GENDER BASED DIFFERENCES IN ABDOMINAL AORTIC ANEURYSM (AAA) RUPTURE - PowerPoint PPT Presentation

GENDER BASED DIFFERENCES IN ABDOMINAL AORTIC ANEURYSM (AAA) RUPTURE -Srikrishna Varun Malayala, MBBS Mentors: -Khalid J Qazi, MD, MACP -Paul M Anain, MD 1. http:/ / a o rtic ste nts.c o m/ wha t-is-a b do mina l-a o rtic -a ne urysm/ (05/ 23/ 13)

Disclosures None 1. http:/ / a o rtic ste nts.c o m/ wha t-is-a b do mina l-a o rtic -a ne urysm/ (05/ 23/ 13)

Cardiovascular diseases • Cardiovascular disease is the number one cause of death for both men and women in the United States 1 . • Preventive medicine is practiced by screening tests, counseling and preventive medications owing to the impact of cardiovascular diseases. U. U.S. Preventi tive Service ces Task For orce ce-March h 2009 09 A- Strongly Screening modality Grade Recommended Smoking Counseling on A Benefit>>Risk cessation Hypertension Blood pressure A B-Recommended monitoring Benefit>Risk Dyslipidemia Lipid profile A Diabetes Mellitus Fasting plasma B glucose Obesity Lifestyle B Performance modification Improvement Prevention of Aspirin B Projects ?? Cardiovascular diseases 1. http:/ / www.uspre ve ntive se rvic e sta skfo rc e .o rg / uspsto pic s.htm

Introduction -My out-patient PI project: Screening for AAA in high risk patients. -Dilatation or widening of the abdominal aorta. -Definition: An abdominal aortic diameter of 3 cm or more, which is usually more than 2 standard deviations above the mean diameter 1 . -Risk factors 1 : Modifiable Non modifiable • Smoking Age • • Hypertension Male gender • • Hyperlipidemia White race • • Atherosclerosis Family history • -AAA rupture is a medical and surgical emergency. -Mortality could be up to 50% 2 . 1.Ste inb e rg I, Ste in HL . Arte ro sc le ro tic a b do mina l a o rtic a ne urysms. re po rt o f 200 c o nse c utive c a se s dia g no se d b y intra ve no us a o rto g ra phy. JAMA 1966;195:1025. 2. Bro wn L C, Po we ll JT (Se pte mb e r 1999). "Risk F a c to rs fo r Ane urysm Rupture in Pa tie nts Ke pt Unde r Ultra so und Surve illa nc e ". Anna ls o f Surg e ry 230 (3): 289–96; disc ussio n 296–7. do i:10.1097/ 00000658-199909000-00002. PMC 1420874. PMID 10493476

Introduction • The strongest risk factor for the rupture of an AAA is maximal aortic diameter 4 . Normal CT scan Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm Rupture 1 2 3 Risk of rupture 4 : • i. < 4 cm = 0.5% per year ii. 4.0 – 4.9 cm = 1% per year iii. 5.0 – 5.9 cm = 11% per year iv. 6.0 – 6.9 cm = 26% per year v. 7.0 – 7.9 cm = 40% per year vi. > 8 cm = 50% year year Management 5 : • i. Open repair : conventional method of repair ii. Endovascular repair: faster recovery, reduced length of stay in ICU, reduced hospital stay 1.http:/ / www.nlm.nih.g o v/ me dline plus/ e nc y/ a rtic le / 003789.htm (05/ 23/ 2013) 2.http:/ / www.surg ic a l-tuto r.o rg .uk/ de fa ult-ho me .htm? syste m/ va sc ula r/ a a a .htm~rig ht (05/ 23/ 2013) 3.http:/ / www.ra dio lo g ya ssista nt.nl/ e n/ p4530b 48a 07db d/ a a a -rupture -1.html (05/ 24/ 13) 4. Bre wste r DC, Ge lle r SC, K a ufma n JA, Ca mb ria RP, Ge rtle r JP, L a Mura g lia GM, e t a l. I nitia l e xp e rie nc e with e nd o va sc ula r a ne urysm re p a ir: c o mp a riso n o f e a rly re sults with o utc o me o f c o nve ntio na l o p e n re p a ir. J Va sc Surg 1998;27:992-1003.

Screening guidelines USPSTF – Grade B recommendation (benefit>risk) • Ultrasound has 90% sensitivity and 100% specificity. • SAAAVE Act “Effective for services furnished on or after January 1, 2007, payment may • be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria 2 : Men aged 65-75 who ever smoked(100 cigarettes in life time) • Men and women with a family history of AAA • As a part of “Welcome to Medicare” within the first year of • enrollment AAA screening in women: Grade D (not recommended) • 1. F le ming C, Whitlo c k E P, Be il T , L e de rle F . Sc re e ning fo r a b do mina l a o rtic a ne urysm: a b e st-e vide nc e syste ma tic re vie w fo r the U.S. Pre ve ntive Se rvic e s T a sk F o rc e . Ann Inte rn Me d 2005;142:203-11. 2. http:/ / www.uspre ve ntive se rvic e sta skfo rc e .o rg / uspstf05/ a a a sc r/ a a a rs.htm 3. http:/ / www.fo ma distric t2.c o m/ wp-c o nte nt/ uplo a ds/ 2012/ 12/ SAAAVE -ACT .pdf

Management guidelines Indications of elective surgery 1 : • Diameter of 5.5 cm for an ‘average’ patient. • Symptomatic AAA (irrespective of the size) • Rapid expansion-1 cm in one year (irrespective of the size) • Decision on repair must be “individualized for each patient”. • 1. Da vid C. Bre wste r,a MD, Ja c k L . Cro ne nwe tt, MD,b Jo hn W. Ha lle tt, Jr, MD,c K. Wa yne Jo hnsto n, MD,d Willia m C. Krupski, MD,e a nd Jo n S. Ma tsumura , MD,f Bo sto n, Ma ss; L e b a no n, NH; Ba ng o r, Me ; T o ro nto , Ca na da ; De nve r, Co lo ; a nd Chic a g o , Ill; Guide lie ns fo r tre a tme nt o f Ab do mina l Ao rtic Ane urysms, Jo urna l o f Va sc ula r Surg e ry, 2007

Night float-PGY-2: 3 female patients with AAA in the same rotation. • Aorto-enteric fistula • 7 cm AAA with elective repair and admitted to ICU • Multiple aneurysms (aorto-iliacs) with rupture • Case report on aorto-enteric fistula “Time bomb in the belly”

Introduction Epidemiological differences: Prevalence: 7.6% in males vs 1.3% in females 1,2 • Rate of rupture for any given size is higher in females 3 . • Women with AAA have a stronger familial association than men 4 . • Estrogen does have a protective effect on the AAA in women 4 . • 1. Ple ume e ke rs HJCM, Ho e s AW, va n de r Do e s E, va n Urk H, Ho fma n A, de Jo ng PT VM, Gro b b e e DE. Ane urysms o f the a b do mina l a o rta in o lde r a dults. Am J E pide mio l . 1995;142:1291–1299. 2. 2c o tt RAP, Bridg e wa te r S, Ashto n HA. Ra ndo mise d c linic a l tria l o f sc re e ning fo r a b do mina l a o rtic a ne urysm in wo me n. Br J Surg . 2002;89: 283–285. K a tz DJ, Sta nle y JC, Ze le no c k GB. Ge nde r diffe re nc e s in a b do mina l a o rtic a ne urysm pre va le nc e , tre a tme nt, a nd o utc o me . J Vasc Surg . 1997; 25:561–568. 3. 4. Ma nso n JE, Hsia J, Jo hnso n K C, Ro sso uw JE, Assa f AR, L a sse r NL , T re visa n M, Bla c k HR, He c kb e rt SR, De tra no R, Stric kla nd OL , Wo ng ND, Cro use JR, Ste in E, Cushma n M, fo r the Wo me n’ s He a lth Initia tive Inve stig a to rs. Estro g e n plus pro g e stin a nd the risk o f c o ro na ry he a rt dise a se . N E ng l J Me d . 2003;349:523–534.

Biological differences: At any given age, males have larger abdominal aortic diameters than women 1,2 . • Suitability for EVAR is different: The angulation of iliacs, size of femoral • arteries and tortuosity of aortas are different in females 3 . 1. L e de rle F A, Jo hnso n GR, Wilso n SE , Go rdo n IL , Chute E P, L itto o y F N, Krupski WN, Bra ndyk D, Ba ro ne GW, Gra ha m L M, Hye RJ, Re inke DB, Ane urysm De te c tio n a nd Ma na g e me nt Inve stig a to rs. Re la tio nship o f a g e , g e nde r, ra c e , a nd b o dy size to infra re na l a o rtic dia me te r. J Vasc S urg . 1997;26:595– 601. 2. Sing h K, Bo na a KH, Ja c o b se n BK, Bjo rk L , So ldb e rg S. Pre va le nc e o f a nd risk fa c to rs fo r a b do mina l a o rtic a ne urysms in a po pula tio n-b a se d study. Am J E pide mio l . 2001;154:236 –244. 3. So ne sso n B, Ha nse n F , Sta le H, L a nne T . Co mplia nc e a nd dia me te r in the huma n a b do mina l a o rta : the influe nc e o f se x a nd a g e . E ur J Vasc S urg . 1993;7:690 – 697.

UK Small Aneurysm trial: • Multicentre, randomised controlled trial conducted across 93 UK hospitals 83% males ADAM study (Aneurysm Detection and Management): • 73451 veterans aged 50 to 79 99% males N-67,800 All of them=men T he Unite d K ing do m Sma ll Ane urysm T ria l Pa rtic ipa nts. L o ng -te rm o utc o me s o f imme dia te re pa ir c o mpa re d with surve illa nc e o f sma ll a b do mina l a o rtic a ne urysms. N E ng l J Me d. 2002;346:1445–1452. 1. L e de rle F , Wiso n S, Jo hnso n G, Re inke D, L ito o y F , Ac he r C, Ba lla rd D, Me ssina L , Go rdo n I, Chute E , K rupski W, Bra dyk D. Imme dia te re pa ir c o mpa re d with surve illa nc e o f sma ll a b do mina l a o rtic a ne urysms. 2. N E ng l J Me d . 2002;346:1437–1444.

Gender based differences in cardiovascular diseases • Traditionally, all the cardiovascular diseases were considered as “men’s diseases.” • Cardiovascular diseases (CVDs) are the number one killer of women 1 . • Mortality is more than all forms of cancers combined (breast , cervical and lung cancer) 2 . “Women continue to be under-represented in research on heart disease. 3 . • Still women continue to receive similar treatments to men on the basis of trials that include • mainly male participants 3 . 1. http :/ / www.wo rld -he a rt-fe d e ra tio n.o rg / p re ss/ fa c t-she e ts/ wo me n-a nd -c a rd io va sc ula r-d ise a se / 2. Ame ric a n He a rt Asso c ia tio n. 1997 He a rt a nd Stro ke F a c ts: Sta tistic a l Up d a te . Da lla s, T e x: Ame ric a n He a rt Asso c ia tio n; 1996. 3. Mikha il GW. Co ro na ry he a rt d ise a se in wo me n is und e rd ia g no se d , und e r- tre a te d , a nd und e r-re se a rc he d . BMJ . 2005;331:467–468.