 patients for age < 60 or > 76 years and 15 patients for AAA diameter < 4 cm. With the exception of age, there were no significant differences between EVARsmall and EVARmatch in pre-operative factors or post-operative outcomes. In comparison to the UKsurveil group of 527 patients, the EVARmatch group was slightly older (70 +/- 4 vs. 69 +/- 4 years, p = 0.009), had larger aneurysms (5.0 +/- 0.3 vs. 4.6 +/- 0.4 cm, p < 0.001), fewer women (7 vs. 18%, p < 0.001), and had a higher prevalence of diabetes and hypertension and a lower prevalence of smoking at baseline. Ruptures occurred in 1.6% of EVARmatch patients and 5.1% of UKsurveil patients; this difference was not significant when adjusted for the difference in length of follow up. Fatal aneurysm rupture rate, adjusted for follow up time, was four times higher in UKsurveil (0.8/100 patient years) than in EVARmatch (0.2/100 patient years, p < 0.001); this difference remained significant when adjusted for difference in gender mix. Elective operative mortality rate was significantly lower in EVARmatch (1.9%) than in UKsurveil (5.9%, p < 0.01). Aneurysm-related death rate was two times higher in UKsurveil (1.6/100 patient years) than in EVARmatch (0.8/100 patient years, p = 0.03). All-cause mortality rate was significantly higher in UKsurveil (8.3/100 patient years) than in EVARmatch (6.4/100 patient years, p = 0.02). CONCLUSIONS: It appears that endovascular repair of small abdominal aortic aneurysms (4.0-5.5 cm) significantly reduces the risk of fatal aneurysm rupture and aneurysm-related death and improves overall patient survival compared to an ultrasound surveillance strategy with selective open surgical repair.     

Negative association between infra-renal aortic diameter and glycaemia: the Health in Men Study.

OBJECTIVE: There is evidence of a negative association between diabetes and abdominal aortic aneurysm (AAA). The aim of this study was to assess whether there is a similar relationship between both diabetes and glucose level, and infra-renal aortic diameter throughout its range. DESIGN AND METHODS: Infra-renal aortic diameter was measured using ultrasound in 12,203 men aged 65-83 years as part of a trial of screening for AAA. A range of cardiovascular risk factors were also assessed. In a follow-up study, fasting serum glucose was measured in 2,859 non-diabetic men. Aortic diameter was logarithmically transformed and treated as both a continuous and categorical variable in stepwise multivariate linear and logistic models. RESULTS: The median aortic diameter was slightly smaller in the diabetic men (21.3+/-3.9 vs 21.6+/-3.8, P<0.0001). There was an independent negative association between diabetes and AAA (OR 0.79, 95% CI: 0.63,0.98), and an inverse correlation (Coefficient: -0.0064, p=0.0024) between fasting glucose and aortic diameter in non-diabetic men. CONCLUSIONS: Diabetes is inversely associated with both AAA and aortic diameter in men over 65 years. This association is independent of other risk factors for AAA. Aortic diameter also has an inverse relationship with fasting glucose concentrations in men without diabetes.     

Ultraschallscreening auf abdominale Aortenaneurysmen (AAA)

Background

Abdominal aortic aneurysm (AAA) rupture is associated with a high mortality. The only preventive therapy is early diagnosis and elective surgery of rupture prone AAAs. Using B-mode sonography AAAs can be detected early with great reliability. Thus, a population-based ultrasound screening might lower the risk of abdominal aortic aneurysm ruptures.

Materials and methods

A literature analysis (until June 2014) was performed in the databases of MEDLINE, PubMed, and SCOPUS including all randomized controlled trials (RCT), systematic reviews, meta-analyses, health technology assessments (HTA reports) and medical guidelines on AAA screening. The following keywords were used: abdominal aortic aneurysm, ultrasound screening, evidence, guidelines. Clinically relevant endpoints were the following: AAA-associated mortality, overall mortality, number of elective AAA operations, number of ruptured AAAs and emergency surgery for different follow-up intervals.

Results

In four RCTs men between 65 and 83 years either had a single or no ultrasound examination of the abdominal aorta. Older women were only analyzed in one RCT. The meta-analysis of the RCT results shows that ultrasound screening caused a significant decrease of AAA-associated mortality, number of ruptured abdominal aneurysms, and number of emergency operations, whereas the number of elective surgeries significantly increased. Overall mortality was only moderately decreased by AAA screening.

Conclusion

Evidence was provided in population-based RCTs and meta-analyses for the efficiency of ultrasound based AAA screening for men older than 65 years. Presently the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWIG) are evaluating a national ultrasound-based AAA screening program for Germany. However, additional clinical trials are necessary to assess risk groups especially men under 65 years, women with nicotine abuse and cardiovascular diseases which were underrepresented in previous studies.     

The Impact of Gender on Prognosis After Non-cardiac Vascular Surgery

Objectives

The objective was to evaluate the impact of gender on long-term survival of patients who underwent non-cardiac vascular surgery.

Design, Material and Methods

Our prospectively collected data contained information on 560 patients undergoing carotid endarterectomy (CEA), 923 elective abdominal aortic aneurysm repairs (AAA) and 1046 lower limb reconstructions (LLR). Patient characteristics and long-term mortality of women were compared to that of men. Kaplan–Meier (KM) survival curves were constructed for men and women, on which we superimposed age- and sex-matched KM survival curves of the general population. Cox proportional hazards regression was used to identify risk factors for mortality.

Results

Men in the CEA group had statistically significant higher all-cause mortality, hazard rate ratio (HRR) 1.41 (95% CI 1.01–1.98) No differences in mortality between the genders were observed in the AAA and LLR groups.Overall, men had more co-morbidities but received more disease-specific medication compared to women. Women retained their higher life expectancy after CEA but lost it in the AAA and LLR groups.

Conclusion

Women retain their higher life expectancy after CEA; however, after AAA repair and LLR, this advantage is lost. Both men and women received too little disease-specific medication, but women were worse off.     

Mortality after groin hernia surgery

OBJECTIVE: To analyze mortality following groin hernia operations. SUMMARY BACKGROUND DATA: It is well known that the incidence of groin hernia in men exceeds the incidence in women by a factor of 10. However, gender differences in mortality following groin hernia surgery have not been explored in detail. METHODS: The study comprises all patients 15 years or older who underwent groin hernia repair between January 1, 1992 and December 31, 2005 at units participating in the Swedish Hernia Register (SHR). Postoperative mortality was defined as standardized mortality ratio (SMR) within 30 days, ie, observed deaths of operated patients over expected deaths considering age and gender of the population in Sweden. RESULTS: A total of 107,838 groin hernia repairs (103,710 operations), were recorded prospectively. Of 104,911 inguinal hernias, 5280 (5.1%) were treated emergently, as compared with 1068 (36.5%) of 2927 femoral hernias. Femoral hernia operations comprised 1.1% of groin hernia operations on men and 22.4% of operations on women. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. Mortality risk was not raised above that of the background population for elective groin hernia repair, but it was increased 7-fold after emergency operations and 20-fold if bowel resection was undertaken. Overall SMR was 1.4 (95% confidence interval, 1.2-1.6) for men and 4.2 (95% confidence interval, 3.2-5.4) for women, in accordance with a greater proportion of emergency operations among women compared with men, 17.0%, versus 5.1%. CONCLUSIONS: Mortality risk following elective hernia repair is low, even at high age. An emergency operation for groin hernia carries a substantial mortality risk. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia.     

Influence of sex on expansion rate of abdominal aortic aneurysms

BACKGROUND: The UK Small Aneurysm Trial suggested that female sex is an independent risk factor for rupture of abdominal aortic aneurysm (AAA). This study assessed the effect of sex on the growth rate of AAA. METHODS: Between January 1985 and August 2005 all patients who were referred to the Royal Infirmary of Edinburgh with an AAA who were not considered for early aneurysm repair were assessed by serial abdominal ultrasonography. Maximum anteroposterior and transverse diameters of the AAAs were measured. RESULTS: A total of 1255 patients (824 men and 431 women) were followed up for a median of 30 (range 6-185) months. A median of six examinations (range 2-37) was performed for each patient. Median diameter on initial examination was 41 (range 25-83) mm. Median growth rate overall was 2.79 (range - 4.80-37.02) mm per year. Median growth rate of AAA was significantly greater in women than men (3.67 (range - 1.2-37.02) versus 2.03 (range - 4.80-21.00) mm per year; P < 0.01). Weighted linear regression analysis revealed that large initial anteroposterior AAA diameter and female sex were significant predictors of faster aneurysm growth rate (P < 0.001 and P = 0.006 respectively). CONCLUSION: The growth rate of AAA was significantly greater in women than in men. This may have implications for the frequency of follow-up and timing of repair of AAA in women.     

Trends in mortality and hospital admission rates for abdominal aortic aneurysm in England and Wales, 1979-1999

BACKGROUND: The aim of this study was to investigate trends in population-based mortality, hospital admission and case fatality rates for abdominal aortic aneurysm (AAA) from 1979 to 1999. METHODS: This was an analysis of routine statistics from 79 495 death certificates in England and Wales and 3217 hospital inpatient admissions in the Oxford Region. RESULTS: Mortality rates for all AAAs increased between 1979 and 1999 from 13 to 25 per million in women and from 80 to 115 per million in men. Admission rates increased in the same time interval from three to 22 admissions per million per year in women, and from 52 to 149 per million per year in men. Case fatality rates for all non-ruptured AAAs that were operated on decreased from 25.8 to 9.0 per cent and for all ruptured AAAs from 69.9 to 54.4 per cent. CONCLUSION: Mortality rates and hospital admission rates for AAA rose in men and even more so in women between 1979 and 1999. Perioperative mortality for ruptured AAA declined a little during the study but nonetheless was still very high at the end. This reinforces the importance of detecting and treating AAA before rupture occurs.