The lifetime prevalence of abdominal aortic aneurysms among siblings of aneurysm patients is eightfold higher than among siblings of spouses: an analysis of 187 aneurysm families in Nova Scotia, Canada

BACKGROUND: Abdominal aortic aneurysms (AAAs) are frequently familial. The aim of this study was to compare the prevalence of AAA among the siblings of AAA patients with that in the spouses' siblings. METHODS: The siblings of 375 AAA patients and the siblings of the spouses of the AAA patients were included in this study and offered ultrasonography screening for AAA. Participants were asked to complete a questionnaire to collect demographic and general health information. Statistical analysis was done with Fisher's exact test. Odds ratios and 95% confidence intervals were also calculated. RESULTS: Abdominal ultrasonography examinations were done for 309 individuals. The results indicated that 11 (11.2%) of 98 brothers of AAA patients, 4 (2.7%) of 147 sisters, and none of the 64 siblings of the spouses of the AAA patients were found to have an AAA. Combining the information from the ultrasonography screening and medical records on already known cases of AAA in these families, altogether 29.0% (44/152) of the brothers of AAA patients, 11.1% (20/181) of the sisters of AAA patients, and 2.3% (2/88) of the siblings of the spouses had an AAA. CONCLUSION: There was a significant difference between the siblings of the AAA patients and those of the spouses both in the frequency of AAA detected by ultrasonography screening and in the overall prevalence of AAA. The overall prevalence of AAA in the siblings of AAA patients was about eight times that observed among the siblings of their spouses (19.2% vs 2.3%). These findings confirmed previous reports on high prevalence of AAA among siblings of AAA patients and emphasized the importance of an ultrasonography screening program for siblings of AAA patients.     

The value of screening in siblings of patients with abdominal aortic aneurysm.

OBJECTIVES: This study aimed to determine the incidence of abdominal aortic aneurysm (AAA) in a large group of siblings of Australian AAA patients to determine if screening in this group is justified. METHODS: 1254 siblings of 400 index AAA patients were identified and offered aortic ultrasound screening. An age and sex matched control group was recruited from patients having abdominal CT scans for non-vascular indications. AAA was defined by an infrarenal aortic diameter of > or =3 cm or a ratio of the infrarenal to suprarenal aortic diameter of > or =2.0. A ratio of 1.0-1.5 was considered normal, and a ratio of >1.5 to <2.0 was considered ectatic. Aortic enlargement was defined as ectasia or aneurysm. RESULTS: 276 (22%) siblings could be contacted and agreed to screening or had previously been diagnosed with AAA. All 118 controls had normal diameter aortas. 55/276 siblings had previously been diagnosed with AAA. The remaining 221 siblings underwent ultrasound screening. Overall, 30% (84/276) had enlarged aortas (5% ectasia, 25% aneurysmal); 43% of male siblings (64/150) and 16% of females siblings (20/126). The incidence was 45% in brothers of female index patients, 42% in brothers of male patients, 23% in sisters of female patients, and 14% in sisters of male index patients. CONCLUSIONS: The overall incidence of aortic enlargement of 30% found in this study warrants a targeted screening approach with ultrasound for all siblings of patients with AAA. A similar targeted approach for screening of the children of AAA patients would also seem advisable.     

Influence of presentation on outcome in abdominal aortic aneurysm repair.

OBJECTIVES: In the absence of formal screening abdominal aortic aneurysms (AAA) are detected in an opportunistic manner. Many remain asymptomatic and undetected until they rupture. Incidentally discovered small AAAs are entered into a surveillance programme until they reach a suitable size for repair. The aim of this study was to examine trends in the management of AAA and whether the method of presentation had an effect on subsequent mortality. DESIGN: Observational study in UK district general hospital. MATERIALS/METHODS: This study reports a single surgeon case series identified using a prospectively maintained database. Data on mode of presentation, management and mortality were retrieved from case notes, PIMS hospital database and the Office of National Statistics. RESULTS: Two hundred and five patients were referred with AAAs between 1992 and 2004, 78% presenting in elective circumstances. The surveillance programme fed 33% of the operated cases. Two aneurysms ruptured whilst under surveillance. Overall elective operative mortality was 11.8% and has progressively decreased over time. Thirty-day operated mortality was significantly lower in patients having a period of surveillance than those having immediate elective repair (2.3 vs. 16.3%, p=0.018). A slight reduction in emergency AAA repairs was noted over the study period (r2=0.6) although registered aneurysm deaths continue to increase (r2=0.83). CONCLUSIONS: Elective mortality following AAA surgery decreased over the study period. Outcome was better in those patients who had surgery for aneurysms that had been under surveillance. Despite opportunistic screening the population adjusted mortality rate of aortic aneurysms showed a progressive increase. A reduction in deaths from aneurysms is unlikely without a formal screening programme.     

Peripheral aneurysms and arteriomegaly: Is there a familial pattern?

Purpose: Studies have shown that 11% to 18% of patients with an abdominal aortic aneurysm (AAA) have a first-degree relative with an AAA. A familial pattern among patients with peripheral arterial aneurysms and arteriomegaly has not been reported. The objective of this study was to examine familial patterns among patients with peripheral arterial aneurysm and arteriomegaly and compare them with patterns among patients with AAA. Methods: Pedigrees were constructed for first-degree relatives of patients who received the diagnosis of peripheral arterial aneurysm, arteriomegaly, or AAA from 1988 through 1996. The presence of aneurysms and risk factors was confirmed for patients and relatives by means of telephone interviews and review of hospital and physician records. Results: Seven hundred three first-degree relatives older than 50 years were contacted for 140 probands with peripheral arterial aneurysm, AAA, or arteriomegaly. There were differences in risk factors for hernia and diabetes mellitus among the probands with peripheral arterial aneurysm, AAA, or arteriomegaly but none for relatives. Patients with peripheral arterial aneurysm (n = 40) had a 10% (4/40) familial incidence rate of an aneurysm, patients with AAA (n = 86) had a 22% (19/86) familial incidence rate, and patients with arteriomegaly (n = 14) had a 36% (5/14) familial incidence rate. AAA (24/28, or 86%) was the aneurysm diagnosed most commonly among first-degree relatives. Most aneurysms (85%) occurred among men. Conclusion: There appears to be a gradation of familial patterns from peripheral arterial aneurysm to AAA to arteriomegaly among patients with degenerative aneurysmal disease, and there appears to be a predominance among men. Relatives of patients with any of the 3 lesions—peripheral arterial aneurysm, AAA, arteriomegaly—most frequently have AAA. Relatives of patients with AAA, peripheral arterial aneurysm, or arteriomegaly may be screened by means of a physical examination for peripheral aneurysmal disease. Screening by means of ultrasound examination of the aorta should be limited to first-degree relatives of patients with aortic aneurysms or arteriomegaly. (J Vasc Surg 1998;28:599-605.)     

Epidemiology and Outcome of Aortic Aneurysms in Hong Kong

Abstract The objective of this study was to determine epidemiology and mortality statistics for abdominal aortic aneurysms (AAAs) in Hong Kong. Data from three sources were obtained and analyzed: (1) Hong Kong Hospital Authority discharge statistics for 1999 and 2000; (2) a survey on aortic aneurysms in public hospitals conducted by the Working Group of Vascular Surgery; and (3) the Department of Surgery, University of Hong Kong Medical Center aortic aneurysm database. The disease pattern, distribution, and operative mortality were determined. The annual incidence of AAA in Hong Kong is 13.7 per 100,000 population and 105 per 100,000 for those aged 65 and above. About 10% of the AAAs that presented were ruptured. The mean age of the AAA patients was 74 years, with 84% of them over age 65. The operative repair rate for AAAs was low, being only 8% for intact aneurysms and 54% for ruptured ones. Overall, 45% of all aneurysm repairs were performed for a ruptured AAA. There is diverse practice between major vascular centers and smaller regional hospitals. The territory-wide operative mortality rates for intact and ruptured aneurysms were 10% (range 4–24%) and 70% (range 38––100%), respectively. There was no gender bias in the rupture and operative rates. The overall mortality was 17% for intact AAAs and 78% for ruptured AAAs. The average length of hospital stay was 19 days for elective AAA surgery and 13 days for ruptured AAAs. The number of operations in high-volume centers is increasing with a concomitant decrease in operative mortality. There are no definitive data to indicate that the incidence of AAAs is rising, but a trend toward an increasing number of operations in referral centers is noted. The low repair rates for intact AAAs and the high proportion of repairs for ruptured aneurysms suggest that AAAs are undertreated in Hong Kong.     

Advantages and pitfalls of abdominal aortic aneurysm screening in high-risk patients

Screening for abdominal aortic aneurysm (AAA) has been suggested for older men. Our aim was to determine the effect of participant selection on prevalence and treatment suitability. Men aged 65 to 75 years attending cardiology clinics composed the high-risk group; the control group was from the community. AAA screening was performed, with follow-up or surgery arranged. Four hundred eight of 651 (62.7%) high-risk men and 109 of 908 (45.0%; p< .0001) men attended from the community. In the high-risk patients, 40 AAAs were diagnosed, with a mean diameter of 41.4 mm (+/-10.4 mm). In the control group, 22 new AAAs were found, with an average size of 40.9 mm (+/-10.4 mm). Higher polypharmacy existed in the high-risk group (4.6+/-2.2 vs 2.3+/-2.0; p< .0001). More aneurysm patients were on dual-antiplatelet therapy (32.5% vs 15.4%; p= .048) compared with the overall high-risk group. In this group, three underwent surgery; one was anatomically unsuitable for endovascular repair and medically unfit for open repair. Two in the control group had surgery. A higher prevalence of AAA is encountered in high-risk men. Most aneurysms are small; however, a significant proportion of the aneurysms detected were of a size that would warrant repair. The decision to perform surgical repair is likely to be influenced by the comorbid medical conditions, which placed the patients in the high-risk category.     

Ultrasound screening of first-degree relatives of patients with an abdominal aortic aneurysm

The pedigrees were constructed of 43 patients (probands) who underwent resection of an abdominal aortic aneurysm. Seven probands (16.2%) had a first-degree relative (parent, sibling, child) known to have had an abdominal aortic aneurysm (multiplex family). To determine the prevalence of undiagnosed abdominal aortic aneurysm, ultrasound screening of first-degree relatives over age 40 years was undertaken. Of 202 eligible relatives, 103 (51.0%) were screened. An occult abdominal aortic aneurysm was defined as an infrarenal aortic diameter greater than 3.0 cm or an infrarenal/suprarenal aortic diameter ratio of greater than 1.5. An incipient abdominal aortic aneurysm was defined as a clear focal bulge of the infrarenal aorta, which was less than 3.0 cm in greatest diameter. Four of 103 relatives (3.9%) were found to have an occult abdominal aortic aneurysm (age/sex: 57M, 60M, 62F, 65M), and three (2.9%) were found with an incipient abdominal aortic aneurysm (age/sex: 56M, 60M, 67F). These smaller abdominal aortic aneurysms were in patients younger than the operated probands (average age men, 67 years; women, 69 years). Six of seven individuals were in families previously considered simplex, increasing the actual multiplex family frequency from 16.2% to 27.9%. All seven new abdominal aortic aneurysms were found in the 49 siblings age 55 years or older. There were no abdominal aortic aneurysms found in the 39 relatives under age 55 years, in 14 children ages 50 to 59 years or in one parent. Therefore of the siblings age 55 years or older, 5/20 men (25.0%) and 2/29 women (6.9%) were found to have a previously undiagnosed abdominal aortic aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited?

PURPOSE: The United Kingdom Small Aneurysm study has demonstrated the low risk of rupture in aneurysms less than 5.5 cm in diameter. With the advent of endoluminal techniques, patients considered unfit to undergo laparotomy are now considered for endovascular repair. However, the natural history of aneurysms larger than 5.5 cm remains uncertain, especially when severe comorbidity is present. In our center, we prospectively maintain records of all patients for whom elective aneurysm surgery was refused. This study documented the outcome of all patients referred with abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter who were turned down for elective open repair and determined the cause of death and risk of rupture in all patients. METHODS: Details of all patients with AAAs from January 5, 1989, to January 5, 1999, were recorded, and demographic details on all patients with AAAs larger than 5.5 cm were collected. Copies of death certificates were obtained from the Office of National Statistics, local in-hospital patient records, and general practitioner records. Results of postmortem examinations were also obtained. Aneurysms were stratified according to their size at presentation (5.5-5.9 cm, 6.0-7.0 cm, and > 7.0 cm), and the reasons no intervention was made were documented. RESULTS: A total of 106 patients were turned down for elective aneurysm surgery in the 10-year period (10.6 per year). The mean age of the patients was 78.4 years (SD, 7.4), and 70 were men and 36 were women. At the end of the study, 76 patients (71.7%) had died. Overall, the 3-year survival rate was 17%. Patients with AAAs larger than 7.0 cm lived a median of 9 months. A ruptured aneurysm was certified as a cause of death in 36% of the patients with an AAA of 5.5 to 5.9 cm, in 50% of the patients with an AAA of 6 to 7.0 cm, and 55% of the patients with an AAA larger than 7.0 cm. Reasons given for not intervening were patient refusal (31 cases), the patient being "unfit for surgery" (18 cases), the "advanced age" of the patient (18 cases), cardiac disease (9 cases), cancer (9 cases), respiratory disease (6 cases), and other (15 cases). CONCLUSION: Although we recognize the problems with death certification, we found that rupture was a significant cause of death in patients with an untreated AAA that was larger than 5.5 cm. Although little difference in outcome was observed in aneurysms in the 5.5 to 7.0 cm size range, patients with an AAA that was larger than 7.0 cm seemed to have a much poorer prognosis.     

Prevalence of unsuspected abdominal aortic aneurysms in male veterans

Abdominal aortic aneurysms (AAA) are potentially lethal arterial lesions that are best managed by elective surgical repair. However, asymptomatic AAAs may go undetected on routine physical examination or patients with such lesions may not consult a physician. To determine the prevalence of asymptomatic AAAs in a high-risk population, weretrospectively reviewed all abdominal CT scans on veterans >50 years of age that had been ordered for indications other than aneurysmal disease during a recent 10-month period. Of the 111 patients studied, 15 (13.5%) had suprarenal and/or infrarenal AAAs (one patient had both). Patients with AAAs were significantly older (p=0.0001) and were heavier tobacco users (p=0.003). For patients >60 years of age with peripheral vascular occlusive disease and a history of tobacco use, there was a 29.2% prevalence for AAA compared with 0% in those without any of these risk factors (p=0.04). There was a very definite trend suggesting that patients with peripheral vascular disease (p=0.06) were more likely to have an AAA. Because of the high prevalence of AAAs found in this population we then conducted aprospective study over a 24-month period during which patients >60 years of age with known peripheral vascular disease and a history of smoking who presented to the vascular laboratory for evaluation of problems not related to AAA were asked to undergo an abdominal CT scan. Fifty-six volunteers agreed to participate in the study. Seven patients had AAAs and one patient had an isolated iliac aneurysm, for a 14.3% overall prevalence of aneurysms. There was no difference in the incidence of risk factors in those patients with aneurysms and those without aneurysms. This represents one of the highest incidences for AAA thus far reported. If immediate repair is not performed, such patients must be followed closely for the development of symptoms or enlargement of their AAA.This study reflects the views of the authors and does not necessarily represent the view of the Department of Veterans Affairs or the United States Government.     

Abdominal aortic aneurysm rupture rates: A 7-year follow-up of the entire abdominal aortic aneurysm population detected by screening

Purpose: The goal of the current study was to identify the risk of rupture in the entire abdominal aortic aneurysm (AAA) population detected through screening and to review strategies for surgical intervention in light of this information. Methods: Two hundred eighteen AAAs were detected through ultrasound screening of a family practice population of 5394 men and women aged 65 to 80 years. Subjects with an AAA of less than 6.0 cm in diameter were followed prospectively with the use of ultrasound, according to our protocol, for 7 years. Patients were offered surgery if symptomatic, if the aneurysm expanded more than 1.0 cm per year, or if aortic diameter reached 6.0 cm. Results: The maximum potential rupture rate (actual rupture rate plus elective surgery rate) for small AAAs (3.0 to 4.4 cm) was 2.1% per year, which is less than most reported operative mortality rates. The equivalent rate for aneurysms of 4.5 to 5.9 cm was 10.2% per year. The actual rupture rate for aneurysms up to 5.9 cm using our criteria for surgery was 0.8% per year Conclusion: In centers with an operative mortality rate of greater than 2%, (1) surgical intervention is not indicated for asymptomatic AAAs of less than 4.5 cm in diameter, and (2) elective surgery should be considered only for patients with aneurysms between 4.5 and 6 cm in diameter that are expanding by more than 1 cm per year or for patients in whom symptoms develop. In centers with elective mortality rates of greater than 10% for abdominal aortic aneurysm (AAA) repair, the benefit to the patient of any surgical intervention for an asymptomatic AAA of less than 6.0 cm in diameter is questionable. (J Vasc Surg 1998;28:124-8.)     

Endovascular aneurysm repair at 5 years: does aneurysm diameter predict outcome?

OBJECTIVE: The appropriate size threshold for endovascular repair of small abdominal aortic aneurysms (AAA) is unclear. We studied the outcome of endovascular aneurysm repair (EVAR) as a function of preoperative aneurysm diameter to determine the relationship between aneurysm size and long-term outcome of endovascular repair. METHODS: We reviewed the results of 923 patients treated in a prospective, multicenter clinical trial of EVAR. Small aneurysms were defined according to two size thresholds of 5.5 cm and 5.0 cm. Two-way analysis was used to compare patients with small aneurysms (<5.5 cm, n = 441) to patients with large aneurysms (> or =5.5 cm, n = 482). An ordered three-way analysis was used to compare patients with small AAA (<5.0 cm, n = 145), medium AAA (5.0 to 5.9 cm, n = 461), and large AAA (> or =6.0 cm, n = 317). The primary outcome measures of rupture, AAA-related death, surgical conversion, secondary intervention, and survival were compared using Kaplan-Meier estimates at 5 years. RESULTS: Median aneurysm size was 5.5 cm. The two-way comparison showed that 5 years after EVAR, patients with small aneurysms (<5.5 cm) had a lower AAA-related death rate (1% vs 6%, P = .006), a higher survival rate (69% vs 57%, P = .0002), and a lower secondary intervention rate (25% vs 32%, P = .03) than patients with large aneurysms (> or =5.5 cm). Three-way analysis revealed that patients with small AAAs (<5.0 cm) were younger (P < .0001) and were more likely to have a family history of aneurysm (P < .05), prior coronary intervention (P = .003), and peripheral occlusive disease (P = .008) than patients with larger AAAs. Patients with smaller AAAs also had more favorable aortic neck anatomy (P < .004). Patients with large AAAs were older (P < .0001), had higher operative risk (P = .01), and were more likely to have chronic obstructive pulmonary disease (P = .005), obesity (P = .03), and congestive heart failure (P = .004). At 5 years, patients with small AAAs had better outcomes, with 100% freedom from rupture vs 97% for medium AAAs and 93% for large AAAs (P = .02), 99% freedom from AAA-related death vs 97% for medium AAAs and 92% for large AAAs (P = .02) and 98% freedom from conversion vs 92% for medium AAAs and 89% for large AAAs (P = .01). Survival was significantly improved in small (69%) and medium AAAs (68%) compared to large AAAs (51%, P < .0001). Multivariate Cox proportional hazards modeling revealed that aneurysm size was a significant independent predictor of rupture (P = .04; hazard ratio [HR], 2.195), AAA-related death (P = .03; HR, 2.007), surgical conversion (P = .007; HR, 1.827), and survival (P = .001; HR, 1.351). There were no significant differences in secondary intervention, endoleak, or migration rates between small, medium, and large AAAs. CONCLUSIONS: Preoperative aneurysm size is an important determinant of long-term outcome following endovascular repair. Patients with small AAAs (<5.0 cm) are more favorable candidates for EVAR and have the best long-term outcomes, with 99% freedom from AAA death at 5 years. Patients with large AAAs (> or =6.0 cm) have shorter life expectancy and have a higher risk of rupture, surgical conversion, and aneurysm-related death following EVAR compared to patients with smaller aneurysms. Nonetheless, 92% of patients with large AAAs are protected from AAA-related death at 5 years. Patients with AAAs of intermediate size (5 to 6 cm) represent most of the patients treated with EVAR and have a 97% freedom from AAA-related death at 5 years.     

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.     

Abdominal aortic aneurysm: consequences of a positive family history

To assess the prevalence of coexisting abdominal aortic aneurysm (AAA) within certain families, a retrospective review was carried out of patients who had undergone AAA repair over a 5-year period. Contact was made with 305 families (52%) and a positive history of an affected, first-degree relative was obtained in 34 (11%). A known AAA was reported to affect approximately 20% of siblings at risk when the proband had an affected parent or sibling. Siblings of patients with an affected first-degree relative represent a high-risk group that may benefit from a screening program for earlier detection and elective management of AAA.     

Selection for screening for familial aortic aneurysms.

The reported familial clustering of abdominal aortic aneurysm (AAA) indicates the possible rewards of family-based screening programmes with respect both to the number of asymptomatic aneurysms detected and to identifying associated genes. Ultrasonographic screening of 28 families (25 brothers and 28 sisters) was carried out together with collecting a history and a blood sample for analysis of the cholesterol level and genetic markers. Among the screened siblings six (11 per cent), all > 60 years old, had an AAA > or = 3.0 cm in diameter. A further 11 siblings (21 per cent), six of whom were < 60 years old, had a wide (2.5-2.9 cm) aorta. The presence of an aneurysmal or wide aorta was significantly associated with smoking (P = 0.027), male sex (P = 0.008) and a proband age of < 60 years (P = 0.031). Polymorphic genetic markers for type III collagen and haptoglobin were not informative in these families. These results indicate that the efficiency of screening siblings of patients with AAA could be improved by limiting it to brothers with a smoking history and/or siblings of younger patients. The familial component appears to be greatest in these younger patients.     

Congenital abdominal aortic aneurysms in the young. Case report and review of the literature

Aneurysms of the aorta are rare in children and young adults. We report a case of a 19-year-old man with a saccular abdominal aortic aneurysm (AAA). No associated disorders were discovered in this patient. The aneurysm was resected and a Dacron aortic graft was implanted. Nine years after operation the patient was in good health without evidence of other aneurysms. Thirty-two cases of probable congenital abdominal aortic aneurysms were collected from the literature. In 19 cases, the cause of aneurysm was not ascertained. We identified two groups of patients with probably congenital AAAs: type I congenital AAA, in which there is a generalized disorder of the arterial tissue and usually aneurysms are present in other areas and type II congenital AAA, in which there is a localized defect of the abdominal aorta, without aneurysms in other areas. We speculate that a congenital defect localized to the wall of the abdominal aorta was the cause of the aneurysm in this patient (type II congenital AAA).     

The case for expanding abdominal aortic aneurysm screening

Both the U.S. Preventive Services Task Force and the UK National Institute for Health and Care Excellence are re-evaluating their screening paradigms for abdominal aortic aneurysms (AAAs). Currently, most countries that screen for AAA do so only in male ever-smokers between the ages of 65 and 75 years and in patients with a family history of AAA. However, these recommendations are based primarily on screening trials predating the endovascular era. The wider applicability of endovascular aneurysm repair and its safety profile, especially in the elderly, have changed the risk-benefit of repair and, by extension, screening. This is despite the decreasing prevalence of AAA thanks to improved medical therapies and lower smoking rates. This evidence summary critically examines the evidence behind screening and the potential for expanded screening.     

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair

OBJECTIVE: Small abdominal aortic aneurysms (AAAs; 4-5.4 cm) are more likely to be suitable for endovascular aneurysm repair (EVAR) than large aortic aneurysms (>5.5 cm). The purpose of this study was to determine whether small AAA growth is associated with the development of morphologic characteristics that decrease eligibility for EVAR. METHODS: We studied 54 patients who underwent 2 or more computed tomography scans with 3-dimensional reconstruction during surveillance of small AAAs. Morphologic aortic aneurysm features and changes were measured according to Society for Vascular Surgery reporting standards. Suitability for EVAR was determined by neck anatomy (diameter, length, and angulations), iliac artery morphology, and total aortic aneurysm angulation and tortuosity. RESULTS: The median age of the study cohort was 73 years (interquartile range [IQR], 65-77 years). The median follow-up period was 24 months (IQR, 15-36 months). The median small AAA diameter increased from 44.5 mm (IQR, 41-48 mm) to 48.9 mm (IQR, 45.7-52.0 mm). The median aortic neck diameter increased from 23.0 to 24.0 mm (P = .002), whereas median neck length decreased from 26.5 to 20.0 mm (P = .001). Aortic aneurysm median tortuosity index increased from 1.09 to 1.11 (P = .05). No significant changes in iliac artery morphology occurred. Overall, the anatomic suitability for endovascular repair did not significantly change during the study period (74% vs 69%; McNemar test; P = .25). CONCLUSIONS: Changes in aortic morphology are frequently associated with small AAA growth at mid-term follow-up, but such changes are minor and do not affect overall anatomic suitability for EVAR. These data reveal that continued surveillance of small AAAs does not threaten the window of opportunity for EVAR.     

Co-existence of abdominal aortic aneurysms and intracranial aneurysms

Summary The occurrence of abdominal aortic aneurysms (AAAs) and intracranial aneurysms (IAs) in the same patient and in the same family was studied among 89 patients with AAAs and 485 patients with IAs. Among the AAA-patients two had IAs themselves and five had IAs in the family, whereas three IA-patients had AAAs themselves and eight had AAAs in the family. Moreover, one of the patients with both AAA and IA had a blood relative with AAA, and in six of the families with both types of aneurysms there were more than two subjects with aneurysms. The results indicate, that AAAs and IAs may have a common aetiologic factor.     

Abdominal aortic aneurysm screening program in Poland

Background

Screening for abdominal aortic aneurysms (AAA) is currently recommended by several vascular societies. In countries where it has been introduced the prevalence of AAAs differed greatly and was mainly related to cigarette smoking. The screening program also had an enormous impact on the decrease of AAA ruptures and reduced mortality rate. These facts have led to the introduction of the first screening program for AAAs in Poland.

Objective

The aim of the study was to determine the prevalence of AAAs among men aged 60 years and older undergoing ultrasound examination of the abdominal aorta.

Material and methods

A single ultrasonography of the abdomen was performed to assess the aorta from the renal arteries to the bifurcation and the diameter of the aorta was measured at its widest point. The cut-off value for determining an aortic aneurysm was set at a diameter of ≥?30 mm. All ultrasonography measurements were performed by physicians in outpatient departments throughout the Kuyavian-Pomeranian Province. Additionally, each subject had to fill out a questionnaire with demographic data, smoking habits, existing comorbidities and familial occurrence of AAAs. The study was conducted from October 2009 to November 2011.

Results

The abdominal aorta ultrasound examinations were carried out in 1556 men aged 60 years and older. The prevalence of AAA in the study population was 6.0?% (94 out of 1556). The average age of the men was 69 years (SD 6 years, range 60–92 years). In the study population 55?% of the men smoked or had smoked and 3?% were aware of the presence of AAAs in family members. There were three risk factors significantly associated with the presence of AAAs: age (p?Conclusion The prevalence of AAAs among men in Poland is higher than in other European countries and the USA. The screening program for AAAs is an easy and reliable method for detecting early stages of the disease and risk factors which are the driving forces for the development of AAAs.     

Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm

BACKGROUND: The prevalence of abdominal aortic aneurysm (AAA) in a community-based sample of men and women aged 65-79 years was correlated with known risk factors. In addition, the effect of high blood pressure and the use of antihypertensive medication on growth of AAAs were studied. METHODS: Aortic diameter was assessed by ultrasonography and data on risk factors were collected by self-administered questionnaire for 5356 men and women as part of a randomized controlled trial. RESULTS: Current hypertension increased the risk of having an aortic aneurysm by 30-40 per cent while use of antihypertensive medication increased the risk by 70-80 per cent, adjusting for current blood pressure. There was no clear relationship between hypertension and growth rates of existing aneurysms in this study, although these results were largely from data on small aneurysms. Men were nearly six times more likely to develop an AAA than women; the risk increased by 40 per cent every 5 years after the age of 65 years. Smoking was an independent risk factor for AAA, with level of exposure being more significant than duration. CONCLUSION: Male sex, smoking and hypertension are strong risk factors for the development of AAA. In this study hypertension did not significantly increase the growth rate of existing aneurysms. Smoking remains the most important avoidable risk factor for AAA. The analyses presented here suggest that selection for screening, other than by age and sex, is not worthwhile.