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Janet T. Powell - One of the best experts on this subject based on the ideXlab platform.
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Treatment Decisions for Descending Thoracic Aneurysm: Preferences for Thoracic Endovascular Aneurysm Repair or Surveillance in a Discrete Choice Experiment
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2014Co-Authors: Nung Rudarakanchana, Barnaby C Reeves, Colin Bicknell, F Heatley, Nicholas J.w. Cheshire, Janet T. PowellAbstract:Objective To investigate and rank factors that influence endovascular treatment decisions by specialists for patients with descending thoracic aortic Aneurysm (dTAA). Methods Specialists completed a diagrammatic survey describing uncertainty about the benefit of thoracic endovascular Aneurysm repair (TEVAR) for dTAA with respect to age, sex, and Aneurysm Diameter. Subsequently, a detailed discrete choice experiment was designed. Specialists were recruited and asked to indicate treatment their preference (TEVAR or surveillance) in 25 hypothetical cases of dTAA, with variable patient attributes: age, sex, American Society of Anesthesiologists (ASA) grade, Aneurysm Diameter, adequate landing zone distal to left subclavian artery (LSA), and length of aortic coverage. Data were analysed using multiple logistic regression. Results The diagrammatic survey, based on 50 respondents, showed that uncertainty about the benefits of TEVAR was greatest for patients aged 80–85 years (up to 47% of respondents were “unsure”) and that uncertainty increased with increasing Aneurysm Diameter (for an 80-year-old man, 7% were unsure at 5.5 cm and 33% were unsure at 7.0 cm). Seventy-one specialists (mainly from Europe and North America, 86% vascular surgeons and 98% working in units offering TEVAR) completed the discrete choice experiment. Preference for TEVAR increased greatly with enlarging Diameter: adjusted odds ratios (OR) >5.5–6.0 cm = 15.8 (95% confidence interval [CI] 9.83–25.40); >6.0–6.5 cm = 393.0 (95% CI 202.00–766.00); >6.5–7.0 cm = 1829.0 (95% CI 400.00–4,181.00). TEVAR was less likely to be preferred in patients older than 75 years (>75–80 years OR 0.32, 95% CI 0.21–0.49; >80–85 years = 0.18, 95% CI 0.11–0.28); in women (OR 0.52, 95% CI 0.37–0.74); in patients classified as ASA grade 4 (OR 0.44, 95% CI 0.36–0.57); and in patients with aorta coverage >25 cm (OR 0.48, 95% CI 0.32–0.74). The proximal landing zone did not influence preference. Conclusion Specialists' preferences for endovascular repair of degenerative dTAA vary widely, and demonstrate clinical uncertainty, especially in octogenarians, and a reluctance to offer TEVAR to women. Aneurysm Diameter dominates treatment preferences, but patient fitness and length of aortic coverage (>25 cm) also were influential, although the landing zone distal to LSA was not.
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The role of Diameter versus volume as the best prognostic measurement of abdominal aortic Aneurysms
Journal of vascular surgery, 2013Co-Authors: Atsushi Kitagawa, Tara M. Mastracci, Regula S Von Allmen, Janet T. PowellAbstract:Accurate measurement of abdominal aortic Aneurysms is necessary to predict rupture risk and, more recently, to follow Aneurysm sac behavior following endovascular repair. Up until this point, Aneurysm Diameter has been the most common measurement utilized for these purposes. Although Aneurysm Diameter is predictive of rupture, accurate measurement is hindered by such factors as aortic tortuosity and interobserver variability, and it does not account for variations in morphology such as saccular Aneurysms. Additionally, decreases in Aneurysm Diameter do not completely describe the somewhat complex remodeling seen following endovascular repair of aortic Aneurysms. Measurement of Aneurysm volume has the advantage of describing Aneurysm morphology in a multidimensional fashion, but it has not been readily available or easily measured until recently. This has changed with the introduction of commercially available software tools that permit quicker and easier to perform volume measurements. Whether it is time for volume to replace, or compliment, Diameter is the subject of the current debate.
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Systematic review and meta-analysis of growth rates of small abdominal aortic Aneurysms.
The British journal of surgery, 2011Co-Authors: Janet T. Powell, Michael J. Sweeting, Louise C. Brown, S. M. Gotensparre, F. G. R. Fowkes, Simon G. ThompsonAbstract:BACKGROUND: Small abdominal aortic Aneurysms are usually asymptomatic and managed safely in ultrasound surveillance programmes until they grow to a Diameter threshold where intervention is considered. The aim of this study was to synthesize systematically the published data on growth rates for small Aneurysms to investigate the evidence basis for surveillance intervals. METHODS: This was a systematic review of the literature published before January 2010, which identified 61 potentially eligible reports. Detailed review yielded 15 studies providing growth rates for Aneurysms 3.0-5.5 cm in Diameter (14 in millimetres per year, 1 as percentage change per year). These studies included 7630 people (predominantly men) enrolled during 1976-2005. RESULTS: The pooled mean growth rate was 2.32 (95 per cent confidence interval 1.95 to 2.70) mm/year but there was very high heterogeneity between studies; the growth rate ranged from - 0.33 to + 3.95 mm/year. Six studies reported growth rates by 5-mm Diameter bands, which showed the trend for growth rate to increase with Aneurysm Diameter. Simple methods to determine growth rate were associated with higher estimates. Meta-regression analysis showed that a 10-mm increase in Aneurysm Diameter was associated with a mean(s.e.m.) 1.62(0.20) mm/year increase in growth rate. Neither mean age nor percentage of women in each study had a significant effect. On average, a 3.5-cm Aneurysm would take 6.2 years to reach 5.5 cm, whereas a 4.5-cm Aneurysm would take only 2.3 years. CONCLUSION: There was considerable variation in the reported growth rates of small Aneurysms beyond that explained by Aneurysm Diameter. Fuller evidence on which to base surveillance intervals for patients in screening programmes requires a meta-analysis based on individual patient data.
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Use of angiotensin converting enzyme inhibitors is associated with increased growth rate of abdominal aortic Aneurysms
Journal of vascular surgery, 2010Co-Authors: Michael J. Sweeting, Roger M. Greenhalgh, Simon G. Thompson, Louise C. Brown, Janet T. PowellAbstract:Objectives To evaluate whether either angiotensin converting enzyme (ACE) inhibitors or other classes of antihypertensive drug attenuate or increase growth rates of small infrarenal abdominal aortic Aneurysms. Methods Prospective cohort study of 1701 patients enrolled in the UK Small Aneurysm Trial or associated study at 93 hospitals between 1991 and 1995 and who had at least two ultrasound measurements of Aneurysm Diameter and baseline drug prescription data recorded. Abdominal aortic Aneurysm Diameter was measured in the anterior-posterior plane using ultrasound. The mean growth rate was estimated through a mixed-effects linear growth model. Results Mean Aneurysm growth rate in 169 patients taking ACE inhibitors at baseline was 3.33 mm/y vs 2.77 mm/y in the remaining 1532 patients, P = .009. The significance of this finding did not alter after adjustment for known confounders. The prescription of any antihypertensive agent and other specific classes of antihypertensive drugs were not found to be associated with Aneurysm growth rate. Conclusion These results show that patients taking ACE inhibitors have faster Aneurysm growth and are in conflict with the observation from a large Canadian data-base that Aneurysm patients taking ACE inhibitors are less likely to present with Aneurysm rupture. There is an urgent need for a randomized trial to assess whether ACE inhibitors are beneficial or harmful to patients with Aneurysms below the threshold size for surgical intervention.
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Aortic Aneurysm Diameter and Risk of Cardiovascular Mortality
Arteriosclerosis thrombosis and vascular biology, 2001Co-Authors: A. R. Brady, F. Gerald R. Fowkes, Simon G. Thompson, Janet T. PowellAbstract:Abstract—After successful surgical repair of an abdominal aortic Aneurysm, patients have for many years an increased risk of death from cardiovascular causes. We have tested the hypothesis that for...
Enrico Ascher - One of the best experts on this subject based on the ideXlab platform.
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Nonoperative versus surgical management of small (less than 3 cm), asymptomatic popliteal artery Aneurysms
Journal of Vascular Surgery, 2011Co-Authors: Jane E. Cross, Anil Hingorani, R.b. Galland, Enrico AscherAbstract:Popliteal artery Aneurysms represent a common pathology that vascular surgeons are often confronted with. However, several issues remain incompletely understood, including indications for intervention and optimal methods of treatment. In the following article, our discussants debate the appropriate management of small popliteal artery Aneurysms. Further complicating this discussion is the unclear relationship between popliteal artery Aneurysm Diameter and subsequent complications. Whereas with abdominal aortic Aneurysms Diameter is linked to rupture risk, it is less clear with popliteal artery Aneurysms where complications are more likely to include thrombosis, embolization, and compression whether Aneurysm Diameter is accurately predictive. Perhaps other anatomic features should be included in our management algorithms? Regardless, our debaters will try to convince us whether small popliteal artery Aneurysms warrant repair or not.
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Small popliteal artery Aneurysms: are they clinically significant?
Journal of Vascular Surgery, 2003Co-Authors: Enrico Ascher, Natalia Markevich, Richard W. Schutzer, Sreedhar Kallakuri, Theresa Jacob, Anil HingoraniAbstract:OBJECTIVE: We undertook this study to determine whether popliteal artery Aneurysm Diameter correlates with initial symptoms and presence of associated occlusive disease. METHODS: Duplex arteriography before infrainguinal revascularization in 500 lower extremities enabled diagnosis of 34 popliteal Aneurysms in 25 patients (24 male, 1 female) over the last 4 years. Fourteen patients (41%) had no symptoms (group 1) and 20 (59%) had symptoms (group 2) of severe claudication (n = 8), acute ischemia (n = 6), rest pain (n = 2), and tissue loss (n = 4). We compared clinical presentation with popliteal artery Diameter, prevalence of thrombosis, and presence of associated occlusive disease. RESULTS: Popliteal artery Aneurysm Diameter averaged 2.8 +/- 0.7 cm (range, 1.8-4.5 cm) in group 1 and 2.2 +/- 0.8 cm (range, 1.3-4.0 cm) in group 2 (P
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Small popliteal artery Aneurysms: are they clinically significant?
Journal of vascular surgery, 2003Co-Authors: Enrico Ascher, Natalia Markevich, Richard W. Schutzer, Sreedhar Kallakuri, Theresa Jacob, Anil HingoraniAbstract:Abstract Objective: We undertook this study to determine whether popliteal artery Aneurysm Diameter correlates with initial symptoms and presence of associated occlusive disease. Methods: Duplex arteriography before infrainguinal revascularization in 500 lower extremities enabled diagnosis of 34 popliteal Aneurysms in 25 patients (24 male, 1 female) over the last 4 years. Fourteen patients (41%) had no symptoms (group 1) and 20 (59%) had symptoms (group 2) of severe claudication (n = 8), acute ischemia (n = 6), rest pain (n = 2), and tissue loss (n = 4). We compared clinical presentation with popliteal artery Diameter, prevalence of thrombosis, and presence of associated occlusive disease. Results: Popliteal artery Aneurysm Diameter averaged 2.8 ± 0.7 cm (range, 1.8-4.5 cm) in group 1 and 2.2 ± 0.8 cm (range, 1.3-4.0 cm) in group 2 ( P Conclusions: Smaller popliteal artery Aneurysm was associated with higher incidence of thrombosis, clinical symptoms, and distal occlusive disease. Liberal use of duplex scanning in this setting may have accounted for the increased awareness that small popliteal artery Aneurysms can thrombose and present with severe ischemia. (J Vasc Surg 2003;37:755-60.)
Anil Hingorani - One of the best experts on this subject based on the ideXlab platform.
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Nonoperative versus surgical management of small (less than 3 cm), asymptomatic popliteal artery Aneurysms
Journal of Vascular Surgery, 2011Co-Authors: Jane E. Cross, Anil Hingorani, R.b. Galland, Enrico AscherAbstract:Popliteal artery Aneurysms represent a common pathology that vascular surgeons are often confronted with. However, several issues remain incompletely understood, including indications for intervention and optimal methods of treatment. In the following article, our discussants debate the appropriate management of small popliteal artery Aneurysms. Further complicating this discussion is the unclear relationship between popliteal artery Aneurysm Diameter and subsequent complications. Whereas with abdominal aortic Aneurysms Diameter is linked to rupture risk, it is less clear with popliteal artery Aneurysms where complications are more likely to include thrombosis, embolization, and compression whether Aneurysm Diameter is accurately predictive. Perhaps other anatomic features should be included in our management algorithms? Regardless, our debaters will try to convince us whether small popliteal artery Aneurysms warrant repair or not.
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Small popliteal artery Aneurysms: are they clinically significant?
Journal of Vascular Surgery, 2003Co-Authors: Enrico Ascher, Natalia Markevich, Richard W. Schutzer, Sreedhar Kallakuri, Theresa Jacob, Anil HingoraniAbstract:OBJECTIVE: We undertook this study to determine whether popliteal artery Aneurysm Diameter correlates with initial symptoms and presence of associated occlusive disease. METHODS: Duplex arteriography before infrainguinal revascularization in 500 lower extremities enabled diagnosis of 34 popliteal Aneurysms in 25 patients (24 male, 1 female) over the last 4 years. Fourteen patients (41%) had no symptoms (group 1) and 20 (59%) had symptoms (group 2) of severe claudication (n = 8), acute ischemia (n = 6), rest pain (n = 2), and tissue loss (n = 4). We compared clinical presentation with popliteal artery Diameter, prevalence of thrombosis, and presence of associated occlusive disease. RESULTS: Popliteal artery Aneurysm Diameter averaged 2.8 +/- 0.7 cm (range, 1.8-4.5 cm) in group 1 and 2.2 +/- 0.8 cm (range, 1.3-4.0 cm) in group 2 (P
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Small popliteal artery Aneurysms: are they clinically significant?
Journal of vascular surgery, 2003Co-Authors: Enrico Ascher, Natalia Markevich, Richard W. Schutzer, Sreedhar Kallakuri, Theresa Jacob, Anil HingoraniAbstract:Abstract Objective: We undertook this study to determine whether popliteal artery Aneurysm Diameter correlates with initial symptoms and presence of associated occlusive disease. Methods: Duplex arteriography before infrainguinal revascularization in 500 lower extremities enabled diagnosis of 34 popliteal Aneurysms in 25 patients (24 male, 1 female) over the last 4 years. Fourteen patients (41%) had no symptoms (group 1) and 20 (59%) had symptoms (group 2) of severe claudication (n = 8), acute ischemia (n = 6), rest pain (n = 2), and tissue loss (n = 4). We compared clinical presentation with popliteal artery Diameter, prevalence of thrombosis, and presence of associated occlusive disease. Results: Popliteal artery Aneurysm Diameter averaged 2.8 ± 0.7 cm (range, 1.8-4.5 cm) in group 1 and 2.2 ± 0.8 cm (range, 1.3-4.0 cm) in group 2 ( P Conclusions: Smaller popliteal artery Aneurysm was associated with higher incidence of thrombosis, clinical symptoms, and distal occlusive disease. Liberal use of duplex scanning in this setting may have accounted for the increased awareness that small popliteal artery Aneurysms can thrombose and present with severe ischemia. (J Vasc Surg 2003;37:755-60.)
Marc L. Schermerhorn - One of the best experts on this subject based on the ideXlab platform.
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Differences in patient selection and outcomes based on abdominal aortic Aneurysm Diameter thresholds in the Vascular Quality Initiative.
Journal of vascular surgery, 2019Co-Authors: Douglas W. Jones, Marc L. Schermerhorn, Sarah E. Deery, Darren B. Schneider, Denis Rybin, Jeffrey J. Siracuse, Alik Farber, Vascular Quality InitiativeAbstract:Abstract Objective Randomized trials have shown no benefit for repair of small abdominal aortic Aneurysms (AAAs), although repair of small AAAs is widely practiced. It has also been suggested that repair of large-Diameter AAAs may incur worse outcomes. We sought to examine differences in patient selection, operative outcomes, and survival after elective endovascular Aneurysm repair (EVAR) based on AAA Diameter thresholds. Methods Elective EVARs for asymptomatic AAAs in the Vascular Quality Initiative were studied from 2003 to 2017. AAAs were classified by Diameter as small ( Results Of 22,975 patients undergoing EVAR, 41% (9353), 47% (10,842), and 12% (2780) had small, medium, and large AAAs, respectively. Patients with small AAAs were younger and had fewer comorbidities. Consequently, patients with small AAAs were more likely to have low predicted operative mortality risk and 5-year mortality risk based on risk models (P Conclusions Small AAAs represent >40% of elective EVARs in the Vascular Quality Initiative. Patients with small AAAs selected for repair are younger and have fewer comorbidities. Consequently, EVAR for small AAAs carries lower risk of operative and 5-year mortality. Aneurysm Diameter is independently associated with reinterventions and mortality after EVAR, suggesting that AAA Diameter may have an important clinical effect on outcomes.
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Thresholds for Abdominal Aortic Aneurysm Repair in England and the United States
The New England journal of medicine, 2016Co-Authors: Alan Karthikesalingam, Marc L. Schermerhorn, Ian M. Loftus, Alberto Vidal-diez, Peter J. Holt, Peter A. Soden, Bruce E. Landon, Matt M. ThompsonAbstract:BackgroundThresholds for repair of abdominal aortic Aneurysms vary considerably among countries. MethodsWe examined differences between England and the United States in the frequency of Aneurysm repair, the mean Aneurysm Diameter at the time of the procedure, and rates of Aneurysm rupture and Aneurysm-related death. Data on the frequency of repair of intact (nonruptured) abdominal aortic Aneurysms, in-hospital mortality among patients who had undergone Aneurysm repair, and rates of Aneurysm rupture during the period from 2005 through 2012 were extracted from the Hospital Episode Statistics database in England and the U.S. Nationwide Inpatient Sample. Data on the Aneurysm Diameter at the time of repair were extracted from the U.K. National Vascular Registry (2014 data) and from the U.S. National Surgical Quality Improvement Program (2013 data). Aneurysm-related mortality during the period from 2005 through 2012 was determined from data obtained from the Centers for Disease Control and Prevention and the U....
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Relative importance of Aneurysm Diameter and body size for predicting abdominal aortic Aneurysm rupture in men and women.
Journal of vascular surgery, 2013Co-Authors: Margriet Fokkema, Mark F. Conrad, Virendra I. Patel, Mark F. Fillinger, Robina Matyal, Marc L. SchermerhornAbstract:Objective Women have been shown to have up to a fourfold higher risk of abdominal aortic Aneurysm (AAA) rupture at any given Aneurysm Diameter compared with men, leading to recommendations to offer repair to women at lower Diameter thresholds. Although this higher risk of rupture may simply reflect greater relative aortic dilatation in women who have smaller aortas to begin with, this has never been quantified. Our objective was therefore to quantify the relationship between rupture and Aneurysm Diameter relative to body size and determine whether a differential association between Aneurysm Diameter, body size, and rupture risk exists for men and women. Methods We performed a retrospective review of all patients in the Vascular Study Group of New England (VSGNE) database who underwent endovascular or open AAA repair. Height and weight were used to calculate each patient's body mass index and body surface area (BSA). Next, indices of each measure of body size (height, weight, body mass index, BSA) relative to Aneurysm Diameter were calculated for each patient. To generate these indices, we divided Aneurysm Diameter (in cm) by the measure of body size; for example, aortic size index (ASI) = Aneurysm Diameter (cm)/BSA (m 2 ). Along with other relevant clinical variables, we used these indices to construct different age-adjusted and multivariable-adjusted logistic regression models to determine predictors of ruptured repair vs elective repair. Models for men and women were developed separately, and different models were compared using the area under the curve. Results We identified 4045 patients (78% male) who underwent AAA repair (53% endovascular aortic Aneurysm repairs). Women had significantly smaller Diameter Aneurysms, lower BSA, and higher BSA indices than men. For men, the variable that increased the odds of rupture the most was Aneurysm Diameter (area under the curve = 0.82). Men exhibited an increased rupture risk with increasing Aneurysm Diameter ( P = .771; 6.5-7.4 cm: OR, 3.9; 95% CI, 1.9-1.0; P P 3.5-3.9: OR, 6.4; 95% CI, 1.7-24.1; P = .006; ASI ≥4.0: OR, 9.5; 95% CI, 2.3-39.4; P = .002). For women, Aneurysm Diameter was not a significant predictor of rupture after adjusting for ASI. Conclusions Aneurysm Diameter indexed to body size is the most important determinant of rupture for women, whereas Aneurysm Diameter alone is most predictive of rupture for men. Women with the largest Diameter Aneurysms and the smallest body sizes are at the greatest risk of rupture.
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Relative importance of Aneurysm Diameter and body size for predicting AAA rupture in men and women
Journal of Vascular Surgery, 2013Co-Authors: Mark F. Conrad, Mark F. Fillinger, Robina Matyal, Allen D. Hamdan, Marc L. SchermerhornAbstract:Objectives Women have been shown to have up to a four-fold higher risk of abdominal aortic Aneurysm (AAA) rupture at any given Aneurysm Diameter compared to men, leading to recommendations to offer repair to women at lower Diameter thresholds. Although this higher risk of rupture may simply reflect greater relative aortic dilatation in women who have smaller aortas to begin with, this has never been quantified. Our objective was therefore to quantify the relationship between rupture and Aneurysm Diameter relative to body size and to determine whether a differential association between Aneurysm Diameter, body size, and rupture risk exists for men and women.
Jon S. Matsumura - One of the best experts on this subject based on the ideXlab platform.
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abstract 13513 serial ct surveillance of abdominal aortic Aneurysm Diameter demonstrates predominantly linear growth n ta3ct
Circulation, 2020Co-Authors: Sydney L Olson, Marniker Wijesinha, Annalise Panthofer, William C Blackwelder, Gilbert R Upchurch, Michael L Terrin, John A Curci, Timothy T Baxter, Jon S. MatsumuraAbstract:Objective: Small abdominal aortic Aneurysms (AAAs) have a low risk of rupture. Intervention is indicated when Diameters exceed established thresholds. This study assessed the growth rates and patte...
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Predictors and outcomes of endoleaks in the Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms.
Journal of vascular surgery, 2015Co-Authors: Brajesh K. Lal, Wei Zhou, Tassos C. Kyriakides, Jon S. Matsumura, Frank A. Lederle, Julie A. FreischlagAbstract:Objective The Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms study was a randomized controlled trial comparing open vs endovascular repair (EVAR) in standard-risk patients with infrarenal aortic Aneurysms. The analysis reported here identifies characteristics, risk factors, and long-term outcome of endoleaks in patients treated with EVAR in the OVER cohort. Methods The OVER trial enrolled 881 patients, of whom 439 received successful EVAR. Logistic regression analysis was used to identify predictors for endoleaks and secondary interventions. Kaplan-Meier survival analysis, longitudinal plots, and generalized linear mixed models methods were used to describe time to endoleak detection, resolution, or death. Results During a mean follow-up of 6.2 ± 2.4 years, 135 patients (30.5%) developed 187 endoleaks. Four patients with EVAR went on to rupture; these four patients did not all have an endoleak. Mortality between patients who did and did not develop endoleaks was not significantly different. The 187 endoleaks included 12% type I, 76% type II, 3% type III, 3% type IV, and 6% indeterminate. Patient demographics and vascular risk factors were not associated with endoleak development. The presence of endoleaks resulted in an increase in Aneurysm Diameter over time ( P P 1 year after EVAR) were associated with Aneurysm enlargement compared with the early counterpart. There was no difference in Aneurysm size or length of survival between type II and other types of endoleak. Conclusions We present one of the most comprehensive and longest follow-up analyses of patients treated with aortic endografts. Endoleaks were common and negatively affected Aneurysm Diameter reduction. Delayed type II endoleaks were associated with late Aneurysm Diameter enlargement. Endoleaks and Aneurysm Diameter enlargement were not associated with excess mortality compared with those without these features.