GENDER BASED DIFFERENCES IN ABDOMINAL AORTIC ANEURYSM (AAA) RUPTURE

1. 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://aorticstents.com/what-is-abdominal-aortic-aneurysm/ (05/23/13)

2. Disclosures None 1. http://aorticstents.com/what-is-abdominal-aortic-aneurysm/ (05/23/13)

3. Cardiovascular diseases • Cardiovascular disease is the number one cause of death for both men and women in the United States1. • Preventive medicine is practiced by screening tests, counseling and preventive medications owing to the impact of cardiovascular diseases. A- Strongly Recommended Benefit>>Risk B-Recommended Benefit>Risk Performance Improvement Projects ?? 1. http://www.uspreventiveservicestaskforce.org/uspstopics.htm

4. 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 diameter1. • -Risk factors1: • Non modifiable • Age • Male gender • White race • Family history • Modifiable • Smoking • Hypertension • Hyperlipidemia • Atherosclerosis -AAA rupture is a medical and surgical emergency. -Mortality could be up to 50%2. 1.Steinberg I, Stein HL. Arterosclerotic abdominal aortic aneurysms. report of 200 consecutive cases diagnosed by intravenous aortography. JAMA 1966;195:1025. 2. Brown LC, Powell JT (September 1999). "Risk Factors for Aneurysm Rupture in Patients Kept Under Ultrasound Surveillance". Annals of Surgery 230 (3): 289–96; discussion 296–7. doi:10.1097/00000658-199909000-00002. PMC 1420874. PMID 10493476

5. Introduction • The strongest risk factor for the rupture of an AAA is maximal aortic diameter4. Normal CT scan Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm Rupture 1 2 3 • Risk of rupture4: • < 4 cm = 0.5% per year • 4.0 – 4.9 cm = 1% per year • 5.0 – 5.9 cm = 11% per year • 6.0 – 6.9 cm = 26% per year • 7.0 – 7.9 cm = 40% per year • > 8 cm = 50% year year • Management5: • Open repair : conventional method of repair • Endovascular repair: faster recovery, reduced length of stay in ICU, reduced hospital stay 1.http://www.nlm.nih.gov/medlineplus/ency/article/003789.htm (05/23/2013) 2.http://www.surgical-tutor.org.uk/default-home.htm?system/vascular/aaa.htm~right (05/23/2013) 3.http://www.radiologyassistant.nl/en/p4530b48a07dbd/aaa-rupture-1.html (05/24/13) 4. Brewster DC, Geller SC, Kaufman JA, Cambria RP, Gertler JP, LaMuraglia GM, et al. Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair. J Vasc Surg 1998;27:992-1003.

6. 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 criteria2: • 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) • Fleming C, Whitlock EP, Beil T, Lederle F. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2005;142:203-11. • http://www.uspreventiveservicestaskforce.org/uspstf05/aaascr/aaars.htm • http://www.fomadistrict2.com/wp-content/uploads/2012/12/SAAAVE-ACT.pdf

7. Management guidelines • Indications of elective surgery1: • 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”. • David C. Brewster,a MD, Jack L. Cronenwett, MD,b John W. Hallett, Jr, MD,c K. Wayne Johnston, MD,d William C. Krupski, MD,e and Jon S. Matsumura, MD,f Boston, Mass; Lebanon, NH; Bangor, Me; Toronto, Canada; Denver, Colo; and Chicago, Ill; Guideliens for treatment of Abdominal Aortic Aneurysms, Journal of Vascular Surgery, 2007

8. 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”

9. Introduction • Epidemiological differences: • Prevalence: 7.6% in males vs 1.3% in females1,2 • Rate of rupture for any given size is higher in females3. • Women with AAA have a stronger familial association than men4. • Estrogen does have a protective effect on the AAA in women4. • Pleumeekers HJCM, Hoes AW, van der Does E, van Urk H, Hofman A, de Jong PTVM, Grobbee DE. Aneurysms of the abdominal aorta in older adults. Am J Epidemiol. 1995;142:1291–1299. • 2cott RAP, Bridgewater S, Ashton HA. Randomised clinical trial of screening for abdominal aortic aneurysm in women. Br J Surg. 2002;89: 283–285. • Katz DJ, Stanley JC, Zelenock GB. Gender differences in abdominal aortic aneurysm prevalence, treatment, and outcome. J Vasc Surg. 1997; 25:561–568. • Manson JE, Hsia J, Johnson KC, Rossouw JE, Assaf AR, Lasser NL, Trevisan M, Black HR, Heckbert SR, Detrano R, Strickland OL, Wong ND, Crouse JR, Stein E, Cushman M, for the Women’s Health Initiative Investigators. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med. 2003;349:523–534.

10. Biological differences: • At any given age, males have larger abdominal aortic diameters than women1,2. • Suitability for EVAR is different: The angulation of iliacs, size of femoral • arteries and tortuosity of aortas are different in females3. 1. Lederle FA, Johnson GR, Wilson SE, Gordon IL, Chute EP, Littooy FN, Krupski WN, Brandyk D, Barone GW, Graham LM, Hye RJ, Reinke DB, Aneurysm Detection and Management Investigators. Relationship of age, gender, race, and body size to infrarenal aortic diameter. J Vasc Surg. 1997;26:595– 601. 2. Singh K, Bonaa KH, Jacobsen BK, Bjork L, Soldberg S. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study. Am J Epidemiol. 2001;154:236 –244. 3. Sonesson B, Hansen F, Stale H, Lanne T. Compliance and diameter in the human abdominal aorta: the influence of sex and age. Eur J Vasc Surg. 1993;7:690 – 697.

11. 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 • The United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1445–1452. • Lederle F, Wison S, Johnson G, Reinke D, Litooy F, Acher C, Ballard D, Messina L, Gordon I, Chute E, Krupski W, Bradyk D. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1437–1444.

12. 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 women1. • 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 participants3. • http://www.world-heart-federation.org/press/fact-sheets/women-and-cardiovascular-disease/ • American Heart Association. 1997 Heart and Stroke Facts: Statistical Update. Dallas, Tex: American Heart Association; 1996. • Mikhail GW. Coronary heart disease in women is underdiagnosed, under- treated, and under-researched. BMJ. 2005;331:467–468.

13. Goals: • Emphasize the importance of screening for AAAs in high risk women. • Emphasize the importance of “sex-specific” management guidelines of AAA. • Objectives: • Compare the outcomes of ruptured Abdominal Aortic Aneurysms between men and women. • Compare the characters of ruptured AAAs in men and women.

14. Methods • Sample: All the AAA ruptures in Sisters and Mercy Hospitals admitted from January 1 2007 to September 2012 (6 years). • Type of study: Retrospective review of paper charts and Electronic Medical Records. • A total of 39 parameters were compared between males and females. • SPSS v.19 was used for statistical analysis. • Binary logistic regression, ANOVA (analysis of variance) and ANCOVA (analysis of co-variance) were used for comparing the means. • Survival plots were created by Kaplan-Meier analysis.

15. Results • Total no. of cases reviewed= 1538 (100%) • Exclusion criteria • Elective repairs • Endovascular leak • Endovascular revision • Total no. of cases excluded = 1417 (92%) • Total no. of cases included= 117 (8%)

16. Results Incidence of AAAs Incidence of AAA ruptures

17. Demographics

18. Co-morbidities and medications

19. Age at rupture p=0.005 • Gender was an independent predictor of age of rupture after controlling the effects of hypertension, co-morbidities, smoking, use of statins and previous history of aneurysms.

20. Characters of AAAs at presentation (Parameters from the CT scan abdomen at admission)

21. Characters of AAAs at presentation Size at rupture p=0.04

22. Effect of gender on Hospital course Incidence of surgery P=0.03 Type of surgery performed

23. Indicators of post-operative morbidity N=98, Men=74 and Women=24 *Major co-morbidities was a significant predictor of post-operative complications, VDRF and use of vasopressors (p<0.001, logistic regression) +Age was a significant predictor of VDRF and use of vasopressors (p<0.001, logistic regression)

24. Overall Mortality -P=0.001 -Adjusted for hypertension, smoking, statins, major co-morbidities (logistic regression) Post-operative mortality -P=0.05 -Adjusted for hypertension, smoking, statins, major co-morbidities (logistic regression) Mortality based on type of surgery -Adjusted for hypertension, smoking, statins, major co-morbidities (logistic regression)

25. Size at previous diagnosis Elective surgery could have been performed !!

26. Long term survival • Patients discharged alive were followed for a period of -2 years. • Date of death was procured from ssdmf.com (SSN database) Kaplan-Meier survival curve analysis Males=11.0 months Females=9.3 months P= 0.41 -unadjusted data. -very small sample.

27. It is about….…. 1 Will the screening be cost effective? 1.http://www.123rf.com/photo_18118258_elderly-woman-suffering-with-a-belly-pain-in-the-living-room.html-05/232013

28. Will the screening be cost effective? • Average re-imbursement for an ultrasound for AAA screening=97.77$1 • Summary of financials from previous 3 years • (SOCH & SBMH) • Average re-imbursement for surgical repair after a AAA rupture was 8500$ more for male patients over female patients. • Average re-imbursement for AAA rupture admissions was 7500$ more for male patients over female patients. http://www.gehealthcare.com/usen/community/reimbursement/docs/Vascular_Surgery_reimbursementv2.pdf

29. Conclusions: “Lower AAA prevalence is balanced by a higher rupture rate, mortality and morbidity. So screening is indeed cost-effective.”

30. Limitations • Study could not comment on the current guidelines of elective surgery at 5.5 cm • Single center study • Missing co-variates: smoking quantity, COPD (use of steroids), family history, age at menopause, occupation Future studies…. • Small AAAs (Prospective trial) • Total no. of visits (Catholic Health System) = >1500

31. Conclusions • The overall incidence of AAA rupture was higher in males (68%) than in females (32%). • There was a significant effect of gender on the age of death from AAA rupture after controlling the effect of hypertension, co-morbidities, smoking, use of statins and previous history of aneurysms; F (1,110)=8, p=0.005. • There was a significant difference in the size of AAA rupture between females (mean=7.4 cm, SD=2.0) and males (mean=8.2 cm, SD=1.8); t (115)=2.0, p = 0.04. • The probability to undergo surgery for ruptured AAA was significantly lower for women as compared to men, even after adjusting for age at admission and major co-morbidities (p=0.03).

32. Conclusions • There was a significant effect of gender on the overall mortality (p=0.001) and post-operative mortality after EVAR (p=0.02) from AAA rupture after controlling the effect of hypertension, co-morbidities, smoking, use of statins and previous history of aneurysm. • Length of ICU stay, incidence of post-operative complications, use of pressors and use of ventilator was more in females. • Using a similar threshold of size (5.5 cm) for elective surgery for both males and females might not be appropriate. • AAA screening might be warranted for high risk females owing to their higher morbidity and mortality.

33. Acknowledgements • CHS IRB members • Andrew Bishop (Data analyst)-- Financial analysis • Kamal Tourbaf, MD • Henri Woodman, MD • Paul M Anain, MD • Khalid J Qazi, MD, MACP

34. THANK YOU