Aneurysm Screening Research Articles

Discrete Event Simulation for Decision Modeling in Health Care: Lessons from Abdominal Aortic Aneurysm Screening.

Markov models are often used to evaluate the cost-effectiveness of new healthcare interventions but they are sometimes not flexible enough to allow accurate modeling or investigation of alternative scenarios and policies. A Markov model previously demonstrated that a one-off invitation to screening for abdominal aortic aneurysm (AAA) for men aged 65 y in the UK and subsequent follow-up of identified AAAs was likely to be highly cost-effective at thresholds commonly adopted in the UK (£20,000 to £30,000 per quality adjusted life-year). However, new evidence has emerged and the decision problem has evolved to include exploration of the circumstances under which AAA screening may be cost-effective, which the Markov model is not easily able to address. A new model to handle this more complex decision problem was needed, and the case of AAA screening thus provides an illustration of the relative merits of Markov models and discrete event simulation (DES) models. An individual-level DES model was built using the R programming language to reflect possible events and pathways of individuals invited to screening v. those not invited. The model was validated against key events and cost-effectiveness, as observed in a large, randomized trial. Different screening protocol scenarios were investigated to demonstrate the flexibility of the DES. The case of AAA screening highlights the benefits of DES, particularly in the context of screening studies.

Abdominal aortic aneurysm screening: concepts and controversies.

Abdominal aortic aneurysms (AAAs) are a leading cause mortality and morbidity but often go undiagnosed until late stages unless imaging is performed. In 2005, the United States Preventive Services Task Force (USPSTF) for the first time recommended one-time ultrasound screening for elderly male smokers and selective screening in other populations. These guidelines were reaffirmed and updated in 2014; a proposal for potential further revisions is now in early planning stages. In this article, we review the past and current USPSTF AAA screening recommendations and techniques for performing optimal screening. Evidence supporting screening and alternative guidelines are also discussed. In addition, emerging concepts and controversies in AAA screening are highlighted, including conflicting data on screening benefits, screening underutilization, inconsistent follow-up recommendations, and the potential for duplicative testing, alternative screening modalities, and clinically significant incidental findings.

Prior Radiological Investigations in 65-Year-Old Men Screened for AAA

The National Health Service abdominal aortic aneurysm screening programme (NAAASP) is now fully operational. Those who have previously been formally investigated for abdominal aortic aneurysm (AAA) are excluded; however, many patients undergo radiological investigation of the abdomen for other reasons. Such practices may find incidental AAA which may be eroding the performance of the NAAASP. We investigated the rates of preinvestigation before invitation to screening in our local AAA screening programme. Electronic patient records were retrospectively reviewed for all patients called between March 2013 and February 2016 in 1 local AAA screening programme. Their records were interrogated to identify any abdominal imaging within 5years of their invitation to screening. Two thousand six hundred thirty-eight men were invited for screening; of these, 563 (21.3%) had been "prescreened". Median time between prescreening and screening was 19months (0-60months). Ultrasound abdomen was the most prevalent at 248 (44.0%). Two thousand two hundred forty-three (85.0%) men attended screening, and 6 (0.27%) were excluded for known AAA. Prevalence of AAA was 1.8% (n=41). Of these, 15 (36.6%) had prior investigation with 6 (40.0%) having AAA diagnosed. Therefore, 9 (22.0%) had potential missed AAA on "prescreening" (mean diameter 35mm [30-45], mean time lapse between investigation and screening 21.1months [1-49]). Incidence of missed aneurysm in the "prescreened" cohort was 1.6% (9/563). Large numbers of men invited for AAA screening have undergone preinvestigation of their abdominal aorta, with 60% of the present AAA being missed. Reliance on incidental detection of AAA would leave many patients undiagnosed in the community-at risk of future rupture.

Participation in bowel screening among men attending abdominal aortic aneurysm screening.

Uptake of population-based screening for colorectal cancer in Scotland is around 55 per cent. Abdominal aortic aneurysm (AAA) screening has recently been introduced for men aged 65 years and the reported uptake is 78 per cent. The aim was to determine the impact of a brief intervention on bowel screening in men who attended AAA screening, but previously failed to complete bowel screening. Men invited for AAA screening between September 2015 and March 2016 within NHS Tayside were included. Attendees who had not responded to their latest bowel screening invitation were seen by a colorectal cancer clinical nurse specialist. Reasons for not completing the faecal occult blood test (FOBT) were recorded; brief information on colorectal cancer screening was communicated, and participants were offered a further invitation to complete a FOBT. Those who responded positively were sent a further FOBT from the Scottish Bowel Screening Centre. Subsequent return of a completed FOBT within 6 months was recorded. A total of 556 men were invited for AAA screening, of whom 38·1 per cent had not completed a recent FOBT. The primary reason stated for not participating was the time taken to complete the test or forgetting it (35·1 per cent). Other reasons included: lack of motivation (23·4 per cent), confusion regarding the aim of screening (16·2 per cent), disgust (19·8 per cent), fear (6·3 per cent) and other health problems (9·9 per cent). Following discussion, 81·1 per cent agreed to complete the FOBT and 49 per cent subsequently returned the test. A substantial proportion of previous bowel screening non-responders subsequently returned a completed FOBT following a brief intervention with a nurse specialist. Attendance at non-bowel screening appointments may provide a valuable opportunity to improve bowel screening uptake.

The angiographic and clinical outcomes of intracranial aneurysms following irradiation in patients with nasopharyngeal carcinoma: A 13-year experience and literature review

Background and purposeIntracranial aneurysms are a known but rare complication of radiotherapy (RT). We reviewed the angiographic and clinical outcomes of intracranial aneurysms following RT in patients with nasopharyngeal carcinoma (NPC), a malignancy endemic in Hong Kong. Materials and methodsThe clinical, angiographic and laboratory data was collected for nine NPC patients harboring fifteen intracranial aneurysms following RT, diagnosed between 1st January 2000 and 31st December 2012. ResultsThe median age at aneurysm diagnosis was 56 years with a male predilection (67%). The median latent period to diagnosis was nine years (0.3–30). Eight patients (89%) presented with aneurysmal subarachnoid hemorrhage. Nine aneurysms were located at the anterior circulation, and 14 were saccular in morphology. Of the treated aneurysms, eight underwent endovascular intervention and two were surgically clipped. Within a year, 50% of the treated aneurysms had recurred. Poor neurological outcome was noted. At two-year follow-up, the median score for modified Rankin score and Glasgow Outcome score was 5 and 2 respectively. The two-year mortality rate of patients with treated ruptured intracranial aneurysms was 50%. ConclusionCompared to previous studies, our irradiated NPC patients had higher mortality and morbidity rates after aneurysm rupture and a higher angiographic recurrence rate following treatment. Greater vigilance is required in the detection of post-treatment recurrence of these aneurysms due to the higher risk of rupture. The authors recommend dedicated screening of intracranial aneurysms by active surveillance in routine CT protocols or the addition of three-dimensional time-of-flight magnetic resonance angiography in MR protocols.

A population-based screening study for cardiovascular diseases and diabetes in Danish postmenopausal women: acceptability and prevalence

BackgroundReducing women’s cardiovascular risk and the economic costs associated with cardiovascular diseases (CVD) and diabetes (DM) continues to be a challenge. Whether a multifaceted CVD screening programme is beneficial as a preventive strategy in women remains uncertain. The aim of this study was to investigate the prevalence of CVD and DM as well as the acceptability toward screening and preventive actions.MethodsAn observational study was performed among all women born in 1936, 1941, 1946 and 1951 living in Viborg Municipality, Denmark, from October 2011. In total, 1984 were invited to screening for abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), carotid plaque (CP), hypertension (HT), atrial fibrillation (AF), DM and dyslipidaemia. Participants with positive tests were offered prophylactic intervention including follow-up consultations in case of AAA, PAD and/or CP. Participants with AAA ≥ 50 mm were referred to specialists in vascular surgery. Women with AF or potential familial hypercholesterolaemia (FH) were referred to cardiology work-up.ResultsAmong those invited, 1474 (74.3%) attended screening, but the attendees’ share decreased with increasing age groups (p < 0.001). AAA was diagnosed in 10 (0.7%) women, PAD in 101 (6.9%) and CP in 602 (40.8%). The percentage of women with these conditions rose with increasing age group (p < 0.05). Unconfirmed potential HT was observed in 94 (6.4%), unknown AF in 6 (0.4%), DM in 14 (1%) and potential FH in 35 (2.4%). None of these findings differed across age groups. Among the 631 women diagnosed with AAA, PAD and/or CP, 182 (28.8%) were already in antiplatelet and 223 (35.3%) in lipid-lowering therapy prior to screening. Antiplatelet therapy was initiated in 215 (34.1%) and lipid-lowering therapy in 191 (30.3%) women. Initiation of antiplatelet and lipid-lowering therapy was further recommended to 134 (21.2%) and 141 (22.4%) women, respectively, who hesitated to follow the recommendation.ConclusionsThe study recorded an acceptable total attendance rate, even though a significantly lower attendance rate was observed in the eldest women. The identified hesitation towards prophylactic therapy may affect the rationale and effectiveness of CVD screening, and hesitation seems a critical issue that should be addressed in the design of future screening programmes.

Invited commentary

Microinhibitory RNA (miRNA) were first described by Ambrose et al1Lee R.C. Feinbaum R.L. Ambros V. The C. elegans heterochronic gene lin-4 encodes small RNAs with antisense complementarity to lin-14.Cell. 1993; 75: 843-854Abstract Full Text PDF PubMed Scopus (9619) Google Scholar in 1993. They represented an entirely new and important layer of gene regulation. They are naturally occurring short, single-stranded RNA sequences that typically regulate many different genes. It is interesting to note that Andy Fire and Craig Mello received the 2006 Nobel Prize for Medicine for the use of synthetic double-stranded RNA that could inhibit protein production (small-interfering RNA).2Fire A. Xu S. Montgomery M.K. Kostas S.A. Driver S.E. Mello C.C. Potent and specific genetic interference by double-stranded RNA in Caenorhabditis elegans.Nature. 1998; 391: 806-811Crossref PubMed Scopus (11712) Google Scholar The discovery of Victor Ambrose is arguably of equal importance. Elegant studies have since demonstrated their role in regulating abdominal aortic aneurysm (AAA).3Maegdefessel L. Azuma J. Toh R. Deng A. Merk D.R. Raiesdana A. et al.MicroRNA-21 blocks abdominal aortic aneurysm development and nicotine-augmented expansion.Sci Transl Med. 2012; 4: 122ra22Crossref PubMed Scopus (227) Google Scholar The work presented by Courtois et al takes these findings to another level. By comparing patients whose AAAs showed activity on positron emission tomography (PET) scan against a group of PET-negative AAA patients, the authors have identified a small number of circulating miRNAs that can effectively distinguish between the groups. Finding an accurate systemic biomarker for the presence of AAA or for AAA that are likely to progress to rupture would be an important advance in public health. The study by Courtois et al does not address the issue of identifying a biomarker to find those with AAA. This remains a critical question, because too many patients at risk are not being screened despite the efforts of the Society for Vascular Surgery in promoting aneurysm screening.4Mell M.W. Hlatky M.A. Shreibati J.B. Dalman R.L. Baker L.C. Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for medicare beneficiaries.J Vasc Surg. 2013; 57 (1523.e1): 1519-1523Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Significant progress in understanding AAA biology has been made in recent decades. We understand that inflammation drives the pathophysiology. An entirely logical assumption, therefore, is that circulating markers that reflect PET fluorodeoxyglucose activity would identify aneurysms most likely to progress, possibly to rupture. Although the results presented in their study are exciting, we should not get ahead of ourselves as clinicians and scientists. Studying AAA rupture is extremely difficult because small aneurysm rupture is rare, and patients at risk of rupture, based on size, are repaired. Although logical to assume a link between increased PET fluorodeoxyglucose activity and risk of rupture, the data are not there to make this jump. Important questions remain, including whether an aneurysm might show increased activity at one point with regression of the inflammation over time. So how might biomarkers that identify more dangerous AAA be found? The most convincing data would be derived from a carefully studied cohort where aneurysm progression is tracked longitudinally by the best available imaging (computed tomography or magnetic resonance imaging). Showing biomarkers that strongly correlate with growth or, conversely, lack of growth over time would provide the best support for clinical application. The carefully conducted studies by Courtois et al suggest that a panel of miRNAs could prove to be a very useful biomarker in the future for tracking AAA progression. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Circulating microRNAs signature correlates with positive [18F]fluorodeoxyglucose-positron emission tomography in patients with abdominal aortic aneurysmJournal of Vascular SurgeryVol. 67Issue 2PreviewPrediction of abdominal aortic aneurysm (AAA) rupture is a challenging issue. Small noncoding microRNAs (miRNAs) are potent regulators of gene expression and are considered as valuable circulating biomarkers. Recently, [18F]fluorodeoxyglucose (FDG) uptake detected by positron emission tomography (PET) in AAA was correlated with cellular and molecular alterations involved in wall instability and its potential rupture. Our study aimed at identifying circulating miRNAs correlated with a positive PET that could help discriminate patients at high risk of rupture. Full-Text PDF Open Archive

Abstract 166: The Brain and Aortic Aneurysm Screening (BAAS) Study - Screening for Occult Intracranial Aneurysms in Those With Abdominal Aortic Aneurysms

Introduction: Abdominal aortic aneurysm (AAA) rupture has a mortality rate of 64% and intracranial aneurysm (IA) rupture has a mortality rate of 50%. Despite the high mortality rates, early detection and treatment of these vascular lesions prior to rupture can prevent devastating clinical outcomes, underscoring the need to identify high-risk populations for screening. Current evidence demonstrates shared genetic and environmental risk factors for both AAA and IA. Methods: The BAAS study sought to establish the co-prevalence of AAA and IA. In one arm of BAAS, we recruited patients presenting with AAA and screened them for IA. All participants underwent a detailed interview to collect demographic, radiographic, and clinical data and also had genetic counseling. Results: Of the 126 individuals with an AAA enrolled, 65% (82/126) completed the MRA. Difficulty with logistics of obtaining the research MRA with long distance travel to clinic was the principal reason for failure to obtain MRA. We identified 20.7% (17/82) with one or more IA, including 21 aneurysms found during systematic screening. IA ranged in size from 1.5-14 mm (height) x 1.4-7 mm (width) and varied in location. 9.5% (2/21) had a maximum diameter of 7 mm or more. One participant with a positive MRA underwent early coil embolization with the remainder undergoing continued clinical surveillance. Of the 15 individuals completing the genetic counseling screening, two underwent recommended clinical genetic testing, revealing one negative screen and one variant of unknown significance in the MYH11 gene. Conclusion: Consistent with our prior cost effectiveness models, these prospective data support the clinical utility of routine screening for IA in patients presenting with AAA.

A supporting tool for screening of brain aneurysms

A supporting tool for screening of brain aneurysms

Lessons learned about prevalence and growth rates of abdominal aortic aneurysms from a 25-year ultrasound population screening programme.

This study aimed to assess how the prevalence and growth rates of small and medium abdominal aortic aneurysms (AAAs) (3·0-5·4 cm) have changed over time in men aged 65 years, and to evaluate long-term outcomes in men whose aortic diameter is 2·6-2·9 cm (subaneurysmal), and below the standard threshold for most surveillance programmes. The Gloucestershire Aneurysm Screening Programme (GASP) started in 1990. Men aged 65 years with an aortic diameter of 2·6-5·4 cm, measured by ultrasonography using the inner to inner wall method, were included in surveillance. Aortic diameter growth rates were estimated separately for men who initially had a subaneurysmal aorta, and those who had a small or medium AAA, using mixed-effects models. Since 1990, 81 150 men had ultrasound screening for AAA (uptake 80·7 percent), of whom 2795 had an aortic diameter of 2·6-5·4 cm. The prevalence of screen-detected AAA of 3·0 cm or larger decreased from 5·0 percent in 1991 to 1·3 percent in 2015. There was no evidence of a change in AAA growth rates during this time. Of men who initially had a subaneurysmal aorta, 57·6 (95 percent c.i. 54·4 to 60·7) percent were estimated to develop an AAA of 3·0 cm or larger within 5 years of the initial scan, and 28·0 (24·2 to 31·8) percent to develop a large AAA (at least 5·5 cm) within 15 years. The prevalence of screen-detected small and medium AAAs has decreased over the past 25 years, but growth rates have remained similar. Men with a subaneurysmal aorta at age 65 years have a substantial risk of developing a large AAA by the age of 80 years.

Population Screening and Intervention for Vascular Disease in Danish Men (VIVA): A Randomised Controlled Trial

Summary Background Abdominal aortic aneurysm is the only cardiovascular disease targeted by population screening. In this study, we test the effect of screening and subsequent intervention for abdominal aortic aneurysm, peripheral arterial disease, and hypertension combined. Methods In this randomised controlled trial, we randomly allocated (1:1) all men aged 65–74 years living in the Central Denmark Region to screening for abdominal aortic aneurysm, peripheral arterial disease, and hypertension, or to no screening. We based allocation on computer-generated random numbers from 1 to 100 in blocks of 1067 to 4392, stratified by 19 municipalities. Only the non-screening group and the investigator assessing outcomes were masked. We invited participants who were found to have abdominal aortic aneurysm or peripheral arterial disease back for confirmation and eventual initiation of relevant pharmacological therapy. We further offered participants with abdominal aortic aneurysm annual control or surgical repair. We referred participants with suspected hypertension to their general practitioner. The primary outcome was all-cause mortality, assessed 5 years after randomisation, analysed in all randomly allocated participants except for those who had incorrect person identification numbers. This trial is registered at ClinicalTrials.gov, number NCT00662480. Findings Between Oct 8, 2008, and Jan 11, 2011, we randomly allocated 50 156 participants, with 25 078 (50%) each in the screening and non-screening groups. Four ( vs 4129 per 100 000 person-years in the non-screening group), intracerebral haemorrhage (146 vs 140), renal failure (612 vs 649), cancer (3578 vs 3719), or 30 day mortality after cardiovascular surgery (44·57 vs 39·33) did not differ between groups. Interpretation The observed reduction of mortality risk from abdominal aortic aneurysm, peripheral arterial disease, and hypertension has never been seen before in the population screening literature and can be linked primarily to initiation of pharmacological therapy. Health policy makers should consider implementing combined screening whether no screening or isolated abdominal aortic aneurysm screening is currently offered. Funding The 7th European Framework Programme, Central Denmark Region, Viborg Hospital, and the Danish Council for Independent Research.

Screening for intracranial aneurysms in autosomal dominant polycystic kidney disease is cost-effective

Intracranial aneurysm rupture is a dramatic complication of autosomal dominant polycystic kidney disease (ADPKD). It remains uncertain whether screening should be widespread or only target patients with risk factors (personal or familial history of intracranial aneurysm), with an at-risk profession, or those who request screening. We evaluated this in a single-center cohort of 495 consecutive patients with ADPKD submitted to targeted intracranial aneurysm screening. Cerebral magnetic resonance angiography was proposed to 110 patients with a familial history of intracranial aneurysm (group 1), whereas it was not our intention to propose it to 385 patients without familial risk (group 2). Magnetic resonance angiography results, intracranial aneurysm prophylactic repair, rupture events, and cost-effectiveness of intracranial aneurysm screening strategies were retrospectively analyzed. During a median follow up of 5.9 years, five non-fatal intracranial aneurysm ruptures occurred (incidence rate 2.0 (0.87-4.6)/1000 patients-year). In group 1, 90% of patients were screened and an intracranial aneurysm was detected in 14, treated preventively in five, and ruptured in one patient despite surveillance. In group 2, 21% of patients were screened and an intracranial aneurysm was detected in five, and treated preventively in one. Intracranial aneurysm rupture occurred in four patients in group 2. Systematic screening was deemed cost-effective and provides a gain of 0.68 quality-adjusted life years compared to targeted screening. Thus, the intracranial aneurysm rupture rate is high in ADPKD despite targeted screening, and involves mostly patients without familial risk factors. Hence, cost-utility analysis suggests that intracranial aneurysm screening could be proposed to all ADPKD patients.

One-Time Screening for AAA and PAD Is Associated with Lower 5-Year Mortality in Older Men

One-time screening for abdominal aortic aneurysm (AAA) in asymptomatic older male ex-smokers (age range, 65–75) lowers AAA-related mortality, but not

Recommendations on screening for abdominal aortic aneurysm in primary care.

KEY POINTS An abdominal aortic aneurysm (AAA) results from a weakening in a section of the aortic wall in the abdomen, which bulges because of pressure from blood flow to form an aneurysm.[1][1] The aneurysm may grow and eventually rupture, causing death from hemorrhage.[1][1] It is estimated that

Psychosocial consequences in men taking part in a national screening program for abdominal aortic aneurysm

Screening for abdominal aortic aneurysm (AAA) has proven to reduce AAA-related mortality, but how the knowledge of having an untreated AAA affects health and daily life requires further clarification. The aim was to investigate the psychosocial consequences and sense of coherence (SOC) in 65-year-old men diagnosed with AAA and participating in a national screening program during a 6-month follow-up compared with men with no AAA. The single-center cohort study included 52 men with AAA and 118 men without AAA. A questionnaire including the Short Form 36 Health Survey, Hospital Anxiety and Depression Scale, SOC, questions concerning stress, and questions related to AAA were answered at baseline and after 6 months. Men with AAA reported more problems with physical functioning, pain, and general health than men with a normal aorta at baseline. After 6 months, men with AAA still reported more problems with physical functioning and stress in relation to disease than men with normal aortic diameter. No differences were observed between groups in SOC, anxiety, and depression. A significantly higher satisfaction with information from the physician and desire to learn about the AAA diagnosis was reported at baseline compared with that at follow-up. Having knowledge about the AAA diagnosis may moderately impact physical health and perceived stress, and in combination with the increased prevalence of other cardiovascular diseases, may lead to impaired perceived health for men diagnosed with AAA.

Population screening and intervention for vascular disease in Danish men (VIVA): a randomised controlled trial

Abdominal aortic aneurysm is the only cardiovascular disease targeted by population screening. In this study, we test the effect of screening and subsequent intervention for abdominal aortic aneurysm, peripheral arterial disease, and hypertension combined. In this randomised controlled trial, we randomly allocated (1:1) all men aged 65-74 years living in the Central Denmark Region to screening for abdominal aortic aneurysm, peripheral arterial disease, and hypertension, or to no screening. We based allocation on computer-generated random numbers from 1 to 100 in blocks of 1067 to 4392, stratified by 19 municipalities. Only the non-screening group and the investigator assessing outcomes were masked. We invited participants who were found to have abdominal aortic aneurysm or peripheral arterial disease back for confirmation and eventual initiation of relevant pharmacological therapy. We further offered participants with abdominal aortic aneurysm annual control or surgical repair. We referred participants with suspected hypertension to their general practitioner. The primary outcome was all-cause mortality, assessed 5 years after randomisation, analysed in all randomly allocated participants except for those who had incorrect person identification numbers. This trial is registered at ClinicalTrials.gov, number NCT00662480. Between Oct 8, 2008, and Jan 11, 2011, we randomly allocated 50 156 participants, with 25 078 (50%) each in the screening and non-screening groups. Four (<1%) participants in the screening group were lost to follow-up. After a median follow-up of 4·4 years (IQR 3·9-4·8), 2566 (10·2%) of 25 074 participants in the screening group and 2715 (10·8%) of 25 078 in the non-screening group had died. This finding resulted in a significant hazard ratio of 0·93 (95% CI 0·88-0·98; p=0·01), an absolute risk reduction of 0·006 (0·001-0·011), and a number needed to invite of 169 (89-1811). Incidences of diabetes (3995 per 100 000 person-years in the screening group vs 4129 per 100 000 person-years in the non-screening group), intracerebral haemorrhage (146 vs 140), renal failure (612 vs 649), cancer (3578 vs 3719), or 30 day mortality after cardiovascular surgery (44·57 vs 39·33) did not differ between groups. The observed reduction of mortality risk from abdominal aortic aneurysm, peripheral arterial disease, and hypertension has never been seen before in the population screening literature and can be linked primarily to initiation of pharmacological therapy. Health policy makers should consider implementing combined screening whether no screening or isolated abdominal aortic aneurysm screening is currently offered. The 7th European Framework Programme, Central Denmark Region, Viborg Hospital, and the Danish Council for Independent Research.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK.

BackgroundThe UK abdominal aortic aneurysm (AAA) screening programmes currently invite only men for screening because the benefit in women is uncertain. Perioperative risk is critical in determining the effectiveness of screening, and contemporary estimates of these risks in women are lacking. The aim of this study was to compare mortality following AAA repair between women and men in the UK.MethodsAnonymized data from the UK National Vascular Registry (NVR) for patients undergoing AAA repair (January 2010 to December 2014) were analysed. Co‐variables were extracted for analysis by sex. The primary outcome measure was in‐hospital mortality. Secondary outcome measures included mortality by 5‐year age groups and duration of hospital stay. Logistic regression was performed to adjust for age, calendar time, AAA diameter and smoking status. NVR‐based outcomes were checked against Hospital Episode Statistics (HES) data.ResultsA total of 23 245 patients were included (13·0 per cent women). Proportionally, more women than men underwent open repair. For elective open AAA repair, the in‐hospital mortality rate was 6·9 per cent in women and 4·0 per cent in men (odds ratio (OR) 1·48, 95 per cent c.i. 1·08 to 2·02; P = 0·014), whereas for elective endovascular AAA repair it was 1·8 per cent in women and 0·7 per cent in men (OR 2·86, 1·72 to 4·74; P < 0·001); the results in HES were similar. For ruptured AAA, there was no sex difference in mortality within the NVR; however, in HES, for ruptured open AAA repair, the in‐hospital mortality rate was higher in women (33·6 versus 27·1 per cent; OR 1·36, 1·16 to 1·59; P < 0·001).ConclusionWomen have a higher in‐hospital mortality rate than men after elective AAA repair even after adjustment. This higher mortality may have an impact on the benefit offered by any screening programme offered to women.

Development of a Noncontrast Gated Aortic Computer Tomography Protocol for Aortic Screening and Surveillance

Computed tomography (CT) evaluation can effectively gauge the presence and size of aneurysms in both chest and abdomen. This is advantageous compared to ultrasound imaging; however, the existing CT protocols are limited by high radiation dose, risk of complication from workup of incidental findings, and high cost of radiologist interpretation time. We present a low-risk and low-cost CT protocol—the noncontrast gated aortic (NCGA) CT—that allows for evaluation of aortic aneurysm pathology. Patients requiring CT scan for surveillance of known aortic pathology were consented for an additional CT scan of the chest, abdomen, and pelvis. Patients underwent a topogram, which allows the CT machine to suggest optimal parameters for imaging the patient’s size and tissue density. Our protocol involved changing parameters that affect dose, including voltage (kV) and tube current-time product (mAs). Postprocessing was applied to optimize image quality and limit the surrounding visible field. Each study was independently reviewed by three qualified physicians to assess adequacy of the study and maximum size of the aorta in each of four segments (ascending, transverse arch, descending thoracic, and abdominal). Assessment of each study was used to modify the protocol for the next patient. Nine patients (8 males, 1 female) were studied. Comparison of NCGA CT protocol and regular protocol in radiation dose, image quality and reading time is shown in the Table. The optimal parameters of 80 kV and one-fifth of the recommended mAs were refined by the sixth patient. Collimation into four separate segments of the aorta minimized visible volume of nonaortic tissues. Interpretation time for the final three studies averaged 30 seconds. Our final protocol allowed adequate definition of the aorta and resulted in an effective dose of between 0.19 and 0.33 mSv, which is equivalent to two to three chest x-rays, 30- to 50-times less than the standard CT chest, abdomen, and pelvis scan. A NCGA CT scan can be performed on currently available CT devices with two to three chest x-rays worth of radiation, minimal risk of incidental findings, and low interpretation time. Such a study protocol may be a useful alternative to standard protocols for aortic aneurysm screening and surveillance.TableComparison of noncontrast gated aortic (NCGA) computed tomography (CT) protocol to regular CT in radiation dose, image quality, and reading timePatient% of Normal CT mAs (%)Dose (mSievert)Image qualityReading rime (sec)198.391.53Excessive27214.490.22Borderline32325.200.41Adequate34411.270.08Inadequate34521.900.13Inadequate30616.500.25Inadequate32721.210.33Adequate27820.310.22Adequate29920.000.19Adequate33 Open table in a new tab

Prevalence of Intracranial Aneurysm in Women With Fibromuscular Dysplasia

The prevalence of intracranial aneurysm in patients with fibromuscular dysplasia (FMD) is uncertain. To examine the prevalence of intracranial aneurysm in women diagnosed with FMD. This cross-sectional study included 669 women with intracranial imaging registered in the US Registry for Fibromuscular Dysplasia, an observational disease-based registry of patients with FMD confirmed by vascular imaging and currently enrolling at 14 participating US academic centers. Registry enrollment began in 2008, and data were abstracted in September 2015. Patients younger than 18 years at the time of FMD diagnosis were excluded. Imaging reports of all patients with reported internal carotid, vertebral, or suspected intracranial artery aneurysms were reviewed. Only saccular or broad-based aneurysms 2 mm or larger in greatest dimension were included. Extradural aneurysms in the internal carotid artery were included; fusiform aneurysms, infundibulae, and vascular segments with uncertainty were excluded. Percentage of women with FMD with intracranial imaging who had an intracranial aneurysm. Of 1112 female patients in the registry, 669 (60.2%) had undergone intracranial imaging at the time of enrollment (mean [SD] age at enrollment, 55.6 [10.9] years). Of the 669 patients included in the analysis, 86 (12.9%; 95% CI, 10.3%-15.9%) had at least 1 intracranial aneurysm. Of these 86 patients, 25 (53.8%) had more than 1 intracranial aneurysm. Intracranial aneurysms 5 mm or larger occurred in 32 of 74 patients (43.2%), and 24 of 128 intracranial aneurysms (18.8%) were in the posterior communicating or posterior arteries. The presence of intracranial aneurysm did not vary with location of extracranial FMD involvement. A history of smoking was significantly associated with intracranial aneurysm: 42 of 78 patients with intracranial aneurysm (53.8%) had a smoking history vs 163 of 564 patients without intracranial aneurysm (28.9%; P < .001). The prevalence of intracranial aneurysm in women diagnosed with FMD is significantly higher than reported in the general population. Although the clinical benefit of screening for intracranial aneurysm in patients with FMD has yet to be proven, these data lend support to the recommendation that all patients with FMD undergo intracranial imaging if not already performed.

Inequalities in Abdominal Aortic Aneurysm Screening in England: Effects of Social Deprivation and Ethnicity

Objective Population screening for abdominal aortic aneurysm (AAA) in men is currently ongoing in several countries. The aim was to examine the effects of deprivation and ethnicity on uptake of screening for abdominal aortic aneurysm (AAA) and prevalence of AAA. Methods This was a review of outcomes from a population screening programme using data collected contemporaneously on a bespoke national database. Men aged 65 in two annual cohorts (2013/14 and 2014/15) were invited for AAA screening. Attendance and prevalence of AAA (aortic diameter >2.9 cm) were recorded. Results were compared according to measures of social deprivation and recorded ethnicity. Results Some 593,032 men were invited and 461,898 attended for ultrasound screening; uptake 77.9%. Uptake was related to social deprivation: 65.1% in the most deprived decile, 84.1% in the least deprived: OR for least deprived 2.84, 95% CI 2.76-2.92, p p Conclusions Social deprivation affects uptake of AAA screening in 65 year old men. Local factors are the most important determinants of uptake, so solutions to improve uptake must be designed at local, not national level.