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JAMA Aug 2016Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and... (Review)
Review
IMPORTANCE
Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.
OBJECTIVE
To systematically review the current evidence on diagnosis and treatment of AAS.
EVIDENCE REVIEW
Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed.
FINDINGS
Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.
CONCLUSIONS AND RELEVANCE
Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.
Topics: Acute Disease; Aged; Aortic Dissection; Aortic Aneurysm; Aortic Diseases; Back Pain; Chest Pain; Fibrin Fibrinogen Degradation Products; Hematoma; Humans; Hypertension; Magnetic Resonance Imaging; Male; Medical Illustration; Middle Aged; Observational Studies as Topic; Randomized Controlled Trials as Topic; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 27533160
DOI: 10.1001/jama.2016.10026 -
European Journal of Vascular and... Mar 2020The objective was to investigate whether endovascular aneurysm repair (EVAR) has better peri-operative and late clinical outcomes than open repair for non-ruptured... (Meta-Analysis)
Meta-Analysis
Editor's Choice - Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials.
OBJECTIVE
The objective was to investigate whether endovascular aneurysm repair (EVAR) has better peri-operative and late clinical outcomes than open repair for non-ruptured abdominal aortic aneurysm.
METHODS
Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to July 2019 using a combination of thesaurus and free text terms to identify randomised controlled trials (RCTs) comparing the outcomes of EVAR and open repair. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). A time to event data meta-analysis was performed using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% CI.
RESULTS
Seven RCTs reporting a total of 2 983 patients were included in quantitative synthesis. Three of the trials reported long term follow up that extended to 15.8 years, 14.2 years, and 12.5 years. Meta-analysis found significantly lower odds of 30 day (OR, 0.36; 95% CI 0.20-0.66) and in hospital mortality with EVAR (RD -0.03; 95% CI -0.04 to -0.02). Meta-analysis of the three trials reporting long term follow up found no significant difference in all cause mortality at any time between EVAR and open repair (HR 1.02; 95% CI 0.93-1.13; p = .62). The hazard of all cause (HR 0.62; 95% CI 0.42-0.91) and aneurysm related death within six months (HR 0.42; 95% CI 0.24-0.75) was significantly lower in patients who underwent EVAR, but with further follow up, the pooled hazard estimate moved in favour of open surgery; in the long term (>8 years) the hazard of aneurysm related mortality was significantly higher after EVAR (HR 5.12; 95% CI 1.59-16.44). The risk of secondary intervention (HR 2.13; 95% CI 1.69-2.68), aneurysm rupture (OR, 5.08; 95% CI 1.11-23.31), and death due to rupture (OR, 3.57; 95% CI 1.87-6.80) was significantly higher after EVAR, but the risk of death due to cancer was not significantly different between EVAR and open repair (OR, 1.03; 95% CI 0.84-1.25).
CONCLUSION
Compared with open surgery, EVAR results in a better outcome during the first six months but carries an increased risk of aneurysm related mortality after eight years.
Topics: Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 31899100
DOI: 10.1016/j.ejvs.2019.11.030 -
Journal of Vascular Surgery May 2019Abdominal aortic aneurysms (AAAs) represent a significant burden of disease worldwide, and their rupture, without treatment, has an invariably high mortality rate.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Abdominal aortic aneurysms (AAAs) represent a significant burden of disease worldwide, and their rupture, without treatment, has an invariably high mortality rate. Whereas some risk factors for ruptured AAAs (rAAAs) are well established, such as hypertension, smoking, and female sex, the impact of seasonal and meteorologic variables is less clear. We systematically reviewed the literature to determine whether these variables are associated with rAAA.
METHODS
Review methods were according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We calculated pooled proportions and incidence rate ratios (IRRs) for the different months and seasons. Funnel plots were constructed to assess for publication bias. Given the poor methodologic quality of included studies, a sensitivity analysis was performed on better-quality studies, which scored 6 and above of 9 in the author-modified Newcastle-Ottawa Scale.
RESULTS
The pooled proportion of rAAA was highest in the autumn season (incidence rate, 26.6%; 95% confidence interval [CI], 25.6%-27.7%; I = 15.4%), followed by winter (incidence rate, 26.2%; 95% CI, 24.1%-28.2%; I = 72.4%), and lowest in summer (incidence rate, 21.1%; 95% CI, 19.3%-23.0%; I = 70.4%). The IRRs of rAAA were -6.9% (95% CI, -9.8% to -3.9%), -19.5% (95% CI, -22% to -16.8%), +10.5% (95% CI, 7.2%-13.9%), and +18.1% (95% CI, 15%-22%) in spring, summer, autumn, and winter compared with the remaining seasons, respectively (all P < .0001), thus affirming existence of seasonal variation. The pooled proportion of rAAA was highest in December (incidence rate, 8.9%; 95% CI, 7.1%-10.9%; I = 54.5%) but lowest in July (incidence rate, 5.7%; 95% CI, 4.2%-7.3%; I = 54.5%). The IRR was significantly the highest in January (IRR, 1.14; 95% CI, 1.01-1.29; P = .031) but lowest in July (IRR, 0.75; 95% CI, 0.65-0.87; P < .0001). There is also some evidence for a possible association with atmospheric pressure. Associations with temperature and daylight hours, however, are at best speculative.
CONCLUSIONS
Autumn and winter are significantly associated with a higher incidence of rAAAs, and autumn is associated with the highest rupture incidence of all the seasons. However, the inability to appropriately control for other confounding factors known to increase the risk of AAA rupture precludes any additional recommendations to alter current provision of vascular services on the basis of these data.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm; Aortic Rupture; Atmospheric Pressure; Female; Humans; Incidence; Male; Middle Aged; Prognosis; Risk Assessment; Risk Factors; Seasons; Time Factors; Weather
PubMed: 30792059
DOI: 10.1016/j.jvs.2018.09.030 -
Chronobiology International Apr 2015Identification and quantification higher risk incidence of aortic rupture or dissection (AARD) could be of clinical interest and improve preventive strategies. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Identification and quantification higher risk incidence of aortic rupture or dissection (AARD) could be of clinical interest and improve preventive strategies.
BACKGROUND
Several studies and subsequent meta-analyses have shown chronobiologic variations in the timing of occurrence of myocardial infarction, stroke, and pulmonary embolism. Conversely, such evidences are currently lacking for AARD despite a number of studies available dealing with periodicity.
METHODS
MEDLINE, EMBASE, and Google Scholar databases were searched up to July 2013. Temporal variation in the incidence of AARD was analyzed including all studies analyzing seasonal, monthly, weekly, and circadian aggregations. Two authors independently reviewed and extracted data.
RESULTS
Forty-two studies for a total of more than 80 000 patients were included. Our results showed a significantly increased incidence of AARD in Winter (Chi-square 854.92, p < 0.001), with a relative risk (RR) of 1.171 (99% CI 1.169, 1.172), in December (Chi-square 361.03, p < 0.001), RR of 1.142 (99% CI 1.141, 1.143), on Monday (Chi-square 428.09, p < 0.001), RR of 1.214 (99% CI 1.211, 1.216), and in the hours between 6 am and 12 pm (Chi-square 212.02, p < 0.001), RR of 1.585 (99% CI 1.562, 1.609). Subgroup and sensitivity analyses confirmed the results of principal analyses.
CONCLUSIONS
Our data strongly support the presence of evident rhythmic patterns in the incidence of acute aortic events, characterized by significantly higher risk in Winter, in December, on Monday and between 6 am and 12 pm. Future studies are needed to better clarify the underlying mechanisms and clinical implications.
Topics: Acute Disease; Aortic Rupture; Circadian Rhythm; Humans; Incidence; Periodicity; Seasons
PubMed: 25414043
DOI: 10.3109/07420528.2014.983604 -
Journal of Clinical Medicine Oct 2023The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs... (Review)
Review
BACKGROUND
The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture risk, and recently, large AAAs just above the threshold (5.5-6.0 cm) seem to be at low risk of rupture as well. The present review aims to investigate the outcomes of AAAs under surveillance through a comprehensive systematic review and meta-analysis.
METHODS
PubMed, Embase, and the Cochrane Central Register were searched (22 March 2022; PROSPERO; #CRD42022316094). The Cochrane and PRISMA statements were respected. Blinded systematic screening of the literature, data extraction, and quality assessment were performed by two authors. Conflicts were resolved by a third author. The meta-analysis of prevalence provided estimated proportions, 95% confidence intervals, and measures of heterogeneity (I). Based on I, the heterogeneity might be negligible (0-40%), moderate (30-60%), substantial (50-90%), and considerable (75-100%). The primary outcome was the incidence of AAA rupture. Secondary outcomes included the rate of small AAAs reaching the threshold for repair, aortic-related mortality, and all-cause mortality.
RESULTS
Fourteen publications (25,040 patients) were included in the analysis. The outcome rates of the small AAA group (<55 mm) were 0.3% (95% CI 0.0-1.0; I = 76.4%) of rupture, 0.6% (95% CI 0.0-1.9; I = 87.2%) of aortic-related mortality, and 9.6% (95% CI 2.2-21.1; I = 99.0%) of all-cause mortality. During surveillance, 21.4% (95% CI 9.0-37.2; I = 99.0%) of the initially small AAAs reached the threshold for repair. The outcome rates of the large AAA group (>55 mm) were 25.7% (95% CI 18.0-34.3; I = 72.0%) of rupture, 22.1% (95% CI 16.5-28.3; I = 25.0%) of aortic-related mortality, and 61.8% (95% CI 47.0-75.6; I = 89.1%) of all-cause mortality. The sensitivity analysis demonstrated a higher rupture rate in studies including <662 subjects, patients with a mean age > 72 years, >17% of female patients, and >44% of current smokers.
CONCLUSION
The rarity of rupture and aortic-related mortality in small AAAs supports the current conservative management of small AAAs. Surveillance seems indicated, as one-fifth reached the threshold for repair. Large aneurysms had a high incidence of rupture and aortic-related mortality. However, these data seem biased by the sparse and heterogeneous literature overrepresented by patients unfit for surgery. Specific rupture risk stratified by age, gender, and fit-for-surgery patients with large AAAs needs to be further investigated.
PubMed: 37959301
DOI: 10.3390/jcm12216837 -
Journal of Endovascular Therapy : An... Oct 2015To report a systematic literature review of late rupture of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) and the results of a pooled... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To report a systematic literature review of late rupture of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) and the results of a pooled analysis of causes, treatment, and outcomes.
METHODS
Electronic information sources and bibliographic reference lists were interrogated using a combination of free text and controlled vocabulary searches; 11 articles were ultimately identified that fulfilled the inclusion criteria. The articles reported a total of 190 patients who were included in the qualitative and quantitative synthesis. Mortality within 30 days or during the admission with aneurysm rupture was a primary endpoint; major perioperative morbidity was a secondary endpoint. A meta-analysis was performed for 30-day/in-hospital mortality using the random effects model.
RESULTS
A total of 152 ruptures occurred after 16,974 EVAR procedures reported by 8 of the case series, giving an incidence of 0.9% [95% confidence interval (CI) 0.77 to 1.05]. The mean time to rupture was 37 months. Twenty-nine percent (95% CI 20 to 39) of the patients had at least one previous secondary endovascular intervention following the initial EVAR, and 37% (95% CI 30 to 45) were not compliant with surveillance. Type I and III endoleaks were the predominant causes of rupture. Open surgical treatment was undertaken in 61% (95% CI 53 to 68) of the patients who underwent treatment. The pooled estimate for perioperative mortality was 32% (95% CI 24 to 41). A significantly lower mortality was found with endovascular treatment than open surgical management (p=0.027).
CONCLUSION
Graft-related endoleaks appear to be the predominant causes of late aneurysm rupture. Quality of and compliance with post-EVAR surveillance are important factors in late rupture; a large proportion of late ruptures are amenable to endovascular treatment.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Hospital Mortality; Humans; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 26286073
DOI: 10.1177/1526602815601405 -
Brain Sciences Feb 2020Most available large animal extracranial aneurysm models feature healthy non-degenerated aneurysm pouches with stable long-term follow-ups and extensive healing... (Review)
Review
BACKGROUND
Most available large animal extracranial aneurysm models feature healthy non-degenerated aneurysm pouches with stable long-term follow-ups and extensive healing reactions after endovascular treatment. This review focuses on a small subgroup of extracranial aneurysm models that demonstrated growth and potential rupture during follow-up.
METHODS
The literature was searched in Medline/Pubmed to identify extracranial in vivo saccular aneurysm models featuring growth and rupture, using a predefined search strategy in accordance with the PRISMA guidelines. From eligible studies we extracted the following details: technique and location of aneurysm creation, aneurysm pouch characteristics, time for model creation, growth and rupture rate, time course, patency rate, histological findings, and associated morbidity and mortality.
RESULTS
A total of 20 articles were found to describe growth and/or rupture of an experimentally created extracranial saccular aneurysm during follow-up. Most frequent growth was reported in rats ( = 6), followed by rabbits ( = 4), dogs ( = 4), swine ( = 5), and sheep ( = 1). Except for two studies reporting growth and rupture within the abdominal cavity (abdominal aortic artery; = 2) all other aneurysms were located at the neck of the animal. The largest growth rate, with an up to 10-fold size increase, was found in a rat abdominal aortic sidewall aneurysm model.
CONCLUSIONS
Extracranial saccular aneurysm models with growth and rupture are rare. Degradation of the created aneurysmal outpouch seems to be a prerequisite to allow growth, which may ultimately lead to rupture. Since it has been shown that the aneurysm wall is important for healing after endovascular therapy, it is likely that models featuring growth and rupture will gain in interest for preclinical testing of novel endovascular therapies.
PubMed: 32069946
DOI: 10.3390/brainsci10020101 -
European Journal of Vascular and... Jul 2022To clarify the natural history of abdominal aortic ectasia (AAE) measuring 25 - 29 mm in maximum diameter, and to determine the optimal follow up based on the growth,... (Review)
Review
OBJECTIVE
To clarify the natural history of abdominal aortic ectasia (AAE) measuring 25 - 29 mm in maximum diameter, and to determine the optimal follow up based on the growth, risk of rupture, and overall mortality of AAE.
DATA SOURCES
MEDLINE, Web of Science Core Collection, and Google Scholar.
REVIEW METHODS
This was a systematic review and meta-analysis of AAE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Web of Science Core Collection, and Google Scholar were searched, with the help of a health sciences librarian, up to 11 August 2021. Studies with longitudinal outcomes of AAE (prevalence, annual growth rate, aneurysmal enlargement, rupture, aneurysm related death, and all cause mortality) were included. Meta-analyses were conducted with a random effects model RESULTS: Twelve studies describing a total of 8 369 patients were eligible. The prevalence at population based settings was 3.2% (95% confidence interval [CI] 2.4 - 4.0); annual growth rate was 0.82 mm/year (95% CI 0.20 - 1.45). The estimated risks of aortic diameters exceeding 30 mm and 55 mm in five years were 45.0% (95% CI 28.5 - 61.5) and 0.3% (95% CI 0 - 0.6) respectively, while those beyond five years were 70.2% (95% CI 46.9 - 93.6) and 5.2% (95% CI 2.2 - 8.2). The rates of rupture and aneurysm related death were minimal until five years (0.1% and 0.1%, respectively) and beyond (0.4% and 0.2%, respectively). Overall mortality was 7.5% (95% CI 3.9 - 11.0) and 17.3% (95% CI 9.5 - 25.1) up to and beyond five years. Overall mortality from three studies showed no statistical difference between AAE and aneurysms (hazard ratio 0.62, 95% CI 0.32 - 1.21; p = .16). Cancer (35.0%) and cardiovascular diseases (31.9%) were major causes of death.
CONCLUSION
AAE carries minimal risk of aneurysm related lethal events during the first five years, but a similar overall mortality risk as abdominal aortic aneurysm. Cancer and cardiovascular diseases are leading causes of death in patients with AAE.
PubMed: 35537643
DOI: 10.1016/j.ejvs.2022.05.005 -
European Journal of Vascular and... Sep 2008The maximal diameter of abdominal aortic aneurysms (AAAs) is the dominating indication for repair. However half of the AAAs repaired would never have ruptured if left... (Review)
Review
BACKGROUND
The maximal diameter of abdominal aortic aneurysms (AAAs) is the dominating indication for repair. However half of the AAAs repaired would never have ruptured if left unrepaired, although small AAAs occasionally rupture. Earlier surgery may be associated with a lower mortality. More precise indicators for surgery are warranted. This systematic review identifies potential systemic biomarkers for AAA rupture or expansion.
METHODS
MEDLINE/PubMed and EMBASE (from 1985 trough May 2007) were searched with the medical subject heading abdominal aortic aneurysm and keywords "size", "progression" or "growth" or "expansion rate" or "rupture" on the basis of MESH tree and as a text search restricted to English, German, French and Italian. In addition, reference lists were studied and manual searches performed. Observational studies investigating the association of circulating biomarkers with AAA rupture, expansion or size were selected.
DATA EXTRACTION
Two reviewers (SU and GU) independently extracted the following data: year of publication, study characteristics, duration of follow-up, circulating biomarker, AAA expansion rate or size or rupture.
RESULTS
699 papers were identified. After exclusion of thoracic aneurysms and cardiac studies (n=118), surgical or medical treatment studies (n=179), case reports and animal studies (n=87), as well as reviews or letters (n=66), 249 articles were selected. Also excluded were 230 papers that did not report AAA size, expansion rate or rupture. 39 papers were included. Several potential biomarkers were identified. The strongest association with AAA was obtained with serum elastin peptides (SEP) and plasmin-antiplasmin (PAP) complexes. Matrix-degrading metalloproteinase 9 (MMP9) and interferon-gamma (IFN-gamma) could have clinical potential while many putative biomarkers showed poor association.
CONCLUSIONS
Several circulating agents in peripheral blood may predict AAA size, expansion rate or rupture. Few of them have clinical potential for future use. Confirmative studies and development of multivariate models are needed, together with continuing search for new biomarkers using the discovery based sciences within proteomics and/or genomics.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Biomarkers; Disease Progression; Elastin; Fibrinolysin; Humans; Interferon-gamma; Matrix Metalloproteinase 9; Peptides; Predictive Value of Tests; alpha-2-Antiplasmin
PubMed: 18639476
DOI: 10.1016/j.ejvs.2008.05.009