Anemia is associated with abdominal aortic aneurysm (AAA) size and decreased long-term survival after endovascular AAA repair

OBJECTIVE: Anemia is a common comorbid condition in various inflammatory states and an established predictor of mortality in patients with chronic heart failure, ischemic heart disease, and end-stage renal disease. The present study of patients with abdominal aortic aneurysm (AAA) undergoing endovascular repair (EVAR) assessed the relationships between baseline hemoglobin concentration and AAA size, as well as anemia and long-term survival. METHODS: Between March 1994 and November 2006, 711 patients (65 women, mean age 75.8 +/- 7.8 years) underwent elective EVAR. Anemia was defined as a hemoglobin level <13 g/dL in men and <12 g/dL in women. Post-EVAR mean follow-up was 48.3 +/- 32.0 months. Association of hemoglobin level with AAA size was assessed with multiple linear regression. Mortality was determined with use of the internet-based Social Security Death Index and the electronic hospital record. Kaplan-Meier survival curves of anemic and nonanemic patient groups were compared by the log-rank method. Multivariable logistic regression models were used to determine the influence of anemia on vital status after EVAR. RESULTS: A total of 218/711 (30.7%) of AAA patients undergoing EVAR had anemia at baseline. After adjustment for various risk factors, hemoglobin level was inversely related to maximum AAA diameter (beta: - .144, 95%-CI: -1.482 - .322, P = .002). Post-EVAR survival was 65.5% at 5 years and 44.4% at 10 years. In long-term follow-up, survival was significantly lower in patients with anemia as compared to patients without anemia (P < .0001 by log-rank). Baseline hemoglobin levels were independently related to long-term mortality in multivariable Cox regression analysis adjusted for various risk factors (adjusted HR: 0.866, 95% CI: .783 to .958, P = .005). Within this model, statin use (adjusted HR: .517, 95% CI: .308 to .868, P = .013) was independently related to long-term survival, whereas baseline AAA diameter (adjusted HR: 1.022, 95% CI: 1.009 to 1.036, P = .001) was an independently associated with increased mortality. CONCLUSIONS: Baseline hemoglobin concentration is independently associated with AAA size and reduced long-term survival following EVAR. Thus, the presence or absence of anemia offers a potential refinement of existing risk stratification instruments.

Prevention of rupture of abdominal aortic aneurysm

Two thirds of patients with an abdominal aortic aneurysm (AAA) have relevant coronary artery disease (CAD). AAAs are prevalent in up to 16% of smokers with CAD. General screening of AAA is controversial. Aim was to assess the potential of finding AAA prior to rupture among patients with known CAD. Main endpoint was whether AAA could have been found during follow-up by sonography or at other time of cardiovascular evaluation.

Explaining the decrease in mortality from abdominal aortic aneurysm rupture

A steady rise in mortality from abdominal aortic aneurysm (AAA) was reported in the 1980s and 1990 s, although this is now declining rapidly. Reasons for the recent decline in mortality from AAA rupture are investigated here.

The management of ruptured abdominal aortic aneurysms: screening for abdominal aortic aneurysm and incidence of rupture

Twenty-five years have passed since the first randomised controlled trial began its recruitment for screening for abdominal aortic aneurysm (AAA) in men aged 65 and above. Since this and other randomised trials, all launched in the late 80s and 90s of the last century, the epidemiologic profile of abdominal aortic aneurysm may have changed. The trials reported an AAA prevalence in the range of 4-7% for men aged 65 years or more. AAA-related mortality was significantly improved by screening, and after 13 years, the largest trial showed a benefit for all-cause mortality. Screening also was shown to be cost-effective. Today, there are studies showing a substantial decrease of AAA prevalence to sometimes less than 2% in men aged ≥ 65 years and there is evidence that the incidence of ruptured aneurysm and mortality from AAA is also declining. This decline preceded the implementation of screening programmes but may be due to a change in risk factor management. The prevalence of smoking has decreased and there has been improvement in the control of hypertension and a rising use of statins for cardiovascular risk prevention. Additionally, there is a shift of the burden to the older age group of ≥ 75 years. Such radical changes may influence screening policy and it is worth reflecting on the optimum age of screening - it might be better to screen at ages >65 years - or rescreening 5 to 10 years after the first screen.

Initial results of a computerized screening alert for abdominal aortic aneurysm in patients undergoing vascular assessment

Although routine ultrasound screening for abdominal aortic aneurysm (AAA) reduces mortality in subjects at risk, it is often omitted in clinical practice. Because computerized alerts may systematically identify subjects at risk of AAA, we hypothesized that such alerts would encourage physicians to perform an ultrasound screening test.

Intraobserver and interobserver variability of 64-row computed tomography abdominal aortic aneurysm neck measurements

BACKGROUND: Integrity of the abdominal aortic aneurysm (AAA) neck is crucial for the long-term success of endovascular AAA repair (EVAR). However, suitable tools for reliable assessment of changes in small aortic volumes are lacking. The purpose of this study was to assess the intraobserver and interobserver variability of software-enhanced 64-row computed tomographic angiography (CTA) AAA neck volume measurements in patients after EVAR. METHODS: A total of 25 consecutive patients successfully treated by EVAR underwent 64-row follow-up CTA in 1.5-mm collimation. Manual CTA measurements were performed twice by three blinded and independent readers in random order with at least a 4-week interval between readings. Maximum and minimum transverse aortic neck diameters were measured twice on two different levels within the proximal neck. Volumetry of the proximal aortic neck was performed by using dedicated software. Variability was calculated as 1.96 SD of the mean arithmetic difference according to Bland and Altman. Two-sided and paired t tests were used to compare measurements. P values <.05 were considered to indicate statistical significance. RESULTS: Intraobserver agreement was excellent for dedicated aneurysmal neck volumetry, with mean differences of less than 1 mL (P > .05), whereas it was poor for transverse aortic neck diameter measurements (P < .05). However, interobserver variability was statistically significant for both neck volumetry (P < .005) and neck diameter measurements (P < .015). CONCLUSIONS: The reliability of dedicated AAA neck volumetry by using 64-row CTA is excellent for serial measurements by individual readers, but not between different readers. Therefore, studies should be performed with aortic neck volumetry by a single experienced reader.

Novel insight into the pathobiology of abdominal aortic aneurysm and potential future treatment concepts

The patient with abdominal aortic aneurysm (AAA) commonly is a nondiabetic, white man with a history of smoking. Moreover, AAA represents a leading cause of death in elderly men in Western countries. The purpose of this manuscript is to review current evidence as to the pathobiology of AAA as well as potential future drug targets to prevent progression of AAA.

To see or not to see – Ambiguous findings on post-mortem cross-sectional imaging in a case of ruptured abdominal aortic aneurysm

We present a case of a ruptured abdominal aortic aneurysm (AAA) with ambiguous accessory findings on post-mortem computed-tomography (PMCT), post-mortem magnetic resonance (PMMR) imaging, and PMCT-angiography (PMCTA) suggestive of thoracic aortic dissection. The diagnosis of ruptured AAA was confirmed by autopsy; however, there was no aortic dissection. The imaging findings that mimicked the presence of aortic dissection might have been an atypical presentation of post-mortem clotting or sedimentation. This case is an ideal example to illustrate benefits, limitations, and challenges of post-mortem cross-sectional imaging. It serves as a reminder that both, training as well as correlation of imaging findings with autopsy are fundamental to improve our understanding of radiologic findings on post-mortem cross-sectional imaging.

[Abdominal aortic aneurysm]

Abdominal aortic aneurysms (AAA) confer a substantial healthcare burden in the Western world. Surgical or endovascular therapy is indicated in patients with a maximum diameter exceeding 5.5 cm. Patients with smaller AAA must undergo a specific ultrasound surveillance program aimed at avoiding exposure to an increased risk of rupture once their AAA exceeds the threshold for active treatment. Based on improved understanding of the pathophysiology of AAA, recent years provided initial insight into potential medical treatment options. The presence of AAA is currently regarded a coronary artery disease risk equivalent. ACE inhibitors, statins and JNK-inhibitors were shown to have the potential to slow down progression. Since cigarette smoking is the main risk factor for both the development and progression of AAA, smoking cessation remains a key goal. Further prospective studies will assess the clinical efficacy of various promising drug treatment approaches aimed at slowing disease progression of small AAA and after endovascular therapy.

Dissecting abdominal aortic aneurysm in Angiotensin II-infused mice: the importance of imaging

INTRODUCTION Since the initial publication in 2000, Angiotensin II-infused mice have become one of the most popular models to study abdominal aortic aneurysm in a pre-clinical setting. We recently used phase contrast X-ray based computed tomography to demonstrate that these animals develop an apparent luminal dilatation and an intramural hematoma, both related to mural ruptures in the tunica media in the vicinity of suprarenal side branches. AIMS The aim of this narrative review was to provide an extensive overview of small animal applicable techniques that have provided relevant insight into the pathogenesis and morphology of dissecting AAA in mice, and to relate findings from these techniques to each other and to our recent PCXTM-based results. Combining insights from recent and consolidated publications we aimed to enhance our understanding of dissecting AAA morphology and anatomy. RESULTS AND CONCLUSION We analyzed in vivo and ex vivo images of aortas obtained from macroscopic anatomy, histology, high-frequency ultrasound, contrast-enhanced micro-CT, micro-MRI and PCXTM. We demonstrate how in almost all publications the aorta has been subdivided into a part in which an intact lumen lies adjacent to a remodeled wall/hematoma, and a part in which elastic lamellae are ruptured and the lumen appears to be dilated. We show how the novel paradigm fits within the existing one, and how 3D images can explain and connect previously published 2D structures. We conclude that PCXTM-based findings are in line with previous results, and all evidence points towards the fact that dissecting AAAs in Angiotensin II-infused mice are actually caused by ruptures of the tunica media in the immediate vicinity of small side branches.

Patient preference for surgical method of abdominal aortic aneurysm repair: postal survey

To determine whether men with small abdominal aortic aneurysm have a preference between either endovascular or open aneurysm repair for future treatment.

Repair of ruptured abdominal aortic aneurysm in octogenarians

To determine whether advanced age was independently associated with prohibitive surgical risks or impaired long-term prognosis after ruptured aortic aneurysm repair.

Endovascular suitability and outcome after open surgery for ruptured abdominal aortic aneurysm

Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) has rapidly gained popularity, but superior results may be biased by patient selection. The aim was to investigate whether suitability for endovascular repair predicted survival, irrespective of technique of repair.