Discrepancies in abdominal aortic aneurysm expressions and repair

227 Pages·2011·2.84 MB·English

Discrepancies in abdominal aortic aneurysm
expressions and repair
Rob Hurks
The work presented in this thesis was supported by a grant from Association Leatare, which
is gratefully acknowledged.
© 2011 Rob Hurks
ISBN: 9789461082329
Cover design: Harrie de Bruijn | Rob Hurks
Lay-out: www.wenzid.nl | Wendy Schoneveld
Printed by: Gildeprint drukkerijen, Enschede
Discrepancies in abdominal aortic aneurysm
expressions and repair
Discrepanties in aneurysma aortae abdominalis expressies en herstel
(met een samenvatting in het Nederlands)
Proefschrift
ter verkrijging van de graad van doctor aan de Universiteit Utrecht
op gezag van de rector magnificus, prof.dr. G.J. van der Zwaan,
ingevolge het besluit van het college voor promoties in het openbaar te verdedigen
op donderdag 8 december 2011 des middags te 2.30 uur
door
Rob Hurks
geboren 7 januari 1982 te Eindhoven
Promotores
Prof. dr. F.L. Moll
Prof. dr. G. Pasterkamp
Co-promotores
Dr. A. Vink
Dr. M.L. Schermerhorn
Contents
Part 1 | Introduction and study design
1 General introduction 9
2 Historical overview of cardiovascular disease and current biobank concepts 17
Adapted from: F uture Cardiol 2008; 4: 639-49
Thromb Haemost 2009; 101: 48-54
3 Aneurysm-express: human abdominal aortic aneurysm wall expression in 39
relation to heterogeneity and vascular events, rationale and design
Eur Surg Res 2010; 45: 34-40
Part 2 | Inflammation in abdominal aortic aneurysms
4 Osteopontin in the abdominal aortic aneurysm vessel wall predicts adverse 53
cardiovascular outcome
Submitted
5 Osteoprotegerin is associated with aneurysm diameter and proteolysis in 67
abdominal aortic aneurysm disease
Submitted
6 Different effects of commonly prescribed statins on abdominal aortic aneurysm 83
walls
Eur J Vasc Endovasc Surg 2010; 39: 569-76
Part 3 | Heterogeneity of aneurysm expressions
7 Atherosclerotic risk factors, advanced atherosclerotic lesions and postoperative 97
events are associated with low inflammation in abdominal aortic aneurysms
Submitted
8 Circumferential heterogeneity in the abdominal aortic aneurysm wall 113
composition suggests lateral sides to be more rupture prone
J Vasc Surg 2011; Epub ahead of print
9 Wall composition of popliteal artery aneurysms differs from abdominal aortic 129
aneurysms
Submitted
Part 4 | Access type and endovascular aneurysm repair
10 Limited benefit after percutaneous versus femoral cutdown access for 141
endovascular aneurysm repair
Submitted
11 Ultrasound guided percutaneous access endovascular aneurysm repair can be 153
performed routinely with high success and minimal complications
Submitted
Part 5 | Trends in abdominal aortic aneurysm management
12 Vascular surgeons repair an increasing majority of abdominal aortic aneurysms, 167
where volume load changes over time and determines outcome
Submitted
13 Management of small abdominal aortic aneurysms 183
Elsevier - Stanley/ Current Therapy in Vascular and Endovascular Surgery, 5th
ed. In press.
Part 6 | General discussion, summary, and appendix
14 General discussion, summary, and perspectives 195
15 Summary in Dutch - Samenvatting in het Nederlands 209
16 Authors and affiliations 222
Review committee 224
Publications 225
Curriculum vitae
227

General introduction
1
10 | Part 1 Chapter 1
“At 3.30 AM the next morning, I was awoken by an excruciating abdominal pain. I can only
describe its intensity as inhuman, evoking dreaded images of horror films in which the victim
is perforated by an industrial drill.”1 In this excerpt, a physician described the symptoms he
encountered when his abdominal aortic aneurysm (AAA) ruptured. He was lucky to be inside
a hospital at the time with a vascular surgeon on call, which in the end allowed him to write
this narrative afterwards.
Epidemiology and risk factors for AAA development
The existence of AAAs was first described by the sixteenth century Belgian anatomist
Vesalius.2 An aneurysm is defined as a focal dilatation of a blood vessel with respect to the
original or adjacent artery. For the diagnosis of an AAA it is required to have an aortic diameter
of at least one and one-half times the diameter measured at the level of the renal arteries.
Clinically, a diameter exceeding 3 cm is used as a cut-off.3 The incidence of AAA is increasing
in Western Countries4, 5, reaching 4.1% in Dutch men and 0.7% in Dutch women of 55 years
and over.6 During the first decade of this century, 10733 men and 4884 women were recorded
to die from AAA in the Netherlands7, both numbers are hampered by the low number of
postmortem examinations and therefore represent an underestimation. In the US, AAAs are
the 15th leading cause of death in patients 55 years of age and older, and in this age category
9800 patients die annually diagnosed with this disease of whom 6500 die of aneurysm
rupture.8, 9
This number is likely to increase due to aging of the population and increased life expectancy,
and is reported more and more in common press media thereby increasing public awareness.10,
11 The number of diagnosed AAAs will furthermore increase because of the introduction of
screening programs. For instance, the U.S. Preventive Services Task suggested in January
2005 that men between 65 and 75 who have ever smoked be screened for AAA trough a
one-time ultrasound examination.12 The basis for this was a meta-analysis of 4 screening trials,
which showed a protective effect of inviting patients to attend screening for AAA (OR 0.57[0.45-
0.74]) on AAA related mortality in this specific high-risk group of patients.13
Several risk factors for development of AAA exist. The most prominent being tobacco use,
both current and a history of smoking. Interestingly, smoking is associated with AAA in men
2.5 times more frequently than it is with coronary artery disease.14 Other important risk factors
for AAA include male gender, advanced age, atherosclerosis, dyslipidemia and a first degree
relative with an AAA.14-16 Remarkably, in contrast with the strong association with arterial
occlusive disease, diabetes mellitus appears to be protective for AAA development and
progression.15, 17
Rupture risk and (preventive) treatment
AAA rupture carries a great risk for the patient, leading to a community mortality rate of 80%.
For patient reaching the operating room the mortality rate is approximately 50%.18-22 The main
determinant of rupture is AAA size: AAAs with diameters ranging from 3-4 cm have an annual
rupture risk of 0%; 4-5 cm 1%; 5-6 cm 1-11%; 6-7 cm 10-22% and >7 cm AAAs are at a 30-
33% risk of rupture per year.23-25 Other factors that are known to elevate rupture risk include:
rapid expansion, eccentric aneurysm shape, female gender, smoking, hypertension, and
COPD.20, 26-33