A large proportion of patients with small ruptured abdominal aortic aneurysms are women and have chronic obstructive pulmonary disease

Abstract

Objective: In a population-based cohort of ruptured abdominal aortic aneurysms (rAAAs), our aim was to investigate clinical, morphological and biomechanical features in patients with small rAAAs.

Methods: All patients admitted to an emergency department in Stockholm and Gotland, a region with a population of 2.1 million, between 2009-2013 with a CT-verified rupture (n = 192) were included, and morphological measurements were performed. Patients with small rAAAs, maximal diameter (Dmax) ≤ 60 mm were selected (n = 27), and matched 2:1 by Dmax, sex and age to intact AAA (iAAAs). For these patients, morphology including volume and finite element analysis-derived biomechanics were assessed.

Results: The mean Dmax for all rAAAs was 80.8 mm (SD = 18.9 mm), women had smaller Dmax at rupture (73.4 ± 18.4 mm vs 83.1 ± 18.5 mm, p = 0.003), and smaller neck and iliac diameters compared to men. Aortic size index (ASI) was similar between men and women (4.1 ± 3.1 cm/m2 vs 3.8 ± 1.0 cm/m2). Fourteen percent of all patients ruptured at Dmax ≤ 60 mm, and a higher proportion of women compared to men ruptured at Dmax ≤ 60 mm: 27% (12/45) vs. 10% (15/147), p = 0.005. Also, a higher proportion of patients with a chronic obstructive pulmonary disease ruptured at Dmax ≤ 60 mm (34.6% vs 14.6%, p = 0.026). Supra-renal aortic size index (14.0, IQR 13.3-15.3 vs 12.8, IQR = 11.4-14.0) and peak wall rupture index (PWRI, 0.35 ± 0.08 vs 0.43 ± 0.11, p = 0.016) were higher for small rAAAs compared to matched iAAAs. Aortic size index, peak wall stress and aneurysm volume did not differ.

Conclusion: More than one tenth of ruptures occur at smaller diameters, women continuously suffer an even higher risk of presenting with smaller diameters, and this must be considered in surveillance programs. The increased supra-renal aortic size index and PWRI are potential markers for rupture risk, and patients under surveillance with these markers may benefit from increased attention, and potentially from timely repair.

Fig 1. Schematic drawing indicating different centerline-based measurements in the abdominal aortic aneurysms.

A Maximal diameter, B Upper limit of neck, C Supra-renal neck, D alpha angle, E Lower limit of neck, F Common iliac diameter.

Fig 2

(A) Histograms displaying Dmax at rupture for men and women. (B) Bars indicate the proportions among men and women with ruptured abdominal aortic aneurysms according to Dmax.

Fig 3

(A) Maximal aneurysm diameter (Dmax) of rAAAs for men and women. (B) Aortic size index (ASI) of rAAAs for men and women. ASI was available for 130 of 192 patients with CT imaging at rupture.

Fig 4. 3D-morphology of 20 small (Dmax ≤ 60mm) ruptured AAAs in the Stockholm Population based cohort, colors indicate relative diameter.