Overview of screening eligibility in patients undergoing ruptured AAA repair from 2003 to 2019 in the Vascular Quality Initiative

Expand the success of screening to reduce aortic aneurysm mortality: progress interpretation and new fronts

Aortic aneurysm is a leading cause of death across the world. Many victicms carry it without knowing. Ruputre of aortic aneurysms leads to devastating sudden death. This brings trauma to families and our society. Based upon sound results out of several cohort studies, US Preventive Services Task Force (USPST) crafted the 1st nationwide abdominal aorta aneurysm (AAA) screening program in 2005. It was renewed and expanded in subsequent revisions in 2014 and 2019. UK and Sweden estalished their own programs as well. Since then, a significant decline in AAA prevalence and mortality has been observed. Two decades into the practice, the state of the art on diagnostics, surgical approaches, and pharmacological options have drastically changed. Patients previously ineligible for treatment or inconclusive on diagnostics now have valid options. The screening program is on the verge for a bold expansion. In this review, we summarize the chroncles leading to the inception of the screening programs, progress in interpretation after implementation including gains, gaps and controversies, advents of new technologies and approaches, new fronts facing us, as well as priorities to be addressed in future phases. Particularly, screening asssys with a clinically tested biomarker, tetrahydrobiopterin (H4B), enables unpresended accessibility, consistency and throughput to accommodate the needs of a larger population. Furthermore, patients with AAAs at size below the eligibility threhold for surgical intervention (e.g., < 5.5 cm) can be treated with novel oral medications. Confronting factors such as changing demographics and COVID-19 aftermath are putting up new challenges. Nevertheless, running a program at national scale demands both unwavering commitment and agile fine-tuning. Technical innovation will be an indispensable chapter of its continued success. The burden of aortic aneurysm-led sudden death is too heavy for any family and the society to bear; it is time to step up our resolve with additional capacities as discussed in the present review.

The effect of aneurysm diameter on perioperative outcomes following complex endovascular repair

OBJECTIVES

Endovascular aneurysm repair (EVAR) for large infrarenal abdominal aortic aneurysms (AAAs) has been associated with worse outcomes compared with EVAR for smaller AAAs. Whether these findings apply to complex AAAs (cAAA) remains uncertain.

METHODS

We identified all intact complex EVAR (cEVAR) from 2012 to 2024 in the Vascular Quality Initiative. cEVAR was defined as having a proximal extent between zones 6 and 9 and at least one side branch/fenestration/chimney/parallel grafting. Aneurysm size was defined as follows: large: >65 mm (males), >60 mm (females); medium: 55 to 65 mm (males), 50 to 60 mm (females); and small: <55 mm (males), <50 mm (females). We assessed perioperative death, any complication, and in-hospital reintervention using logistic regression and midterm mortality using adjusted Kaplan-Meier methods and Cox regression analyses. Medium-sized aneurysms were compared with large and small aneurysms.

RESULTS

Of the 3426 patients, 22.6% had large, 60.4% medium, and 17.0% had small aneurysms. As compared with medium and small aneurysms, large aneurysms demonstrated higher rates of perioperative death (4.8% vs 2.6% vs 0.5%), any complication (33.3% vs 23.6% vs 19.4%), and in-hospital reintervention (6.2% vs 4.0% vs 2.6%) (all P < .05). The median follow-up was 445 days. One-year mortality rates were higher in large aneurysms (12.3% vs 7.8% vs 3.8%; P < .001). After adjustment, when compared with medium-sized aneurysms, large aneurysms were associated with a significantly higher risk of perioperative death (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.09-2.72), any complication (aOR, 1.44; 95% CI, 1.18-1.76), and midterm mortality (adjusted hazard ratio, 1.50; 95% CI, 1.19-1.88), but not in-hospital reintervention (aOR, 1.46; 95% CI, 0.99-2.13). Although small aneurysms, as compared with medium-sized aneurysms, did not demonstrate a difference in any complication (aOR, 0.87; 95% CI, 0.68-1.10), in-hospital reintervention (aOR, 0.77; 95% CI, 0.42-1.33), and midterm mortality (adjusted hazard ratio, 0.78; 95% CI, 0.57-1.08], they did demonstrate a lower risk of perioperative death (aOR, 0.26; 95% CI, 0.06-0.71).

CONCLUSIONS

In cEVAR for cAAA, large aneurysms, compared with medium-sized aneurysms, were associated with higher rates of perioperative death, any complication, and midterm mortality, with in-hospital reinterventions trending toward a statistically significant higher risk. Although these results align with expectations, they emphasize the importance of effectively managing patients with large cAAAs and highlight the need for future research to determine whether patients might benefit more from medical therapy or open repair.

Trends, risk factors, and outcomes of selective screening for abdominal aortic aneurysms in at-risk patients

OBJECTIVES

For men ages 65 to 75 years without a smoking history and for women ages 65 to 75 years with a smoking history, the United States Preventative Service Task Force recommends that primary care providers (PCPs) use their clinical judgement when offering abdominal aortic aneurysm (AAA) screening. This study describes the trends in screening for these cohorts, identifies factors that may influence screening rates, and compares outcomes between screened and unscreened patients.

METHODS

The TriNetX population database was queried for subjects with routine PCP visit between ages 65 to 75 from 2007 to 2023 to create cohorts of male smokers, male nonsmokers, and female smokers. Prevalence and 1- and 3-year incidences of AAA screening by ultrasound and computed tomography scans/magnetic resonance imaging (CT/MRI) were calculated. Screened and unscreened patients' demographics, diagnoses, and medications were compared. Rates of AAA diagnosis and repair were compared between unmatched screened and unscreened patients.

RESULTS

Screening for all groups peaked in 2023. Male smokers had the highest screening prevalence (21.2%), followed by male nonsmokers (3.1%) and female smokers (0.90%). The 1-year incidence of screening increased for male smokers, peaking at 8.2% in 2021. The 1-year incidence plateaued at 1.9% for male nonsmokers in 2020 and remained between 0.25% and 0.35% for female smokers for the whole observation period. By 2023, 23.6%, 14.3%, and 24.3% of male smokers, male nonsmokers, and female smokers had been screened via CT/MRI, respectively, with CT/MRI comprising the majority of screening events for all three cohorts. Hyperlipidemia and statin use were associated with screening for all groups (P < .05), whereas a personal history of coronary artery disease was associated with no screening. Screening for male nonsmokers was associated with hypertension, diabetes, and chronic pulmonary obstructive disease (P < .05). Screening in female smokers was associated with family history of coronary artery disease (odds ratio, 1.50; P < .001). For all groups, screening was associated with unruptured AAA diagnosis and endovascular aortic repair (P < .05). Screened female smokers had similar rates of AAA diagnosis as male nonsmokers (4.58% and 4.37%, respectively).

CONCLUSIONS

AAA screening in all at-risk populations increases diagnosis and treatment of AAA, but the screening rate is low for all groups, even with increasing CT/MRI use. Patients with strong risk factors for AAA are not undergoing screening. Collaboration with PCPs is necessary to increase screening rates and ensure that patients with the most clinically consequential risk factors are managed appropriately.

Women have higher morbidity and mortality after repair of complex aortic aneurysms due to symptomatic presentation and more extensive aneurysms

OBJECTIVE

Prior studies have found disparities in outcomes by sex after repair of abdominal aortic aneurysms. However, little is known about the disparities in outcomes after endovascular repair of complex abdominal aortic aneurysms. This study aims to assess differences in presentation and outcomes by sex after endovascular repair of complex abdominal aortic aneurysms.

METHODS

All patients treated via an endovascular approach for complex abdominal aortic aneurysms treated in the Vascular Quality Initiative database from 2014 to 2022 were included. Demographics, comorbidities, and operative details were compared by sex. Perioperative outcomes and long-term survival were then assessed using univariable and adjusted analysis.

RESULTS

4671 patients were treated for complex abdominal aortic aneurysms, including 74% men and 26% women. Women had higher rates of chronic obstructive pulmonary disease (46% vs 38%, P < .001), but lower rates of coronary artery disease (20% vs 32%, P < .001) and lower baseline creatinine (0.9 vs 1.1, P < .001). Women more commonly presented with symptomatic (18% vs 9%), ruptured (2.9% vs 2.0%), and thoracoabdominal aneurysms (vs juxtarenal) (38% vs 26%) than men (all P < .001). Women had higher 30-day mortality (5.2% vs 2.8%, P < .001) and long-term mortality (P < .001) than men. This trend persisted after adjustment for 30-day mortality (odds ratio [OR]: 1.5, confidence interval [CI]: 1.0-2.2) but not long-term survival (hazard ratio: 1.2, CI: 0.96-1.4). Before adjustment, major morbidities were also more common among women, including cardiac complications (12% vs 10%, P = .024), respiratory complications (7.0% vs 4.2%, P < .001), intestinal ischemia (2.8% vs 1.5%, P = .005), stroke (2.6% vs 1.2%, P = .002), and spinal cord ischemia (5.3% vs 3.3%, P = .002). Prolonged length of stay exceeding 7 days was also more common among women (25% vs 14%, P < .001). Only prolonged length of stay (OR: 1.7, CI: 1.4-2.1) was more common among women after adjustment. Rather, nonelective repair (OR: 1.9, CI: 1.5-2.3) and thoracoabdominal extent (OR: 1.3, CI: 1.1-1.6) was associated with late mortality.

CONCLUSIONS

Women experience higher morbidity and mortality after endovascular repair of complex abdominal aortic aneurysms, primarily due to urgent presentations and more extensive aneurysms at the time of repair. These findings highlight the critical need for improved screening and earlier intervention in women, which may help mitigate this inequality and improve outcomes.

Lower Rates of Abdominal Aortic Aneurysm Repair and Higher Long-term Aortic Mortality in Women Compared With Men: Results of a Population-Based Study Spanning 4 Decades

OBJECTIVE

To determine the population-level impact of screening and endovascular repair as well as mortality in women with abdominal aortic aneurysms (AAAs).

PATIENTS AND METHODS

We conducted a population-based cohort study of patients from Olmsted County, Minnesota, in whom AAA was diagnosed between January 1, 1980, and December 31, 2017. The AAAs were identified using the International Classification of Diseases, Ninth and Tenth Revisions and Current Procedural Terminology codes with medical record review to confirm the diagnosis and identify late events. Survival analysis for overall and aortic mortality was performed and stratified based on sex and repair status.

RESULTS

There were 1537 patients in our study cohort (75% [1156] male; median age, 74 years). Compared with men, women were older (80 vs 73 years; P<.001), had smaller initial aneurysm size (4 vs 4.3 cm; P<.001), underwent AAA repair less frequently (26% [99] vs 41% [475]; P<.001), and had similar 30-day mortality from AAA repair (4% [4 of 381] vs 5% [22 of 1156]; P=.50). Median follow-up was 18 years. Aortic and all-cause mortality at 10 and 20 years were highest in females who did not undergo repair (hazard ratio, 3; 95% CI, 1.8 to 4.5; P<.001), as compared with all men and women who underwent AAA repair. Cumulative aortic mortality analyzed with non-aortic-related deaths as a competing risk factor remained significantly higher in NRF (15% [40 of 282] vs 5% to 8% in other groups; 5/99 in females undergoing repair, 39/681 in non repaired males and 37/475 in males who underwent repair, P=.001). All patients with aortic-related mortality had refused repair due to older age and comorbidities, except 2 females with ruptures of 4.8 and 5.5 cm AAAs awaiting repair.

CONCLUSION

Abdominal aortic aneurysms are diagnosed in women almost a decade later and repaired less often than in men. There is a 3-fold greater long-term aortic-related mortality in women not undergoing AAA repair compared with men and women who underwent AAA repair.

Thirty-Nine Percent of Patients with a Ruptured Abdominal Aortic Aneurysm (AAA) Have an Incidentally Detected AAA Prior to Rupture

BACKGROUND

Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred in individuals who are not eligible for screening. The primary aim of this study was to describe the group of patients admitted to Oslo University Hospital with a ruptured AAA after the implementation of the local AAA screening project. The following parameters were investigated: AAA detection before rupture, surveillance status, eligibility for screening, and comorbidities. We also sought to compare outcomes (repair rates and 30-day mortality) between patients with and without an incidentally detected AAA prior to rupture.

METHODS

This cohort study included patients admitted acutely to Oslo University Hospital due to a symptomatic or ruptured AAA in the period January 2011 to December 2022. Data on demographics, prior AAA detection, surveillance status, treatment, and mortality were collected retrospectively through electronic medical records.

RESULTS

We identified 200 patients with a symptomatic or ruptured AAA, among which 79 (40%) had an AAA detected before rupture-one (1%) through screening and 78 (39%) incidentally. Up to 30% of the incidentally detected AAAs were not under any surveillance. Six patients were found eligible for screening: one had attended, three were non-attenders, and two had not been invited. Patients with an incidentally detected AAA before rupture had a more advanced age and a significantly higher degree of comorbidities than patients without a previously detected AAA, and the repair rates in these groups were 56% and 84%, respectively (P < 0.001). Adjusted for comorbidities and risk factors, the odds ratio for repair among patients with incidentally detected AAA was 0.56 (P = 0.292). The 30-day mortality was not significantly different between the two groups (P = 0.097).

CONCLUSIONS

Most patients with a ruptured AAA were not eligible for screening, but 39% of the patients had an incidentally detected AAA prior to rupture. Standardized reporting and follow-up of incidentally detected AAAs is thus identified as an additional measure to organized screening in the effort to reduce AAA-related mortality.

A 20-Year Analysis of Ruptured Abdominal Aortic Aneurysm Outcomes and Associated Factors in Korea

BACKGROUND

Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades.

METHODS

A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020.

RESULTS

The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years.

CONCLUSIONS

The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA.

The association of ruptured abdominal aortic aneurysm diameter with mortality in the International Consortium of Vascular Registries

BACKGROUND

The mortality after ruptured abdominal aortic aneurysm (rAAA) repair is high, despite improvements in perioperative care, centralization of emergency vascular surgical services, and the introduction of endovascular aneurysm repair (EVAR). The diameter of intact AAA has been shown to be a predictor of short- and long-term survival. The aim of this study was to analyze the impact of AAA diameter on mortality for rAAA repair using contemporary data collected from the International Consortium of Vascular Registries and compare outcomes by sex and the type of repair patients received.

METHODS

Prospective registry data on repair of rAAA from seven countries were collected from 2010 to 2016. The primary outcome was perioperative mortality after EVAR and open surgical repair (OSR). Data were stratified by type of repair and sex. Logistic regression models were used to estimate odds ratio (OR) for the association between AAA diameter and perioperative mortality and the association between type of repair and mortality. Multivariable logistic regression models were used to adjust for differences in patient characteristics.

RESULTS

The study population consisted of 6428 patients with a mean age ranging from 70.2 to 75.4 years; the mean AAA diameter was 7.7 ± 1.8 cm. Females had a significantly smaller AAA diameter at presentation compared with males (6.9 ± 1.6 cm vs 7.9 ± 1.8 cm; P < .001). who underwent OSR had larger AAA diameters compared with those who underwent EVAR (P < .001). Females who underwent repair were significantly older (P < .001). Males were more likely to have cardiac disease, diabetes mellitus, and renal impairment. Overall, AAA diameter was a predictor of mortality in univariate and multivariate analysis. When analyzing EVAR and OSR separately, the impact of AAA diameter per cm increase on mortality was apparent in both males and females undergoing EVAR, but not OSR (EVAR: male OR, 1.09 [95% confidence interval, 1.03-1.16] and EVAR: female OR, 1.17 [95% confidence interval, 1.02-1.35]). The early mortality rate for males and females who underwent EVAR was 18.9% and 25.9% (P < .001), respectively. The corresponding mortality for males and females who underwent OSR was 30.2% and 38.6% (P < .001), respectively.

CONCLUSIONS

In these real-world international data, there is a significant association between rAAA diameters and early mortality in males and females. This association was more evident in patients undergoing EVAR, but not shown in OSR. Despite improvements in overall AAA repair outcomes, the risk of mortality after rAAA repair is consistently higher for females.

Association between socioeconomic deprivation and presentation with a ruptured abdominal aortic aneurysm

OBJECTIVE

Given the ongoing nature of research in the social determinants space and urges to improve United States Preventive Services Task Force screening efforts for abdominal aortic aneurysms (AAAs), this project aims to characterize the association between the level of socioeconomic deprivation, rurality, and ruptured AAA (rAAA) presentation across the United States.

METHODS

We queried the Vascular Quality Initiative registry (2010-2019) for patients with AAAs. The area deprivation index (ADI) is an index from 1 to 100 used to capture socioeconomic status. ADI was grouped into quintiles, with the most deprived regions being quintile 5 and having the highest ADI index. Multivariable logistic regression assessed the association between ADI, rurality, and rAAA presentation overall and before age 65.

RESULTS

Of the 82,909 patients included, 11,458 patients (14%) resided in the most socioeconomically deprived regions, and 18,083 patients (22%) lived in rural regions. Overall, 6831 patients (8.2%) experienced an rAAA, with 4696 patients (69%) residing in the three most deprived quintiles. Most patients underwent endovascular repair (n = 67,933; 82%), followed by open repair (n = 14,976; 18%). On multivariable analysis, residence in the most socioeconomically deprived region was associated with a near 1.5-fold increased odds of presenting with an rAAA compared with a residence in the least deprived regions (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.31-1.63; P < .001), whereas urban residence was associated with a decreased odds to present with an rAAA compared with rural residence (OR, 0.84; 95% CI, 0.79-0.89; P < .001). When stratifying the study population by the United States Preventive Services Task Force recommended age for AAA screening (65 years old), 14,147 patients (17%) were under 65. Of those under 65, 1381 patients (9.8%) experienced a rAAA, and 9955 patients (71%) resided in the three most deprived quintiles. Residence in the most socioeconomically deprived region was associated with an increased odds of presenting with an rAAA compared with residence in the least deprived region (OR, 1.31; 95% CI, 1.01-1.69; P = .042). However, there were no significant associations between rural residence and increased rAAA presentation among individuals under 65 (OR, 1.07; 95% CI, 0.93-1.23; P = .36).

CONCLUSIONS

Among all patients in this study, patients residing in highly socioeconomically deprived or rural regions were more likely to present with an rAAA, but among those under 65, only residence in a socioeconomically deprived area was associated with increased odds of rAAA presentation. Understanding the effects of socioeconomic deprivation on rAAA presentation can identify at-risk populations for early AAA screening before rupture.

Validation of I71.3 code for ruptured abdominal aortic aneurysm in Korea: misplaced diagnosis in claims data

Purpose

Studies in western countries have shown a decline in the incidence of ruptured abdominal aortic aneurysm (rAAA) with advancements in endovascular repair and screening. However, according to health insurance data in Korea based on rAAA code (I71.3), overall rAAA has been increasing. This study aimed to validate the I71.3 code for rAAA and attempt to define the true incidence of rAAA in Korea.

Methods

A 20-year multicenter retrospective review of rAAA was undertaken from the period of January 1, 2000 to December 31, 2020. All patients were diagnosed with the rAAA code I71.3 in each of the 4 hospitals. The CT images and surgical records of these patients were reviewed to differentiate true rAAA and misdiagnosis. Further data on true rAAA patient outcomes including mortality and treatment success were also collected.

Results

A total of 305 rAAA (I71.3) codes were identified in the 4 centers. However, medical record review showed true rAAA in only 131 (43.0%). The remaining 174 cases (57.0%) were misdiagnosed. Impending ruptures were the most common misdiagnoses (37.9%). The total in-hospital mortality including deaths before treatment was 38.9% (n = 51), while mortality of treated patients was 24.4% (n = 15).

Conclusion

The analysis of I71.3 code for rAAA showed that only 43.0% were true rAAA and the remaining 57.0% were misdiagnosed. This indicates that the I71.3 code is overestimated in National Health Insurance-based data and that the true incidence of rAAA could be much lower.

Harnessing the Electronic Medical Record to Improve the Utilization of Ultrasound Screening for Abdominal Aortic Aneurysms

PURPOSE

The US Preventive Services Task Force recommends one-time ultrasound screening to detect abdominal aortic aneurysms (AAAs) in male smokers. Despite this recommendation, AAA screening is still underutilized. The aim of this study was to determine the effectiveness of an electronic medical record (EMR) automated ordering program in increasing AAA screening at an integrated health care system.

METHODS

This study was a retrospective chart review of patients who underwent ultrasound screening for AAA from January 1, 2016, to December 31, 2021, at a geographically isolated integrated health care system. An automated ordering system was implemented in a stepwise fashion within our EMR beginning in March 2019. The number of ultrasound studies and the incidence of AAA were compared between manual referral and EMR automated ordering periods.

RESULTS

A total of 4,176 patients met the inclusion criteria for this study, among whom 148 aneurysms were identified. There was an increase in the average number of monthly screening ultrasound studies performed during the automated ordering period compared with the manual referral period (105 vs 16.3 studies, P < .001). The incidence of AAA was lower in the automated ordering period compared with the manual referral period (3.2% vs 5.3%, P = .013).

CONCLUSIONS

An EMR automated ordering program can increase the number of screening ultrasound studies performed for AAA, which may help clinicians identify more high-risk aneurysms requiring urgent repair.