Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair

Parkinson, Fran; Ferguson, Stuart; Lewis, P.; Williams, Ian; Twine, Christopher P.

doi:10.1016/j.jvs.2014.10.023

Cited by 121 publications

(74 citation statements)

References 29 publications

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“…30,31 A more recent pooled analysis suggested that the current rupture risk may be much lower: 5.3% per year for AAA diameters between 5.5 and 7.0 cm and 6.3% per year for AAAs >7.0 cm. 32 Similar to the EVAR-2 trial, the risk of death from causes other than AAA was higher than the risk of death from aneurysm rupture. 29,32 This raises the important question of whether there should be a different size threshold for AAA repair in frail patients.…”

Section: Discussionmentioning

confidence: 91%

“…32 Similar to the EVAR-2 trial, the risk of death from causes other than AAA was higher than the risk of death from aneurysm rupture. 29,32 This raises the important question of whether there should be a different size threshold for AAA repair in frail patients. Comparing published data to our Kaplan-Meier survival curves, we suggest that elective aneurysm repair in frail patients be performed only for AAA diameters >7.0 cm because 1-year survival after surgery in frail patients was 86.0% for EVAR and 78.2% for OAR.…”

Section: Discussionmentioning

confidence: 91%

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Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

George

Chen

Trickey

et al. 2020

Journal of Vascular Surgery

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Objective: Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database. Methods:Patients undergoing elective open and endovascular AAA repair (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with $10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI $35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year.Results: A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F ¼ 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001). Conclusions:There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair. (J Vasc Surg 2020;71:46-55.)

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 91%

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

George

Chen

Trickey

et al. 2020

Journal of Vascular Surgery

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“…139 The abnormally dilated abdominal aorta often ruptures if left untreated and this event is associated with a high mortality rate. 128 Therapeutic options for AAA patients are limited and no single drug or pharmacological therapy has been proven effective for preventing growth or rupture of AAA. 165 …”

Section: Pgg As a Potential Therapeutic Option For Aaa Patientsmentioning

confidence: 99%

Pentagalloyl Glucose and Its Functional Role in Vascular Health: Biomechanics and Drug-Delivery Characteristics

et al. 2018

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Pentagalloyl glucose (PGG) is an elastin-stabilizing polyphenolic compound that has significant biomedical benefits, such as being a free radical sink, an anti-inflammatory agent, anti-diabetic agent, enzymatic resistant properties, etc. This review article focuses on the important benefits of PGG on vascular health, including its role in tissue mechanics, the different modes of pharmacological administration (e.g., oral, intravenous and endovascular route, intraperitoneal route, subcutaneous route, and nanoparticle based delivery and microbubble-based delivery), and its potential therapeutic role in vascular diseases such as abdominal aortic aneurysms (AAA). In particular, the use of PGG for AAA suppression and prevention has been demonstrated to be effective only in the calcium chloride rat AAA model. Therefore, in this critical review we address the challenges that lie ahead for the clinical translation of PGG as an AAA growth suppressor.

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“…Although a large body of both clinical trials (De Bruin et al 2010; Lederle et al 2002b; Parkinson et al 2015; Powell et al 2007; Schermerhorn et al 2008; UK Small Aneurysm Trial Participants 1998) and epidemiologic data (Darling et al 1977; Pleumeekers et al 1995; Singh 2001) exist to quantify population-based risk of rupture at a given size, each of these studies accepted some degree of rupture mortality within the population (Thompson et al 2012). A recent single-center report (Skibba et al 2015) and meta-analysis (Parkinson et al 2015) suggest that not only do patients rupture below clinically acceptable thresholds for repair, typically ≥5.0 cm in women and ≥5.5 cm in men (Grant et al 2015), but most patients rupture at sizes substantially greater than the accepted diameters for surgical repair. These data would suggest that prior reports of rupture risk are likely overestimations and that many patients are exposed to surgical risk with possible limited personal benefit (Lederle et al 2002a).…”

Section: Introductionmentioning

confidence: 99%

Detecting Regional Stiffness Changes in Aortic Aneurysmal Geometries Using Pressure-Normalized Strain

Mix

Yang

Johnson

et al. 2017

Ultrasound in Medicine & Biology

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Transabdominal ultrasound elasticity imaging could improve the assessment of rupture risk for abdominal aortic aneurysms by providing information on the mechanical properties and stress or strain states of vessel walls. We implemented a non-rigid image registration method to visualize the pressure-normalized strain within vascular tissues and adapted it to measure total strain over an entire cardiac cycle. We validated the algorithm’s performance with both simulated ultrasound images with known principal strains and anatomically accurate heterogeneous polyvinyl alcohol cryogel vessel phantoms. Patient images of abdominal aortic aneurysm were also used to illustrate the clinical feasibility of our imaging algorithm and the potential value of pressure-normalized strain as a clinical metric. Our results indicated that pressure-normalized strain could be used to identify spatial variations in vessel tissue stiffness. The results of this investigation were sufficiently encouraging to warrant a clinical study measuring abdominal aortic pressure-normalized strain in a patient population with aneurysmal disease.

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Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair

Abstract: Rupture rates of untreated AAA were lower than those currently quoted in the literature. Non-AAA-related mortality in this group of patients is high.

Cited by 121 publications

References 29 publications

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms

Pentagalloyl Glucose and Its Functional Role in Vascular Health: Biomechanics and Drug-Delivery Characteristics

Detecting Regional Stiffness Changes in Aortic Aneurysmal Geometries Using Pressure-Normalized Strain

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