The Impact of Decreasing Abdominal Aortic Aneurysm Prevalence on a Local Aneurysm Screening Programme

High prevalence of abdominal aortic aneurysm in older men with cerebrovascular disease: Evaluation of a local screening program

Introduction

Patients with cerebrovascular disease may suffer from other vascular morbidities, such as abdominal aortic aneurysm (AAA). Previously, a high prevalence of AAA has been demonstrated in men 60 years of age and older who have experienced TIA or stroke. This report evaluates the results of a decade's operation of a local screening program for AAA in this selected neurologic population.

Methods

Men aged ≥60 years and admitted to the neurology ward of a community-based hospital in the Netherlands from 2006 to 2017 with a diagnosis of TIA or stroke were selected for screening. The diameter of the abdominal aorta was assessed by abdominal ultrasonography. Patients with detected AAA were referred for evaluation by a vascular surgeon.

Results

AAA was detected in 72 of 1,035 screened patients (6.9%). AAAs with a diameter of 3.0-3.9 cm accounted for 61.1% of the total aneurysms found; AAAs with a diameter of 4.0-5.4 cm accounted for 20.8% of the total; and large aneurysms with a diameter of ≥5.5 cm accounted for 18.1% of all aneurysms discovered. A total of 18 patients (1.7%) underwent elective aneurysm repair.

Discussion

The detection rate of AAA in older men with cerebrovascular disease was roughly 5-fold the detection rate in known European screening programs in older men from the general population. The proportion of large AAAs (≥5.5 cm) was also substantially higher. These findings reveal a previously unknown co-morbidity in patients with cerebrovascular disease and may be helpful for cardiovascular management of this large group of neurologic patients. Current and future AAA screening programs may also benefit from this knowledge.

Risk Factors for Abdominal Aortic Aneurysm in Population-Based Studies: A Systematic Review and Meta-Analysis

Abdominal aortic aneurysm (AAA) represents an important public health problem with a prevalence between 1.3% and 12.5%. Several population-based randomized trials have evaluated ultrasound screening for AAA providing evidence of a reduction in aneurysm-related mortality in the screened population. The aim of our study was to perform a systematic review and meta-analysis of the risk factors for AAA. We conducted a systematic review of observational studies and we performed a meta-analysis that evaluated the following risk factors: gender, smoking habits, hypertension, coronary artery disease and family history of AAA. Respect to a previous a meta-analysis we added the funnel plot to examine the effect sizes estimated from individual studies as measure of their precision; sensitivity analysis to check the stability of study findings and estimate how the overall effect size would be modified by removal of one study; cumulative analysis to evaluate the trend between studies in relation to publication year. Abdominal aortic aneurysm prevalence is higher in smokers and in males. On the other hand, while diabetes is a risk factor for many cardiovascular diseases, it is not a risk factor for AAA. In addition, it is important to underline that all countries, where AAA screening was set up, had high income level and the majority belong to Western Europe (United Kingdom, Sweden, Italy, Poland, Spain and Belgium). Abdominal aortic aneurysm screening is fundamental for public health. It could avoid deaths, ruptures, and emergency surgical interventions if abdominal aortic aneurysm was diagnosed early in the population target for screening.

Abdominal Aortic Aneurysm: Evolving Controversies and Uncertainties

Abdominal aortic aneurysm (AAA) is defined as a permanent dilatation of the abdominal aorta that exceeds 3 cm. Most AAAs arise in the portion of abdominal aorta distal to the renal arteries and are defined as infrarenal. Most AAAs are totally asymptomatic until catastrophic rupture. The strongest predictor of AAA rupture is the diameter. Surgery is indicated to prevent rupture when the risk of rupture exceeds the risk of surgery. In this review, we aim to analyze this disease comprehensively, starting from an epidemiological perspective, exploring etiology and pathophysiology, and concluding with surgical controversies. We will pursue these goals by addressing eight specific questions regarding AAA: (1) Is the incidence of AAA increasing? (2) Are ultrasound screening programs for AAA effective? (3) What causes AAA: Genes versus environment? (4) Animal models: Are they really relevant? (5) What pathophysiology leads to AAA? (6) Indications for AAA surgery: Are surgeons over-eager to operate? (7) Elective AAA repair: Open or endovascular? (8) Emergency AAA repair: Open or endovascular?

Association of high sensitivity C-reactive protein and abdominal aortic aneurysm: a meta-analysis and systematic review

OBJECTIVE

To evaluate the association of high sensitivity C-reactive protein (hsCRP) with the presence of abdominal aortic aneurysm (AAA).

METHODS

Medline, Cochrane, Embase, and Google Scholar databases were searched until 22 June 2016 using the keywords predictive factors, biomarkers, abdominal aortic aneurysm, prediction, high sensitivity C-reactive protein, and hsCRP. Prospective studies, retrospective studies, and cohort studies were included.

RESULTS

Twelve case-control studies were included in the meta-analysis with a total of 8345 patients (1977 in the AAA group and 6368 in the control group). The pooled results showed that AAA patients had higher hsCRP value than the control group (difference in means = 1.827, 95% CI = 0.010 to 3.645, p = .049). Subgroup analysis found AAA patients with medium or small aortic diameter (<50 mm) had higher hsCRP plasma levels than the control group (difference in means = 1.301, 95% CI = 0.821 to 1.781, p < .001). In patients with large aortic diameter (≥50 mm), no difference was observed in hsCRP levels between the AAA and control groups (difference in means = 1.769, 95% CI = -1.387 to 4.925, p = .272). Multi-regression analysis found the difference in means of hsCRP plasma levels between AAA and control groups decreased as aortic diameter increased (slope = -0.04, p < .001), suggesting that hsCRP levels may be inversely associated with increasing aneurysm size.

CONCLUSIONS

Our findings suggest that hsCRP levels may possibly be used as a diagnostic biomarker for AAA patients with medium or small aortic diameter but not for AAA patients with large aortic diameter. The correlation between serum hsCRP level and AAA aneurysm is not conclusive due to the small number of included articles and between-study heterogeneity.

Risk of abdominal aortic aneurysm (AAA) among male and female relatives of AAA patients

Sex affects the presentation, treatment, and outcomes of abdominal aortic aneurysm (AAA). Although AAAs are less prevalent in women, at least in the general population, women with an AAA have a poorer prognosis in comparison to men. Sex differences in the genetic predisposition for aneurysm disease remain to be established. In this study we investigated the familial risk of AAA for women compared to men. All living AAA patients included in a 2004-2012 prospective database were invited to the multidisciplinary vascular/genetics outpatient clinic between 2009 and 2012 for assessment of family history using detailed questionnaires. AAA risk for male and female relatives was calculated separately and stratified by sex of the AAA patients. Families of 568 AAA patients were investigated and 22.5% of the patients had at least one affected relative. Female relatives had a 2.8-fold and male relatives had a 1.7-fold higher risk than the estimated sex-specific population risk. Relatives of female AAA patients had a higher aneurysm risk than relatives of male patients (9.0 vs 5.9%, p = 0.022), corresponding to 5.5- and 2.0-fold increases in aneurysm risk in the female and male relatives, respectively. The risk for aortic aneurysm in relatives of AAA patients is higher than expected from population risk. The excess risk is highest for the female relatives of AAA patients and for the relatives of female AAA patients. These findings endorse targeted AAA family screening for female and male relatives of all AAA patients.

Screening for abdominal aortic aneurysms

Ultrasonography remains the screening modality of choice for abdominal aortic aneurysms despite many advances in imaging modalities. Several randomized trials were performed that demonstrated the effectiveness of ultrasound-based screening to reduce aneurysm-related mortality. Ultrasound is both cost effective and low risk. Controversies do persist in selecting the appropriate populations for screening, and several national societies have set recommendations.

Baseline prevalence of abdominal aortic aneurysm, peripheral arterial disease and hypertension in men aged 65–74 years from a population screening study (VIVA trial)

Background

Abdominal aortic aneurysm (AAA) screening has been introduced into some health systems and could easily be supplemented with broader vascular screening. The aim of this study was to evaluate the screening set-up and investigate combined screening for AAA, peripheral arterial disease (PAD) and possible hypertension (HT), and detection rates.

Methods

This observational study was based on the intervention arm of a screening trial in 25 083 Danish men aged 65–74 years. A combined screening programme for AAA, PAD and HT was offered at local hospitals. Participants with positive test results were offered secondary prophylaxis and/or referred to their general practitioner. The programme set-up included decentralized screening by three mobile teams at 14 venues. Diagnostic criteria were: aortic diameter at least 30 mm for AAA, ankle : brachial pressure index below 0·9 or above 1·4 for PAD, and BP exceeding 160/100 mmHg for HT.

Results

Overall, 18 749 men (uptake 74·7 per cent) attended the screening. An AAA was diagnosed in 3·3 (95 per cent c.i. 3·0 to 3·6) per cent, PAD in 10·9 (10·5 to 11·4) per cent and HT in 10·5 (10·0 to 10·9) per cent. Lipid-lowering and/or antiplatelet treatment was initiated in 34·8 per cent of the participants.

Conclusion

Preventive actions were started in one-third of the attenders. The long-term effect of this on morbidity and mortality is an important part of future analysis. The trial confirms that the prevalence of AAA in Denmark has decreased only slightly in the past decade, from 4·0 to 3·3 per cent, in contrast to other nations.

Reference diameters of the abdominal aorta and iliac arteries in the Korean population

PURPOSE

It is important to know the normal diameter of artery throughout the body so that clinicians are able to determine when an artery becomes aneurysmal. However, there are no previous studies on the normal diameter of arteries in the general Korean population. The purpose of this article is to determine the normal reference diameters of the abdominal aorta and iliac arteries in the Korean population.

MATERIALS AND METHODS

We recruited the study population from three cities in Korea for the abdominal aortic aneurysm (AAA) screening. We measured the diameter of the aorta and iliac arteries. We analyzed the reference diameter of the population without AAA. The results were analyzed by Student's t-test and ANOVA on SPSS version 19. A p value <0.05 was considered to be statistically significant.

RESULTS

One thousand two hundred and twenty-nine people were enrolled. 478 men and 751 women, with a mean age of 63.9 ± 10.1 years (range 50 to 91) were examined. Eleven out of 1229 (0.89%) were diagnosed with AAA. In the population of 1218 people without AAA, the mean diameters (cm) of male/female were 2.20/2.11 (p<0.001) at suprarenal, 2.04/1.90 (p<0.001) at renal, 1.90/1.79 (p<0.001) at infrarenal, 1.22/1.17 (p<0.001) at right iliac and 1.47/1.15 (p=0.097) at the left iliac, respectively. There was a significantly larger diameter in the male population. The diameter of each level increased with age.

CONCLUSION

The normal reference diameter of the infrarenal abdominal aorta in the Korean population is 1.9 cm in males and 1.79 cm in females. The diameter of the abdominal aorta increases with age.