Systematic review and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance intervals and their cost-effectiveness

Thompson, SG; Brown, L.C.; Sweeting, Michael; Bown, Matthew J.; Kim, Lois; Glover, Matthew; Buxton, Martin; Powell, J.T.

doi:10.3310/hta17410

Cited by 184 publications

(194 citation statements)

References 122 publications

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“…Addressing CV risk may theoretically impact on AAA growth rates, given the shared pathogenetic mechanisms. However, a paucity of evidence still remains in the factors affecting growth rate of such aneurysms (18). Addressing CV risk factors may potentially impact on AAA growth, and potentially have a larger impact on mortality rates than any prophylactic AAA surgery for this cohort group, but more evidence is definitely required to prove such rationale.…”

Section: Discussionmentioning

confidence: 99%

Patients with Small Abdominal Aortic Aneurysm are at Significant Risk of Cardiovascular Events and this Risk is not Addressed Sufficiently

Bath¹,

Saratzis²,

Saedon³

et al. 2017

Journal of Vascular Surgery

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Previous data suggest that patients with small AAA have a high risk of cardiovascular (CV) mortality and morbidity. The recent implementation of the NHS AAA screening programme (NAAASP) and similar programmes elsewhere has led to several individuals being diagnosed with small AAA, yet addressing their CV risk-factors is still not formalised clinical practice within screening programmes. The precise contemporary CV risk-profiles of these patients also remain unknown. Our findings suggest that despite recent advances in CV prevention in highrisk populations, the management of patients with small AAA remains suboptimal. Better CVprotection should be offered and monitored during surveillance. ABSTRACTBackground: Patients with abdominal aortic aneurysm (AAA) are at significant-risk of

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Section: Discussionmentioning

confidence: 99%

Patients with Small Abdominal Aortic Aneurysm are at Significant Risk of Cardiovascular Events and this Risk is not Addressed Sufficiently

Bath¹,

Saratzis²,

Saedon³

et al. 2017

Journal of Vascular Surgery

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“…[79][80][81] A number of studies have also explored the costs and outcomes of preoperative surveillance. 82,83 However, less is known about the costs and utilities associated with preoperative assessments and postoperative care. In addition, the existing evidence is primarily from trial settings and patient samples, which may be atypical of those in routine care, collected over a limited follow-up period.…”

Section: Data Inputsmentioning

confidence: 99%

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Grant

Sperrin

Carlson

et al. 2015

Health Technology Assessment

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BackgroundAbdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities.ObjectiveTo develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice.Data sourcesThe UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases.MethodsA combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit.ResultsThe analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty.LimitationsLack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation.ConclusionsThe ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…15 The variation could not be explained by differences in initial AAA diameter alone. 16 The authors suggested that methodological issues, such as differences in imaging modalities, variation in the plane of measurement, and cursor positioning, likely explained the large heterogeneity. Frequently, important methodological aspects were not reported.…”

mentioning

confidence: 99%

Surrogate Markers of Abdominal Aortic Aneurysm Progression

Wanhainen

Mani

Golledge

2016

ATVB

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Abstract-The natural course of many abdominal aortic aneurysms (AAA) is to gradually expand and eventually rupture and monitoring the disease progression is essential to their management. In this publication, we review surrogate markers of AAA progression. AAA diameter remains the most widely used and important marker of AAA growth. Wanhainen et al Surrogate Markers of Aneurysm Progression 237in all studies when a standardized protocol is used. 7,8 One of the challenging aspects to assessing maximum AAA diameter is the variety of methods that can potentially be used and the lack of reporting of the exact techniques used in individual studies. Variations may occur in the plane of acquisition (eg, coronal or sagittal), the axis of measurement (eg, axial or orthogonal), the position of the measuring calipers (eg, inner to inner or outer to outer), the relationship with the cardiac cycle (systole versus diastole), and the selected region of the AAA. 9 It has been suggested that diameters measured perpendicular to the aorta centerline (orthogonal), rather than within the axial plane, are more representative of the true AAA diameter. 4,6 With ultrasound, measurements within the anteroposterior, rather than the transverse plane, have been reported to be more reproducible. 4 There is no current consensus on how to place the calipers when measuring the diameter with ultrasound. Methods used include the outer-to-outer method, where calipers are placed on the outer layer of the aortic wall; the inner-to-inner method, where calipers are placed on the inner layer of the aortic wall; and the leading edge-to-leading edge method, where calipers are placed on the outer layer of the anterior wall and the inner layer of the posterior wall ( Figure 1). Much of the reported variation in ultrasound measured AAA diameter is likely because of the variation in caliper placement. 5,10 The UK Small Aneurysm Trial 11 is based on the measurement of AAA diameter on the outer-to-outer method, and this method has been adopted into the current UK intervention criteria. 12 The inner-to-inner method was used in the Multicentre Aneurysm Screening Study, 13 and consequently it is used in the current UK National Health Service AAA screening programme.14 The leading edgeto-leading edge method is used in the current Swedish AAA screening programme.15 Studies comparing these methods show there is a significant difference in diameters measured with the different methods, which has an impact on the reported prevalence rates of AAA. 5,10 In a Swedish AAA screening study, the difference in mean diameter was 4 mm between inner-toinner and outer-to-outer, which resulted in an astonishing 77% difference in AAA prevalence (ie, 1.3% compared with 2.3%). 5A systematic review of 15 studies reported considerable variation in small AAA growth rates (mean, −0.3 to +4.0 mm/y). 15 The variation could not be explained by differences in initial AAA diameter alone. 16 The authors suggested that methodological issues, such as differences in imaging modalities, variation ...

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Systematic review and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance intervals and their cost-effectiveness

Cited by 184 publications

References 122 publications

Patients with Small Abdominal Aortic Aneurysm are at Significant Risk of Cardiovascular Events and this Risk is not Addressed Sufficiently

Patients with Small Abdominal Aortic Aneurysm are at Significant Risk of Cardiovascular Events and this Risk is not Addressed Sufficiently

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation

Surrogate Markers of Abdominal Aortic Aneurysm Progression

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