ruptured abdominal aortic and iliac artery aneurysms

132 Pages·2017·1.75 MB·English

by  Matti Laine

Doctoral Programme in Clinical Research
University of Helsinki
Department of Vascular Surgery
Helsinki University Hospital
Helsinki, Finland

RUPTURED ABDOMINAL AORTIC AND ILIAC
ARTERY ANEURYSMS

Matti Laine

ACADEMIC DISSERTATION

To be presented, with the permission of the Faculty of Medicine at the University
of Helsinki, for public examination in lecture room 1, Meilahti Tower Hospital,
Helsinki University Hospital, on 9 June 2017, at 12 noon.

Helsinki 2017
Supervised by:
Professor Maarit Venermo
Department of Vascular Surgery
University of Helsinki and Helsinki University Hospital
Helsinki, Finland

Reviewed by:
Professor Jari Laurikka
Department of Surgery
Tampere University Hospital
Tampere, Finland

Adjunct Professor Tuija Ikonen
Administrative Centre
Hospital District of Southwest Finland
and
Public Health
University of Turku
Turku, Finland

Discussed with:
Professor Janet Powell
Imperial College London
Vascular Surgery Research Group
Charing Cross Hospital
London, United Kingdom

Cover photograph by Matti Laine
©2017 Matti Laine

ISBN 978-951-51-3241-3 (pbk.)
ISBN 978-951-51-3242-0 (PDF)

Unigrafia
Helsinki 2017
In vascular surgery no change for the better has occurred that wise
and good men have not opposed
John J. Bergan (1927-2014)

Contents
CONTENTS
CONTENTS ............................................................................. 5
LIST OF ORIGINAL PUBLICATIONS ..................................... 9
ABBREVIATIONS ................................................................. 11
ABSTRACT ........................................................................... 13
INTRODUCTION .................................................................. 15
REVIEW OF THE LITERATURE ............................................ 19
1 History of aneurysm surgery ......................................... 19
1.1 Early history ............................................................................ 19
1.2 Modern times .......................................................................... 22
1.3 The endovascular era .............................................................. 24
2 Abdominal aortic aneurysm .......................................... 26
2.1 Definition ................................................................................ 26
2.1.1 Diameter ............................................................................... 26
2.1.2 True and false aneurysm ...................................................... 27
2.1.3 Degenerative aneurysm ....................................................... 27
2.1.4 Genetic aneurysm ................................................................ 29
2.1.4.1 Ehlers-Danlos syndrome .......................................... 29
2.1.4.2 Marfan syndrome .................................................... 30
2.1.4.3 Loeys-Dietz syndrome .............................................. 31
2.1.4.4 Other genetic aneurysms .......................................... 31
2.1.5 Inflammatory aneurysm ...................................................... 31
2.1.5.1 Inflammatory aortic aneurysm ................................. 32
2.1.5.2 Vasculitides ............................................................... 33
2.1.6 Infected aneurysms .............................................................. 35
2.1.7 Dissection and aneurysm ..................................................... 37
2.2 Pathophysiology ..................................................................... 38
2.3 Risk factors and comorbidities .............................................. 38
2.3.1 Aneurysm development ...................................................... 38
2.3.2 Expansion rate and rupture risk .......................................... 41
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Ruptured Abdominal Aortic and Iliac Artery Aneurysms
2.3.3 Common comorbidities....................................................... 42
2.4 Prevalence .............................................................................. 43
2.5 Natural course ......................................................................... 45
2.6 Ruptured and symptomatic aneurysms ................................. 47
2.7 Treatment ............................................................................... 48
2.7.1 Medical Treatment .............................................................. 48
2.7.1.1 Inhibition of aneurysm growth ................................ 48
2.7.1.2 Reducing mortality ................................................... 51
2.7.2 Elective surgery: intact aneurysms ...................................... 52
2.7.2.1 Indications for repair ................................................ 53
2.7.2.2 Open surgery versus EVAR ...................................... 55
2.7.3 Urgent surgery: symptomatic aneurysms ........................... 57
2.7.3.1 Indications and timing of repair ............................... 57
2.7.3.2 Open surgery versus EVAR ..................................... 58
2.7.4 Emergency surgery: ruptured aneurysms ........................... 59
2.7.4.1 Open surgery versus EVAR ....................................... 59
2.8 Screening ................................................................................ 60
2.8.1 Studies on screening ........................................................... 60
2.8.2 Results of screening programmes ....................................... 63
2.8.3 Cost-effectiveness of screening ........................................... 66
2.9 Sex-related differences in AAA .............................................. 68
3 Iliac artery aneurysms ................................................... 71
3.1 Definition ................................................................................ 71
3.2 Natural course ......................................................................... 71
3.3 Treatment ................................................................................ 72
3.3.1 Indications............................................................................ 72
3.3.2 Open surgery and endovascular repair ................................ 73
3.3.3 Complications ...................................................................... 73
3.3.4 Results of repair ................................................................... 74
AIMS OF THE STUDY ........................................................... 77
METHODS ............................................................................ 79
1 Patients ............................................................................................ 79
2 Data analysis .................................................................................... 81
3 Statistical methods ......................................................................... 82
RESULTS ............................................................................. 83
6
Contents
1 RAAA incidence in Finland (I) ....................................................... 83
2 Prehospital RAAA mortality (I,II) ................................................... 85
3 Turn-down rate for RAAA (I,II) ..................................................... 86
4 AAA rupture at under screening age (III) ....................................... 87
5 AAA rupture at under the operative threshold diameter (III) ....... 88
6 Rupture of IIAA (IV) ....................................................................... 89
DISCUSSION ........................................................................ 91
1 RAAA incidence ............................................................................... 91
2 Mortality and turndown .................................................................. 94
3 Implications for AAA screening ...................................................... 95
4 AAA in women ................................................................................ 98
5 Ruptured IIAA ................................................................................. 99
6 Limitations of the study................................................................. 100
CONCLUSIONS ................................................................... 101
ACKNOWLEDGEMENTS .................................................... 103
REFERENCES ..................................................................... 105
ORIGINAL PUBLICATIONS ................................................. 131
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Ruptured Abdominal Aortic and Iliac Artery Aneurysms
8
List of original publications

LIST OF ORIGINAL PUBLICATIONS
This thesis is based on the following publications:

I Laine MT, Laukontaus SJ, Aho PS, Kantonen I, Albäck A,
Venermo M. Population-based study of abdominal aortic
aneurysm treatment in Finland 2000-2014. Submitted.

II Laine MT, Laukontaus SJ, Kantonen I, Venermo M. Population-
based study of ruptured abdominal aortic aneurysm. Br J Surg.
2016 Nov; 103(12):1634-1639.

III Laine MT, Vänttinen T, Kantonen I, Halmesmäki K, Weselius EM,
Laukontaus S, Salenius J, Aho PS, Venermo M. Rupture of
abdominal aortic aneurysms in patients under screening age and
elective repair threshold. Eur J Vasc Endovasc Surg. 2016 Apr;
51(4):511-516.

IV Laine MT, Björck M, Beiles CB, Szeberin Z, Thomson I, Altreuther
M, Debus ES, Mani K, Menyhei G, Venermo M. Few internal iliac
artery aneurysms rupture under 4 cm. J Vasc Surg. 2017 Jan;
65(1):76-81.

The publications are referred to in the text by their roman numerals.

9
Ruptured Abdominal Aortic and Iliac Artery Aneurysms
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