Systematic Review and Meta-Analysis of Health Related Quality of Life and Reported Experiences in Patients With Abdominal Aortic Aneurysm Under Ultrasound Surveillance

Health Related Quality of Life Following Intervention for Thoracoabdominal Aortic Aneurysm: A Systematic Review and Narrative Synthesis

BACKGROUND

Thoracoabdominal aortic aneurysms (TAAA) pose significant risks of morbidity and mortality. Considering the evolving techniques for TAAA intervention and the growing interest in quality of life (QoL) outcomes for decision-making, we aimed to evaluate the impact of patient and perioperative characteristics on short-term, medium-term, and long-term postoperative QoL in TAAA repair patients.

METHODS

A systematic search was conducted in CINAHL, APA PsycINFO, EMBASE, Medline and Cochrane to identify primary research studies evaluating QoL post TAAA surgery, published in English or Swedish between January 01, 2012 and September 26, 2022. A narrative synthesis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of evidence was assessed using the Critical Appraisal Skills Program and Joanna Briggs Institute checklists.

RESULTS

Eight studies of low or moderate quality with 455 patients were included. Preoperative QoL in TAAA patients was lower compared to the general population. While there is an initial short-term improvement in postoperative QoL, patients fail to reach baseline levels even after 7 years, with physical activity and functioning domains being particularly affected. Experiencing postoperative complications, including paraplegia and cardiovascular events, negatively impacts postoperative QoL. Patients with uncomplicated postoperative status had improved QoL. Prolonged hospital stay negatively affects physical functioning.

CONCLUSIONS

Individuals with TAAA are likely to have lower baseline QoL compared to the general population. Following TAAA repair, postoperative QoL may remain lower than baseline levels, persisting over the long-term. Comorbidities, postoperative complications, and hospitalization duration appear to exert adverse effects on postoperative QoL.

A highly selective mPGES-1 inhibitor to block abdominal aortic aneurysm progression in the angiotensin mouse model

Abdominal aortic aneurysm (AAA) is a deadly, permanent ballooning of the aortic artery. Pharmacological and genetic studies have pointed to multiple proteins, including microsomal prostaglandin E2 synthase-1 (mPGES-1), as potentially promising targets. However, it remains unknown whether administration of an mPGES-1 inhibitor can effectively attenuate AAA progression in animal models. There are still no FDA-approved pharmacological treatments for AAA. Current research stresses the importance of both anti-inflammatory drug targets and rigor of translatability. Notably, mPGES-1 is an inducible enzyme responsible for overproduction of prostaglandin E2 (PGE2)-a well-known principal pro-inflammatory prostanoid. Here we demonstrate for the first time that a highly selective mPGES-1 inhibitor (UK4b) can completely block further growth of AAA in the ApoE-/- angiotensin (Ang)II mouse model. Our findings show promise for the use of a mPGES-1 inhibitor like UK4b as interventional treatment of AAA and its potential translation into the clinical setting.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Patients' health and quality of life after complex endovascular aortic repair: A prospective cohort study

RATIONALE

Complex endovascular aortic repair often involves multiple major procedures over time with a high risk of complications and little time for recovery. This exposes patients to great stress, both physically and mentally, with potentially long-lasting effects. There is limited knowledge about these effects and who is most at risk - information on this could help vascular nurses and other healthcare professionals anticipate and meet care needs.

AIM

To investigate the health and quality of life effects of complex endovascular aortic repair, in relation to patients' demographic and health characteristics.

DESIGN

A prospective cohort study.

METHODS

Patients undergoing elective complex endovascular aortic repair were consecutively recruited from one university hospital during one year (n=25). Self-report questionnaires on health disability (WHODAS 2.0), quality of life (WHOQoL-BREF) and symptoms of anxiety and depression (HADS) were filled out preoperatively and repeated one and six months postoperatively. Prospective changes in health and quality of life, and associations with patient demographics and preoperative health characteristics, were assessed. Ethical approval was obtained prior to study performance.

RESULTS

Overall, patients had significantly greater health disability at one month (WHODAS 2.0 score median 31.5, range 1.1-63.0) than preoperatively (median 13.6, range 0.0-41.3) (n=22, p=.017); the majority had recovered at six months (median 11.4, range 3.3-58.7) (n=18, p=.042). No significant effects were seen in quality of life and symptoms of anxiety and depression (p>.05). However, the participants showed heterogeneity, with certain individuals not recovered at six months (n=8). Factors associated with worse six-month outcomes were being female, age < 70 years, postoperative complications, and history of anxiety or depression.

CONCLUSIONS

Complex endovascular aortic repair have limited long-term negative effects on patients' health and quality of life. However, some patients are not recovered at six months postoperatively, which could be explained by individual characteristics. To improve recovery outcomes, vascular nurses and other health care professionals should be aware of the possible recovery trajectories and factors associated with impaired recovery, and use them to anticipate and meet the patients' individual care needs.

The impact of population screening for cardiovascular disease on quality of life

Aims

To examine the impact of population screening-generated events on quality of life: invitation, positive test result, initiation of preventive medication, enrolment in follow-up at the surgical department, and preventive surgical repair.

Methods and results

A difference-in-difference design based on data collected alongside two randomized controlled trials where general population men were randomized to screening for cardiovascular disease or to no screening. Repeated measurements of health-related quality of life (HRQoL) were conducted up to 3 years after inclusion using all relevant scales of the EuroQol instrument: the anxiety/depression dimension, the EuroQol 5-dimension profile index (using Danish preference weights), and the visual analogue scale for global health. We compare the mean change scores from before to after events for groups experiencing vs. not experiencing the events. Propensity score matching is additionally used to provide both unmatched and matched results. Invitees reported to be marginally better off than non-invitees on all scales of the EuroQol. For events of receiving the test result, initiating preventive medication, being enrolled in surveillance, and undergoing surgical repair, we observed no impact on overall HRQoL but a minor impact of being enrolled in surveillance on emotional distress, which did not persist after matching.

Conclusion

The often-claimed detrimental consequences of screening to HRQoL could not be generally confirmed. Amongst the screening events assessed, only two possible consequences were revealed: a reassurance effect after a negative screening test and a minor negative impact to emotional distress of being enrolled in surveillance that did not spill over to overall HRQoL.

MetAAA trial patients show superior quality of life compared to patients under regular surveillance for small AAA: a single-center retrospective cohort study

BACKGROUND

Abdominal aortic aneurysm (AAA) is a multifactorial vascular disease associated with high morbidity and mortality. Currently, surgical intervention is the only treatment option, and there is no drug therapy available for AAA. Hence, surveillance of AAA until indication for surgery may impact patient quality of life (QoL). There is a paucity of high-quality observational data on health status and QoL, particularly among AAA patients participating in randomized controlled trials. The objective of this study was to compare the QoL scores of AAA patients on surveillance to those of AAA patients enrolled in the MetAAA trial.

MATERIAL AND METHODS

Overall, 54 MetAAA trial patients and 23 AAA patients under regular surveillance for small AAA (part of a longitudinal monitoring study) were asked to complete three established and validated (in total 561 longitudinally collected) QoL questionnaires: the 36-Item Short Form Health Survey (SF-36), the Aneurysm Symptom Rating Questionnaire (ASRQ), and the Aneurysm-Dependent Quality of Life questionnaire (ADQoL).

RESULTS

A superior health status and QoL was found in AAA patients participating in the MetAAA trial compared to AAA patients under regular surveillance. In detail, MetAAA trial patients showed superior general health perception ( P =0.012), higher energy level ( P =0.036) as well as enhanced emotional well-being ( P =0.044) and fewer limitations due to general malaise ( P =0.021), which was subsequently reflected in an overall superior current QoL score ( P =0.039) compared to AAA patients under regular surveillance.

CONCLUSION

AAA patients enrolled in the MetAAA trial showed superior health status and QoL compared to AAA patients under regular surveillance.

Evaluating feasibility of using national registries for identification, invitation, and ultrasound examination of persons with hereditary risk for aneurysm disease-detecting abdominal aortic aneurysms in first degree relatives (adult offspring) to AAA patients (DAAAD)

BACKGROUND

Sweden and the UK invite all 65-year-old men to a population-based ultrasound-based screening program to detect abdominal aortic aneurysms (AAA). First-degree relatives of patients with AAA are reported to have an increased risk to develop AAA, both women and men, but are not invited to screening. The "Detecting AAA in First Degree Relatives to AAA patients" (DAAAD) was designed to detect the true prevalence in adult offspring to AAA patients and to evaluate if national registries could be used for identification of index persons and their adult children with a high risk for the disease. The aim of this study is to summarize the design and methodology for this registry-based study.

METHODS

The study is based on a registry-based extraction and identification of a risk group in the population with a subsequent identification of their adult offspring. The targeted risk group suffers a heredity for a potentially lethal disease, AAA (n = 750) and matched control group without heredity for AAA is also identified and invited (n = 750). The participation rate in the population-based AAA screening program for men is 75% regionally. This population is younger and have a lower prevalence. A participation rate of 65% is considered clinically adequate. For the DAAAD study, a stratified analysis of the primary outcome, prevalence, will be performed for women and men separately. Two other planned projects are based on the material: firstly, evaluation of the anxiety for disease and health-related quality of life (HRQoL) and, secondly, the cost-effectiveness of the study.

DISCUSSION

In conclusion, this feasibility study will be instrumental in supporting the development of a possible new model to invite persons with high risk to develop hereditary rare diseases. To our knowledge, this is a unique, safe, and most likely to be a cost-efficient model to invite targeted risk groups for selected screening. If the study design and the results are shown to be cost-effective at the detected participation rate and prevalence, it should be further evaluated and adopted to a national screening program. The model also invites both women and men, which is unique for this specific patient group, considering that all population-based screening programs only include men.

TRIAL REGISTRATION

This trial is registered at the website of Clinical Trials.

CLINICALTRIALS

gov identifier, NCT4623268.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Towards Patient Centred Outcomes for Elective Abdominal Aortic Aneurysm Repair: A Scoping Review of Quality of Life Scales

OBJECTIVE

In order to better incorporate the patient's perspective in medical decision making, core outcome sets (COS) are being defined. In the field of abdominal aortic aneurysm (AAA), efforts to capture the patient's perspective focus on generic quantitative quality of life (QoL) scales. The question arises whether these quantitative scales adequately reflect the patient's perspective on QoL, and whether they can be included in the QoL aspect of COS. A scoping review of QoL assessment in the context of elective AAA repair was undertaken.

DATA SOURCES

PubMed, Embase, Web of Science, and the Cochrane Library.

REVIEW METHODS

A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Articles reporting QoL assessment in the context of elective AAA repair were identified. Quantitative studies (i.e., traditional QoL scales) were aligned (triangulation approach) with qualitative studies (i.e., patient perspective) to identify parallels and discrepancies. Mean Short Form 36 item survey (SF-36) scores were pooled using a random effects model to evaluate sensitivity to change.

RESULTS

Thirty-three studies were identified, of which 29 (88%) were quantitative and four (12%) qualitative. The 33 studies reported a total of 54 quantitative QoL scales; the most frequently used were the generic SF-36 (16 studies) and five dimension EuroQol (EQ-5D; eight studies). Aneurysm specific scales were reported by one study. The generic quantitative scales showed poor alignment with the patient's perspective. The aneurysm specific scales better aligned but missed "concerns regarding symptoms" and "the impact of possible outcomes/complications". "Self control and decision making", which was brought forward by patients in qualitative studies, was not captured in any of the current scales.

CONCLUSION

There is no established tool that fully captures all aspects of the patient's perspective appropriate for a COS for elective AAA repair. In order to fulfil the need for a COS for the management of^, AAA disease, a more comprehensive overview of the patient's perspective is required.

Long Term Outcome of Screen Detected Sub-Aneurysmal Aortas in 65 Year Old Men: a Single Scan After Five Years Identifies Those at Risk of Needing AAA Repair

OBJECTIVE

The epidemiology of sub-aneurysmal aortic dilatation (SAA) 25 - 29 mm is not fully understood, and the management of SAA is debated. Lack of evidence is particularly problematic in the screening setting. This study aimed to evaluate the long term outcome of men with screen detected SAAs, focusing on progression to an abdominal aortic aneurysm (AAA), and on the AAAs reaching the threshold diameter for surgical repair.

METHODS

Between 2006 and 2015, all 65 year old men with a screen detected SAA in middle Sweden were re-examined with ultrasound after five and 10 years. The primary outcomes were expansion to AAA ≥ 30 mm and progression to AAA ≥ 55 mm. Secondary outcomes were risk factors for progression, repair rate, and mortality.

RESULTS

A total of 1 020 65 year old men with a SAA were identified, of whom 940 (92.2%; 95% confidence interval 91.0 - 93.8) had follow up. The Kaplan-Meier estimated incidence of AAA ≥ 30 mm development after the five year follow up (which was de facto carried out after a mean of 4.9 years) was 65.8% (61.6 - 69.4), all < 55 mm. The corresponding KM-estimated incidence after the 10 year follow up (carried out after a mean of 11.9 years) was 95.1% (90.1 - 97.4), and 29.7% (18.0 - 39.7) reached ≥ 55 mm. All 41 SAAs eventually expanding to ≥ 55 mm were ≥ 30 mm at the five year follow up. Of these, 32 had surgical repair with 100% survival, six have scheduled repairs, and three (7.3%) were unfit for repair. The KM estimated all cause mortality rates at five and 10 years were 7.0% and 17.9%, respectively, with no proven AAA related deaths.

CONCLUSION

A majority of SAAs eventually progress to an AAA, of which 30% are estimated to eventually reach the threshold for repair within 10 years. A follow up policy with an ultrasound examination after five years can safely and effectively identify those SAAs at risk of developing into clinically significant AAAs needing repair and may be considered for anyone with reasonably good life expectancy.

A randomized clinical trial of an eHealth intervention on anxiety in patients undergoing abdominal aortic aneurysm surgery

BACKGROUND

The potential benefit of eHealth interventions in patients with abdominal aortic aneurysm (AAA) is uncertain. The primary aim of this study was to investigate the effect of an eHealth intervention on anxiety in patients with AAA undergoing surgery.

METHODS

A single-centre randomized clinical trial of patients with AAA scheduled for surgical repair was undertaken. The intervention group received an eHealth tool and psychosocial support besides standard care. The control group received standard care. The analysis of treatment effects was performed as intention-to-treat and per protocol analysis. The primary outcome measure was anxiety mean score (Hospital Anxiety and Depression Scale Anxiety (HADS)-A). Secondary outcomes measures were HADS Depression and short-form 12-item health survey mean scores.

RESULTS

Some 120 participants were randomized. No effect on anxiety mean scores was found in the intention-to-treat analysis (-1.21 versus -0.54, P = 0.330). Among those randomized to the intervention, only 30 of 60 participants used the eHealth tool (application (app) users). The app users were younger and had a higher educational level. A decrease in anxiety mean scores was noted in those who used the app in the per protocol analysis (-2.00 versus -0.54, P = 0.028). The intervention group stated a lower physical-component health-related quality of life (HRQoL) (-4.32 versus -1.16, P = 0.042) but mental-component HRQoL and depressive symptoms were unchanged.

CONCLUSIONS

Delivery of an eHealth intervention in this RCT did not result in an improvement in anxiety scores in patients awaiting AAA surgery. Uptake of the eHealth tool was low, although it resulted in lower anxiety scores in those participants who actually used it.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03157973 (http://www.clinicaltrials.gov).

Screening Older Adult Men for Abdominal Aortic Aneurysm: A Scoping Review

Abdominal aortic aneurysm (AAA) is a potentially fatal condition predominantly affecting older adult men (60 years or over). Based on evidence, preventative health-care guidelines recommend screening older males for AAA using ultrasound. In attempts to reduce AAA mortality among men, screening has been utilized for early detection in some Western countries including the UK and Sweden. The current scoping review includes 19 empirical studies focusing on AAA screening in men. The findings from these studies highlight benefits and potential harms of male AAA screening. The benefits of AAA screening for men include decreased incidence of AAA rupture, decreased AAA mortality, increased effectiveness of elective AAA repair surgery, and cost-effectiveness. The potential harms of AAA screening included lack of AAA mortality reduction, negative impacts on quality of life, and inconsistent screening eligibility criteria being applied by primary care practitioners. The current scoping review findings are discussed to suggest changes to AAA screening guidelines and improve policy and practice.

Systematic Review of the Co-Prevalence of Arterial Aneurysms Within the Vasculature

OBJECTIVE

Aneurysms are considered focal manifestations of a systemic vascular condition, and various studies report co-prevalence of aneurysms in different vascular beds. Insight into profiles of patients at risk of multiple aneurysms is lacking, and few clinical algorithms exist if additional screening is indicated. This systematic review assessed the co-prevalence of aneurysms in different vascular beds and analysed putative risk factors for multiple aneurysms.

METHODS

Medline, Embase, and Cochrane libraries were searched up to February 2020 for studies reporting co-prevalence of aneurysms in different vascular beds using the keywords: "aneurysm", "co-prevalence", or synonyms. All studies were reviewed by two authors independently. Studies were excluded if they described concomitant treatment of multi-aneurysms, or if the aneurysm was reported solely bilateral, post-dissection, mycotic, traumatic, iatrogenic, or caused by a connective tissue disease. Radar plots were used to indicate studies that found an association between the investigated features and aneurysm co-prevalence against those that did not.

RESULTS

Thirty-two studies met the inclusion criteria, describing in total 16 353 patients of whom 2 015 had at least one additional aneurysm. The weighted co-prevalence was 16.9% (95% confidence interval [CI] 11.8-22.6), I² > 90%. At least 19 combinations of aneurysms were described, mostly derived from retrospective studies. Seventeen of 32 (53%) studies described concurrent aneurysms in patients with an abdominal aortic aneurysm. Predominantly positive associations were found for higher age, hypertension, stenotic disease, presence of multiple (at least three) aneurysms, and primary aneurysm size.

CONCLUSION

Approximately one in six patients with a primary aneurysm harbours an additional aneurysm, increasing to one in four if the patient has a popliteal artery aneurysm. Higher age, hypertension, stenotic disease, presence of multiple (at least three) aneurysms, and primary aneurysm size were predictive of aneurysm co-prevalence. These clinical predictors may assist when deciding whether a patient with a primary aneurysm needs to be screened for additional aneurysms.