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Emergency Medicine Australasia : EMA Oct 2023Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta... (Review)
Review
Point-of-care ultrasound (POCUS) is becoming ubiquitous in emergency medicine. POCUS for abdominal aortic aneurysm is well established in practice. The thoracic aorta can also be assessed by POCUS for dissection and aneurysm and transthoracic echocardiography is endorsed by international guidelines as an initial test for thoracic aortic pathologies. A systematic search of Ovid Medline, PubMed, EMBASE, SCOPUS and Web of Science from January 2000 to August 2022 identified four studies evaluating diagnostic accuracy of emergency physician POCUS for thoracic aortic dissection (TAD) and five studies for thoracic aortic aneurysm (TAA). Study designs were heterogeneous including differing diagnostic criteria for aortic pathology. Convenience recruitment was frequent in prospective studies. Sensitivity and specificity ranges for studies of TAD were 41-91% and 94-100%, respectively when an intimal flap was seen. Sensitivity and specificity ranges for studies of thoracic aorta dilation >40 mm were 50-100% and 93-100%, respectively; for >45 mm ranges were 64-65% and 95-99%. Literature review identified that POCUS is specific for TAD and TAA. POCUS reduces the time to diagnosis of thoracic aortic pathology; however, it remains insensitive and cannot be recommended as a stand-alone rule-out test. We suggest that detection of thoracic aorta dilation >40 mm by POCUS at any site increases the suspicion of serious aortic pathology. Studies incorporating algorithmic use of POCUS, Aortic Dissection Detection Risk Score and D-dimer as decision tools are promising and may improve current ED practices. Further research is warranted in this rapidly evolving field.
Topics: Humans; Point-of-Care Systems; Prospective Studies; Ultrasonography; Aortic Aneurysm, Thoracic; Aortic Dissection; Physicians
PubMed: 37364927
DOI: 10.1111/1742-6723.14262 -
VASA. Zeitschrift Fur Gefasskrankheiten 2016Diabetes, a state of relative insulin resistance, is negatively associated with both the presence and growth abdominal aortic aneurysms (AAA), which could suggest a... (Review)
Review
Diabetes, a state of relative insulin resistance, is negatively associated with both the presence and growth abdominal aortic aneurysms (AAA), which could suggest a protective role of obesity against AAA presence or growth. A recent meta-analysis demonstrated a trend toward a positive, though statistically non-significant, association between body mass index (BMI) and the presence of AAA. With respect to the association between obesity and AAA growth, however, the evidence had been very limited. To determine whether obesity (or BMI) is associated with AAA growth, we reviewed currently available studies with a systematic literature search. Our comprehensive search identified seven eligible studies reporting the association of BMI and AAA growth rates, which included data on a total of 3,768 AAA patients. All seven identified studies demonstrated no association between BMI and AAA growth. Despite a trend toward a positive association between BMI and AAA presence, the reason why BMI is not associated with AAA growth (suggested in the present review) is unclear. A discrepancy between associated comorbidities (coronary artery disease, peripheral artery disease, and chronic obstructive pulmonary disease) and AAA presence and between the same comorbidities and AAA growth, however, could be identified. Further investigations are required to elucidate why BMI is not associated with AAA growth despite the trend for a positive association with AAA presence.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Body Mass Index; Dilatation, Pathologic; Disease Progression; Humans; Obesity; Risk Assessment; Risk Factors
PubMed: 27058797
DOI: 10.1024/0301-1526/a000505 -
Journal of Cardiothoracic and Vascular... Apr 2020The purpose of this systematic review was to assess the perioperative clinical outcomes in using local/regional anesthesia (LA/RA) or general anesthesia (GA) in patients... (Meta-Analysis)
Meta-Analysis Review
The purpose of this systematic review was to assess the perioperative clinical outcomes in using local/regional anesthesia (LA/RA) or general anesthesia (GA) in patients undergoing endovascular abdominal aortic aneurysm repair. A comprehensive electronic literature search was undertaken from inception to September 2018, identifying all randomized and nonrandomized studies comparing LA/RA versus GA in patients with abdominal aortic aneurysm who underwent endovascular repair. A total of 12,024 patients (n = 1,664 LA/RA, n = 10,360 GA) were analyzed from 12 observational studies included in this analysis. No difference in mean age between LA/RA and GA group was noted (73.8 ± 7.8 y v 72.4 ± 7.6 y, 95% confidence interval 0.85 [-0.08 to 1.79]; p = 0.07). No differences in preoperative rate of chronic obstructive pulmonary disease, ischemic heart disease, diabetes mellitus, and American Society of Anesthesiologists grades were noted between the 2 groups (p = 0.21, p = 0.85, p = 0.46, and p = 0.67, respectively). Shorter total surgical time in LA/RA patients was reported (135 ± 40 min v 164 ± 43 min; p < 0.00001). Shorter hospital stay was observed in LA/RA patients (3.6 ± 3.3 d v 4.6 ± 5 d; p = 0.002). No difference in cardiac or renal complications was noted between the LA/RA and GA groups postoperatively (2.7% v 2.5%; p = 0.46 and 1.2% v 1.6%; p = 0.13). Similarly, no difference in vascular complications was noted in LA/RA versus GA patients (8.4% v 7.7%; p = 0.44). Thirty-day morality was not different between the 2 cohorts (2% v 1.7%; p = 0.97). Use of LA/RA in selective endovascular abdominal aortic aneurysm repair procedures provides satisfactory and comparable perioperative outcomes with those of GA, with the advantage of a shorter hospital stay. A large randomized controlled trial or multicenter study is required to confirm the present study's findings.
Topics: Anesthesia, General; Anesthesia, Local; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Multicenter Studies as Topic; Postoperative Complications; Risk Factors; Treatment Outcome
PubMed: 31473112
DOI: 10.1053/j.jvca.2019.07.007 -
Current Cardiology Reviews 2021Aortic aneurysms are worrisome because of their predisposition to dissection and rupture. Beta-blockers are considered first-line therapy for aortic aneurysms. The... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Aortic aneurysms are worrisome because of their predisposition to dissection and rupture. Beta-blockers are considered first-line therapy for aortic aneurysms. The following meta-analysis assesses if beta-blockers diminish aortic aneurysm growth.
METHODS
A literature search was performed to collect information on clinical trials that have assessed aortic aneurysm growth between beta-blockers and placebo. The primary endpoint was aortic aneurysm growth rate per year. A forest plot with a random-effects model was used for analysis.
RESULTS
Eight clinical trials were included in the analysis. Beta-blockers showed a statistically non-significant effect on aortic aneurysm growth (standard mean difference -0.44; 95% CI [-0.44, 0.00]).
CONCLUSION
Beta-blockers do not significantly influence aortic aneurysm growth. Further studies are required to find a suitable medical therapy to reduce growth rates.
Topics: Adrenergic beta-Antagonists; Aortic Aneurysm, Abdominal; Humans
PubMed: 33143615
DOI: 10.2174/1573403X16999201102213619 -
European Journal of Vascular and... Nov 2023To assess which ultrasound (US) method of maximum anteroposterior (AP) abdominal aortic diameter measurement can be considered most reproducible. (Review)
Review
Editor's Choice - Comparison of the Reproducibility of Ultrasound Calliper Placement Methods in Abdominal Aortic Diameter Measurements: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies.
OBJECTIVE
To assess which ultrasound (US) method of maximum anteroposterior (AP) abdominal aortic diameter measurement can be considered most reproducible.
DATA SOURCES
MEDLINE, Scopus, and Web of Science were searched (PROSPERO ID: 276694). Eligible studies reported intra- and or interobserver agreement according to Bland-Altman analysis (mean ± standard deviation [SD]) for abdominal aortic diameter AP US evaluations with an outer to outer (OTO), inner to inner (ITI), and or leading edge to leading edge (LELE) calliper placement.
REVIEW METHODS
The Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies statement was followed. The QUADAS-2 tool and QUADAS-C extension were used for risk of bias assessment and the GRADE framework to rate the certainty of evidence. Pooled estimates (fixed effects meta-analysis, after a test of homogeneity of means) for each US method were compared with pairwise one sided t tests. Sensitivity analyses (for studies published in 2010 or later) and meta-regression were also performed.
RESULTS
21 studies were included in the qualitative analysis. Twelve were eligible for quantitative analysis. Studies showed heterogeneity in the US model and transducer used, sex of participants, and observer professions, expertise, and training. Included studies shared a common mean for each US method (OTO: p = 1.0, ITI: p = 1.0, and LELE: p = 1.0). A pooled estimate of interobserver reproducibility for each US method was obtained, combining the mean ± SD (Bland-Altman analysis) from each study: OTO: 0.182 ± 0.440; ITI: 0.170 ± 0.554; and LELE: 0.437 ± 0.419. There were no statistically significant differences between the methods (OTO vs. ITI: p = .52, OTO vs. LELE: p = .069, ITI vs. LELE: p = .17). Considering studies published in 2010 and later, the pooled estimate for LELE was the smallest, without statistically significant differences between the methods. Despite the low risk of bias, the certainty of the evidence for both meta-analysed outcomes remained low.
CONCLUSION
The interobserver reproducibility for OTO and ITI was 2.5 times smaller (indicating better reproducibility) than LELE; however, without statistically significant differences between the methods and low GRADE evidence certainty. Additional data are needed to validate these findings, while inherent differences between the methods need to be emphasised.
PubMed: 37331424
DOI: 10.1016/j.ejvs.2023.06.010 -
BMC Cardiovascular Disorders Mar 2023A paradoxical protective effect of diabetes on the development and progression of abdominal aortic aneurysms (AAA) has been known for years. This study aimed to... (Meta-Analysis)
Meta-Analysis
The association between diabetes and abdominal aortic aneurysms in men: results of two Danish screening studies, a systematic review, and a meta-analysis of population-based screening studies.
BACKGROUND
A paradoxical protective effect of diabetes on the development and progression of abdominal aortic aneurysms (AAA) has been known for years. This study aimed to investigate whether the protective role of diabetes on AAAs has evolved over the years.
METHODS
A cross-sectional study, a systematic review and meta-analysis. This study was based on two large, population-based, randomised screening trials of men aged 65-74; VIVA (2008-2011) and DANCAVAS (2014-2018), including measurement of the abdominal aorta by ultrasound or CT, respectively. Analyses were performed using multiple logistic regressions to estimate the odds ratios (ORs) for AAAs in men with diabetes compared to those not having diabetes. Moreover, a systematic review and meta-analysis of population-based screening studies of AAAs to visualise a potential change of the association between diabetes and AAAs. Studies reporting only on women or Asian populations were excluded.
RESULTS
In VIVA, the prevalence of AAA was 3.3%, crude OR for AAA in men with diabetes 1.04 (95% confidence interval, CI, 0.80-1.34), and adjusted OR 0.64 (CI 0.48-0.84). In DANCAVAS, the prevalence of AAA was 4.2%, crude OR 1.44 (CI 1.11-1.87), and adjusted OR 0.78 (CI 0.59-1.04). Twenty-three studies were identified for the meta-analysis (N = 224 766). The overall crude OR was 0.90 (CI 0.77-1.05) before 2000 and 1.16 (CI 1.03-1.30) after 1999. The overall adjusted OR was 0.63 (CI 0.59-0.69) before 2000 and 0.69 (CI 0.57-0.84) after 1999.
CONCLUSION
Both the crude and adjusted OR showed a statistically non-significant trend towards an increased risk of AAA by the presence of diabetes. If this represents an actual trend, it could be due to a change in the diabetes population.
TRIAL REGISTRATION
DANCAVAS: Current Controlled Trials: ISRCTN12157806. VIVA: ClinicalTrials.gov NCT00662480.
Topics: Male; Humans; Female; Cross-Sectional Studies; Diabetes Mellitus; Aortic Aneurysm, Abdominal; Ultrasonography; Denmark; Mass Screening; Risk Factors
PubMed: 36927295
DOI: 10.1186/s12872-023-03160-8 -
World Journal of Emergency Surgery :... Mar 2023Studies on the mortality of blunt abdominal aortic injury (BAAI) are rare and have yielded inconsistent results. In the present study, we aimed to quantitatively analyse... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Studies on the mortality of blunt abdominal aortic injury (BAAI) are rare and have yielded inconsistent results. In the present study, we aimed to quantitatively analyse the retrieved data to more accurately determine the hospital mortality of BAAI.
METHODS
The Excerpta Medica Database, PubMed, Web of Science and Cochrane Library databases were searched to identify relevant publications without date restrictions. The overall hospital mortality (OHM) of BAAI patients was set as the primary outcome measure. English publications with data that met the selection criteria were included. The quality of all included studies was assessed by the Joanna Briggs Institute checklist and the American Agency for Health Care Quality and Research's cross-sectional study quality evaluation items. After data extraction, a meta-analysis of the Freeman-Tukey double arcsine transformation of data was performed using the Metaprop command in Stata 16 software. Heterogeneity was assessed and reported as a percentage using the I index value and as a P value using the Cochrane Q test. Various methods were used to determine the sources of heterogeneity and to analyse the sensitivity of the computation model.
RESULTS
Of the 2147 references screened, 5 studies that involved 1593 patients met the selection criteria and were included. There were no low-quality references after assessment. One study that only included 16 juvenile BAAI patients was excluded from the meta-analysis of the primary outcome measure due to high heterogeneity. Due to the low heterogeneity (I = 47.6%, P = 0.126 for Q test) that was observed after using the random effects model, the fixed model was subsequently used to pool the effect sizes of the remaining four studies, thus yielding an OHM of 28.8% [95% confidence interval (CI) 26.5-31.1%]. The stability of the model was verified by sensitivity analysis, and Egger's test (P = 0.339) indicated a low level of publication bias. In addition, we also performed meta-analyses and obtained a pooled hospital mortality of operation (13.5%, 95% CI 8.0-20.0%), a pooled hospital mortality of non-operation (28.4%, 95% CI 25.9-31.0%), and a pooled rate of aortic rupture (12.2%, 95% CI 7.0-18.5%) of BAAI.
CONCLUSIONS
The present study indicated that BAAI has an OHM of 28.8%, indicating that this disease deserves more attention and research.
Topics: Humans; United States; Hospital Mortality; Cross-Sectional Studies; Aorta, Abdominal; Wounds, Nonpenetrating
PubMed: 36991444
DOI: 10.1186/s13017-023-00492-w -
European Journal of Vascular and... Feb 2018New and re-designed stent grafts for endovascular aortic aneurysm repair (EVAR) are released regularly. Manufacturers use data from registries to assess stent graft... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
New and re-designed stent grafts for endovascular aortic aneurysm repair (EVAR) are released regularly. Manufacturers use data from registries to assess stent graft performance, but little is known about the ability of such registries to detect rates of clinically relevant complications. The aim of this paper was to perform a systematic review and meta-analysis to determine pooled failure rates for EVAR stent grafts, to define an acceptable non-inferiority limit for these devices, and then to calculate the number of patients needed for a new device to achieve non-inferiority against published devices.
DATA SOURCES AND REVIEW METHODS
MEDLINE and EMBASE were searched for studies reporting outcomes of specific EVAR grafts being used for intact infrarenal abdominal aortic aneurysms, from inception to November 2016. Meta-regression was performed to pool data and calculate the patient numbers needed to detect non-inferiority of a future graft performance. An expert consensus was performed to define adequate standards for device safety.
RESULTS
One hundred and forty-seven moderate quality papers involving 27,058 patients were included. Multiple outcomes were pooled. Of these, the estimated rate (±standard error) of overall endoleak (excluding Type II) at 2 years was 5.7 ± 0.6%. The pooled re-intervention rate was 11.1 ± 0.7% at 2 years. There were differences in pooled endoleak rates between different stent graft types. Expert consensus defined non-inferiority as better performance than the worst performing 25% of stent grafts. The most popular outcome in the expert consensus was cumulative endoleak rate (excluding Type II). The number of patients who would need to be enrolled in a registry to demonstrate non-inferiority at this level was 525. Only two of 147 included studies achieved this. The second most popular choice in the expert consensus was re-intervention rate; 492 patients are required to demonstrate this.
CONCLUSIONS
Five hundred and twenty-five patients need to be entered into a registry to demonstrate non-inferiority to previous stent grafts. Almost all previous publications have captured lower patient numbers. With performance varying between devices, and new devices being introduced regularly, there is an urgent need to capture higher quality long-term data on EVAR stent grafts.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Equivalence Trials as Topic; Humans; Prosthesis Failure; Registries; Reoperation; Stents; Treatment Outcome
PubMed: 29288059
DOI: 10.1016/j.ejvs.2017.11.013 -
Clinical Imaging Oct 2021To assess the efficacy and safety of abdominal aortic (AA) balloon occlusion versus internal iliac arteries (IIA) balloon occlusion in patients with placenta accreta... (Meta-Analysis)
Meta-Analysis Review
Efficacy and safety of prophylactic abdominal aortic balloon occlusion versus internal iliac arterial balloon occlusion for placenta accreta spectrum disorder: A systematic review and meta-analysis.
PURPOSE
To assess the efficacy and safety of abdominal aortic (AA) balloon occlusion versus internal iliac arteries (IIA) balloon occlusion in patients with placenta accreta spectrum (PAS) disorders.
METHODS
Databases of Embase, PubMed, Web of Science and Cochrane Library were systematically searched from inception to May 2020. The relevant literature was screened and the quality was assessed. RevMan software 5.3 was used to analyze the data.
RESULTS
Six studies involving 239 patients in AA occlusion and 281 patients in IIA occlusion were included. The results demonstrated that the intraoperative hemorrhage volume (MD - 410.61 ml, 95% CI -779.74 to -41.47 ml, p < 0.001), balloon dilatation duration (MD -5.34 min, 95% CI -9.91 to -0.77 min, p = 0.02) and fetus radiation dose (MD-20.81 mGy, 95% CI -31.84 to -9.78 mGy, p < 0.001) were significantly less in AA occlusion compared to IIA occlusion. There was no significant difference in the rate of lower extremity thrombosis between AA occlusion and IIA occlusion (OR 0.21, 95% CI 0.02 to 2.21, p = 0.19); similarly, no significant differences were found in blood transfusion volume (MD -344.50 ml, 95% CI -735.74 to 46.74 ml, p = 0.08), the rate of hysterectomy (OR 0.99, 95% CI 0.22 to 4.44, p = 0.99) and other outcome variables.
CONCLUSION
The available data demonstrated AA occlusion was more effective in reducing intraoperative hemorrhage volume and fetus radiation dose compared with IIA occlusion in patients with PAS disorders. Larger studies or randomized controlled trials are needed to further assert this evidence.
Topics: Aorta, Abdominal; Balloon Occlusion; Cesarean Section; Female; Humans; Hysterectomy; Iliac Artery; Placenta Accreta; Pregnancy; Retrospective Studies
PubMed: 34171597
DOI: 10.1016/j.clinimag.2021.06.020 -
Annals of Vascular Surgery Jul 2022Bacillus Calmette-Guerin (BCG) is a live attenuated strain of Mycobacterium bovis that has been used as immunotherapy against several malignancies. In particular,... (Review)
Review
BACKGROUND
Bacillus Calmette-Guerin (BCG) is a live attenuated strain of Mycobacterium bovis that has been used as immunotherapy against several malignancies. In particular, intravesical instillation of BCG has become a well-accepted adjuvant treatment for bladder cancer. BCG vascular infections are a rare complication of BCG therapy. Many aspects of these infections, including the presentations, risk factors, and treatment strategies, are poorly understood. Through a systematic review of the existing literature, we aimed to identify potential associations between this condition and patient characteristics, presentations, its treatments, and outcomes.
METHODS
We searched the PubMed, MEDLINE, and Embase databases for cases of BCG vascular infections from inception to June 2021. English-language reports of BCG vascular infections were included.
RESULTS
A total of 74 cases of BCG vascular infections were included. Seventy-three (99%) cases were male patients, all of whom were exposed to BCG through bladder instillation. Fifty (68%) cases were diagnosed more than 12 months after exposure to BCG. Twenty-six (35%) cases presented with arterial rupture at the time of diagnosis. Concurrent BCG infections in nonvascular locations were present in 37 (50%) cases. The most common locations of BCG vascular infection were the abdominal aorta (57%), prosthetic grafts (15%), and thoracic aorta (12%). The most common treatment for BCG infection was open repair with synthetic graft in situ replacement for the abdominal aorta and endovascular repair for the thoracic aorta. The 30-day mortality, among the 59 cases where these data were reported, was 10%.
CONCLUSIONS
We observed that many aspects of BCG vascular infections are similar to other forms of vascular infections. The high incidence of rupture or fistulation and the propensity toward abdominal aortic involvement and its prognosis are similar to those described in other vascular infections. However, our study also highlights 2 idiosyncratic features of BCG vascular infections: association with male sex and concurrent musculoskeletal infections.
Topics: Administration, Intravesical; BCG Vaccine; Female; Humans; Male; Mycobacterium bovis; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 35248739
DOI: 10.1016/j.avsg.2022.01.027