Abdominal Aorta Aneurysm Screening

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Safety

Authors: Iñaki Imaz, Sonia García-Pérez, Jesús González-Enríquez, Javiera Valdés, Andrés Fernández-Ramos, Carmen Bouza, Antonio Sarría-Santamera

Summary

We searched for studies that could provide us with information on the harms produced by the interventions that result from the implementation of an abdominal aortic aneurysm (AAA) screening programme, which are mainly the ultrasound diagnostic test and the surgical interventions to repair a detected AAA. We found large observational studies that describe the long-term consequences of the surgical repair of non-ruptured AAA. These studies describe large series of data that show what happens to subjects who undergo AAA repair without symptoms of rupture.

The harms include a short term (in-hospital and 30 days after surgery) overall mortality of between 1.15% and 4.8%, and a cumulative overall long-term mortality rate of 36% after 5 years of follow up. It has been reported that, after 8 years of follow up, of the deaths among patients who had an intact AAA repaired by endovascular aneurysm repair (EVAR), 24% were procedure-related and the rest (76%) were not related to surgical repair of the aneurysm.

Complications after intact AAA repairs are also frequent. After 4 years of follow-up, the rates of rupture were 1.8% after EVAR and 0.5% after open aneurysm repair (OAR); and the rate of AAA related interventions was 9% after EVAR and 1.7% after OAR, with 4 years of follow-up. Age, gender, preoperative morbidity, smoking and aneurysm size are relevant risk factors that predict outcomes in the elective AAA repairs that follow the detection of an AAA suitable for repair.

Ultrasonographic scanning is a highly accurate screening method for AAA. Close to 100% sensitivity and specificity values have been reported. The available information about harms indicates no relevant safety issues regarding the accuracy of the test used for AAA screening.

Inconsistent results have been found regarding psychological effects of an AAA screening programme. An appropriate design for measurement of changes in quality of life for participants versus not participants was not identified. Therefore, it is not possible to determine whether screening for AAA affects the health related quality of life among participants.

Relevant factors that can influence the safety profile of the AAA screening performance are hospital volume, surgeon volume, and surgeon´s specialisation in vascular surgery. The implementation of an AAA screening programme can increase the burden on local vascular surgical services by increasing the rate of elective repairs, but the need to operate on emergency ruptures can be reduced.

Introduction

The implementation of an abdominal aortic aneurysm (AAA) screening programme can cause harm to the screened subjects due to the expected increase in the number of detected AAAs (increase of incidence) and consequently in the number of surgical interventions to repair intact or non-ruptured AAAs suitable for repair. We have searched for information on AAA screening programme effects including psychological effects, on the impact of organisational issues on the screening effects and on the validity of the diagnostic tests. A search was focused on the effects produced by the interventions that come from the implementation of an AAA screening programme, which are mainly the surgical interventions to repair a detected AAA. The detection of an intact AAA may lead to a high risk surgical intervention to repair it. These interventions, carried out by EVAR (endovascular aneurysm repair) or OAR (open aneurysm repair), can cause serious harms in terms of mortality, morbidity and psychological effects. Some subjects may suffer early harms, even though the natural history of their AAA would not cause clinical problems during their lifetime.

The objective of this domain has been to describe the most important harms that derive for implement an AAA screening programme according to the available literature. We have considered that this information should come not only from articles that describe the performance of a screening programme but also from articles describing the surgical interventions to repair non-ruptured, elective, eligible, asymptomatic or intact AAAs. These terms are used as synonyms in the literature.

Methodology

Frame

The collection scope is used in this domain.

Technology	AAA Screening Description Population-based systematic abdominal aortic aneurysm (AAA)screening. This includes one single invitation for the whole target population to do one ultrasound scan examination. Purpose of use: Detect abdominal aortic aneurysm in unruptured phase in order to treat those aneurysms with high risk of rupture.
Intended use of the technology	Screening Screening programme for abdominal aortic aneurysm Target condition Abdominal Aorta Aneurysm (AAA) Target condition description All men and women aged 64 or more Target population Target population sex: Any. Target population age: elderly. Target population group: Possible future health condition. Target population description All men and women aged 64 or more For: All men and women aged 64 or more. There is some international variance in the prevalence of AAA. In the western countries the prevalence varies between 5 to 10 % for the 65 – 74 years old men. In Japan the prevalence is 1 % for the same group of men. The prevalence increases with age. In England the prevalence is 2 % for men aged 50 – 64 year and 12 % for men aged 80 years or older. In Denmark the prevalence is 4 % for men aged 65 – 69 and 6 % for men aged 70 – 74 years old. The prevalence for women is significant lower than the prevalence for men.
Comparison	not doing anything Description No population-based AAA screening. This includes incidental detection of AAA without age or sex limitation while performing abdominal ultrasound examinations due to other/unclear clinical indications and various opportunistic AAA-screening practices

Assessment elements

	Topic	Issue	Relevant	Research questions or rationale for irrelevance
C0001	Patient safety	What kind of harms can use of the technology cause to the patient; what are the incidence, severity and duration of harms?	yes	What harms can Screening for AAA cause to the screened subjects and what are the characteristics of the harms?
C0005	Patient safety	Are there susceptible patient groups that are more likely to be harmed through use of the technology?	yes	Are there susceptible participant groups that are more likely to be harmed through use of the technology?
C0006	Patient safety	What are the consequences of false positive, false negative and incidental findings brought about using the technology to the patients from the viewpoint of patient safety?	yes	What are the consequences of false positive, false negative and incidental findings brought about using Screening for AAA from the viewpoint of safety?
C0029	Patient safety	Does the existence of harms influence tolerability or acceptability of the technology?	yes	Does the existence of harms influence tolerability or acceptability of Abdominal Aorta Aneurysm Screening?
C0007	Patient safety	What are the special features in using (applying/interpreting/maintaining) the technology that may increase the risk of harmful events?	yes	What are the special features in using (applying/interpreting/maintaining) Screening for AAA that may increase safety risks?
C0002	Patient safety	What is the dose relatedness of the harms to patients?	no	This screening programme doesn't include different doses of intervention. The effects of diferent kind of Screening programmes will be assessed in the COO60 element of this domain.
C0003	Patient safety	What is the timing of onset of harms to patients: immediate, early or late?	no	A precise description of harms, including their timing, will be included in the COOO1 element within this domain.
C0004	Patient safety	Is the incidence of the harms to patients likely to change over time?	no	Changes over time dependant on the experience or learning curve performing the Screening Programme (i.e.: surgical interventions, diagnostic test, organizational issues) will be included in the C0007 element within this domain.
C0008	Patient safety	What is the safety of the technology in comparison to alternative technologies used for the same purpose?	no	Considering that mortality is the most relevant indicator to answer this question and that a comparison of mortality between screening and no screening is going to be provided in the “Clinical Effectiveness” domain (EFF1, EFF2, EFF3, EFF4, EFF24 questions), we consider this question already included in other Assessment Elements.
C0060	Safety risk management	How does the safety profile of the technology vary between different generations, approved versions or products?	yes	How does the safety profile of the technology vary between different kind of Screening programmes?
C0061	Safety risk management	Is there evidence that harms increase or decrease in different organizational settings?	yes	Is there evidence that harms increase or decrease in different organizational settings?
C0062	Safety risk management	How can one reduce safety risks for patients (including technology-, user-, and patient-dependent aspects)?	yes	How can one reduce safety risks for screened subjects?
C0063	Safety risk management	How can one reduce safety risks for professionals (including technology-, user-, and patient-dependent aspects)?	no	The introduction of a new health-care programme can affect organizations, including the health of their professionals. Those effects depend on the balance between new resources / new requirements allocated to the organization and how the organizations implement them. We have judged this issue irrelevant because it can be dealt with in a more coherent manner within the organizational domain.
C0064	Safety risk management	How can one reduce safety risks for environment (including technology-, user-, and patient-dependent aspects)?	no	The procedures included in this screening programme don't cause relevant environmental risks.
C0020	Occupational safety	What kind of occupational harms can occur when using the technology?	no	The introduction of a new health-care programme can affect organizations, including the health of their professionals. Those effects depend on the balance between new resources / new requirements allocated to the organization and how the organizations implement them. We have judged this issue irrelevant because it can be dealt with in a more coherent manner within the organizational domain.
C0040	Environmental safety	What kind of risks for public and environment may occur when using the technology?	no	The procedures included in this screening programme don't cause relevant risks for public or environmental. Anyway, a precise description of harms will be included in the COOO1 element within this domain.

Methodology description

Information sources and selection criteria

In addition to the general bibliographic searches that were done for the whole project (Core HTA), four specific searches on Medline using OVID and Embase were also performed. The searches were limited to articles published after the year 1999. All the searches were done in June 2011.

The first search sought articles about harms and risks of AAA screening, including psychological aspects and test validity. Inclusion criteria:

• Population-based systematic AAA screening that includes one single invitation for men and/or women aged 64 or over to do one ultrasound scan examination
• OR opportunistic abdominal aneurysm screening suggested by the general practitioner for population at risk: smokers, apoplexy, arteriosclerosis, hypertension or chronic obstructive pulmonary disease (COPD)
• AND describing harms associated with AAA screening including the psychological aspects, and ultrasonographic test validity.

The second search focused on effectiveness and adverse effects of AAA treatment, including open surgery and endovascular repair. Inclusion criteria:

• Men and/or women aged 65 with non-ruptured AAA
• AND AAA repair performed by open or endovascular surgery
• AND describing harms, adverse effects and effectiveness of the AAA treatment.

The third search sought clinical trials and systematic reviews about health related effects of AAA screening. Inclusion criteria:

• Population-based systematic AAA screening that includes one single invitation for men and/or women aged 64 or over to do one ultrasound scan examination
• OR opportunistic abdominal aneurysm screening suggested by the general practitioner for population at risk: smokers, apoplexy, arteriosclerosis, hypertension or COPD
• AND describing health related outcomes of screening AAA
• AND randomised clinical trials or systematic review studies

The fourth search sought articles about the relationship between outcomes of AAA repair and characteristics of the health centre, surgeon and surgery team. Inclusion criteria:

• Men and/or women aged 65 with non-ruptured AAA
• AND AAA repair performed by open or endovascular surgery
• AND describing the relationship between surgeon’s experience, surgery team’s experience, centre’s characteristics and risks and benefits of AAA surgical repair.

We retrieved also information from the general bibliographic searches that were done for the whole project (Core HTA for AAA Screening), and from other searches on the Cochrane and INAHTA databases, and from the references of the retrieved articles.

After reading the abstracts a list of 126 non-duplicated studies was available. The full texts of all of these articles were read and 52 of them were selected based on the inclusion criteria. The flow chart of the literature screening and selection process is shown in the figure {SAF Figure 1}.

The template for study characteristics table (16 November 2011 version) that is proposed in the online tools was used to extract data from the articles. Individual tables of the included articles are available upon request.

Detailed methodology of the literature search, selection process and data extraction is available in {Appendix SAF-1}.

Result cards

Patient safety

Safety risk management

Discussion

The rationale for the screening is that early detection and treatment of asymptomatic AAA should extend life or improve quality of life compared with treatment at the time of symptomatic clinical diagnosis. However, the safety domain is focused on a description of the harms but not on the estimation of the effect of population-based AAA screening. To estimate the effect of the screening a comparison against a similar population must be done. This has not been the objective of our investigation given that the effectiveness domain covers those objectives.

Important sources of information for this domain have been large observational studies that describe what happens to patients who undergo the proposed intervention following screening within the programme. We have identified serious consequences for intact AAA repair in terms of mortality and morbidity and psychological effects.

Adverse events are variably and sometimes poor reported in randomised controlled trials {38,39}. We have identified real-world data from large observational studies describing the effect of the surgical repair of intact AAAs. We have found this information useful for estimating what might happen in a hypothetic situation if a screening programme was implemented in a European scenario. The implementation of an AAA screening programme in Europe would result in a high number of high-risk surgical interventions done in different kinds of healthcare systems, in different hospitals with different surgeons and to different patients.

The evidence table template for extracting data proposed in the online tool has been used. However, we found this template more oriented to clinical trials than observational studies. We did not find the assessment criteria proposed in that template completely applicable for our set of studies. The variability between methods and designs among our selected studies made it difficult to apply a systematic system for grading the evidence.

References

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11. Chong T, Nguyen L, Owens CD, Conte MS, Belkin M. Suprarenal aortic cross-clamp position: a reappraisal of its effects on outcomes for open abdominal aortic aneurysm repair. J Vasc Surg 2009; 49(4):873-880.
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13. McPhee JT, Hill JS, Eslami MH. The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004. J Vasc Surg 2007; 45(5):891-899.
14. Walschot LHB. Outcome after endovascular abdominal aortic aneurysm repair: A meta-analysis. J Endovasc Ther 2002; 9(1):82-89.
15. Forbes TL, Lawlor DK, DeRose G, Harris KA. Gender differences in relative dilatation of abdominal aortic aneurysms. Ann Vasc Surg 2006; 20(5):564-568.
16. Mastracci TM, Cina CS. Screening for abdominal aortic aneurysm in Canada: review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg 2007; 45(6):1268-1276.
17. Brady AR, Fowkes FG, Greenhalgh RM, Powell JT, Ruckley CV, Thompson SG. Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 2000; 87(6):742-749.
18. Egorova N, Giacovelli J, Gelijns A, Greco G, Moskowitz A, McKinsey J et al. Defining high-risk patients for endovascular aneurysm repair. J Vasc Surg 2009; 50(6):1271-1279.
19. Wilmink AB, Forshaw M, Quick CR, Hubbard CS, Day NE, Wilmink ABM et al. Accuracy of serial screening for abdominal aortic aneurysms by ultrasound. J Med Screen 2002; 9(3):125-127.
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22. Singh K, Jacobsen BK, Solberg S, Kumar S, Arnesen E. The difference between ultrasound and computed tomography (CT) measurements of aortic diameter increases with aortic diameter: analysis of axial images of abdominal aortic and common iliac artery diameter in normal and aneurysmal aortas. The Tromso Study, 1994-1995. Eur J Vasc Endovasc Surg 2004; 28(2):158-167.
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24. Holt PJE. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg 2007; 94(4):395-403.
25. Young EL, Holt PJ, Poloniecki JD, Loftus IM, Thompson MM, Young EL et al. Meta-analysis and systematic review of the relationship between surgeon annual caseload and mortality for elective open abdominal aortic aneurysm repairs. J Vasc Surg 2007; 46(6):1287-1294.
26. McPhee JT, Robinson WP, III, Eslami MH, Arous EJ, Messina LM, Schanzer A et al. Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair. J Vasc Surg 2011; 53(3):591-599.
27. Dimick JB, Cowan JA, Jr., Stanley JC, Henke PK, Pronovost PJ, Upchurch GR, Jr. Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States. J Vasc Surg 2003; 38(4):739-744.
28. Pearce WH, Parker MA, Feinglass J, Ujiki M, Manheim LM. The importance of surgeon volume and training in outcomes for vascular surgical procedures. J Vasc Surg 1999; 29(5):768-776.
29. Tu JV, Austin PC, Johnston KW, Tu JV, Austin PC, Johnston KW. The influence of surgical specialty training on the outcomes of elective abdominal aortic aneurysm surgery. J Vasc Surg 2001; 33(3):447-452.
30. Thompson SG, Ashton HA, Gao L, Scott RA, Multicentre Aneurysm Screening Study Group., Thompson SG et al. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 2009; 338:b2307.
31. Jamrozik K, Norman PE, Spencer CA, Parsons RW, Tuohy R, Lawrence-Brown MM et al. Screening for abdominal aortic aneurysm: lessons from a population-based study. Med J Aust 2000; 173(7):345-350.
32. Lindholt JS, Juul S, Henneberg EW, Fasting H. Is screening for abdominal aortic aneurysm acceptable to the population? Selection and recruitment to hospital-based mass screening for abdominal aortic aneurysm. J Public Health Med 1998; 20(2):211-217.
33. Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study. Br J Surg 1995; 82(8):1066-1070.
34. Jepson R, Clegg A, Forbes C, Lewis R, Sowden A, Kleijnen J. The determinants of screening uptake and interventions for increasing uptake: a systematic review. Health Technol Assess 2000; 4(14):i-133.
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Appendices

Appendix SAF-1 Safety domain specific search.

The following searches have been performed:

1. FIRST SEARCH

Search about harms and risks of AAA screening, including psychological aspects.

2. SECOND SEARCH

Search about effectiveness and adverse effects of AAA treatment, including open surgery and endovascular repair.

3. THIRD SEARCH

Search of clinical trials and systematic reviews about health related effects of AAA screening

4. FOURTH SEARCH

Search about the relation between Health Centre’s, surgeon’s and surgery team characteristics and risks and benefits of AAA repair.

The flow chart on the literature screen and selection process is included in the domain methodology section {SAF Figure 1}.

The first Medline search retrieved 144 references, 15 of them were selected after abstract screening and deletion of duplicates. The first Embase search retrieved 116 references, 4 of them were selected after abstract screening and deletion of duplicates.

The second Medline search retrieved 67 references, 40 of them were selected after abstract screening and deletion of duplicates. The second Embase search retrieved 22 references, 14 of them were selected after abstract screening and deletion of duplicates.

The third Medline search retrieved 88 references, 26 of them were selected after abstract screening and deletion of duplicates. The third Embase search retrieved 93 references, 3 of them were selected after abstract screening and deletion of duplicates.

The fourth Medline search retrieved 131 references, 28 of them were selected after abstract screening and deletion of duplicates. The fourth Embase search retrieved 40 references, 2 of them were selected after abstract screening and deletion of duplicates.

More references were retrieved and selected from other sources of information through searches on Cochrane, INAHTA databases, references from the articles retrieved and others sources.

After merging all of these sources of information a list of 126 non-duplicated  studies was available. The full texts of all of these articles were read by investigators of the domain, namely JGE, SGP, II, CA and CB. After reading all these articles 52 were selected because they met the inclusion criteria. The template for study characteristics table (version Nov 16 2011) that is proposed in the online tools was used to extract data from the articles. Individual tables of the articles are available upon request.

1. FIRST SEARCH

Search about harms and risks of AAA screening, including psychological aspects and test validity.

Inclusion criteria:

• Population-based systematic AAA screening that includes one single invitation for men and/or women aged 64 or over to do one ultrasound scan examination OR
• An opportunistic abdominal aneurysm screening suggested by the general practitioner for population at risk: smokers, apoplexy, arteriosclerosis, hypertension or COPD.
• AND describing harms associated with AAA screening including the psychological aspect.

Name of the database or link/reference to other source: MEDLINE via OVID

Search string or search terms:

1. Stress, psychological.sh .
2. Anxiety.sh .
3. (anxiety or anxious*) .ab.ti.
4. Depression.sh .
5. Depressive disorder .sh .
6. depress*.ab.ti.
7. harm* .ab.ti.
8. adverse effect* .ab.ti .
9. “Risk Assessment”
10. “Predictive Value of Tests”
11. “Attitude to Health”
12. “Psychiatric Status Rating Scales”
13. “Health Status”
14. “Health Status Indicators”
15. “Severity of Illness Index”
16. “Quality of Life”
17. false positive reactions.sh .
18. false negative reactions .sh .
19. or/1–18
20. aortic aneurysm, abdominal .sh .
21. mass screening.sh .
22. screen* .ab.ti
23. or/21–22
24. 20 and 23
25. 24 and 19
26. Limits: Humans, Publication Date from 2000-current

Date of search 15/06/2011

Name and affiliation of person who performed the search: Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 144

Abstract screen:

Number included 15

Name of the database or link/reference to other source: EMBASE

Search string or search terms

1. stress/
2. anxiety/
3. (anxiety or anxious*).ti,ab.
4. depression/
5. "depress*".ti,ab.
6. "adverse effect*".ti,ab.
7. risk assessment/
8. predictive value/
9. attitude to health/
10. psychological rating scale/
11. health status/
12. hospitalization/
13. "quality of life"/
14. laboratory diagnosis/
15. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14
16. abdominal aorta aneurysm/
17. mass screening/
18. "screen*".ti,ab.
19. 17 or 18
20. 16 and 19
21. 15 and 20
22. limit 21 to (human and yr="2000 -Current")

Date of search 23/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 116

Abstract screen:

Number included 4

Total selection for the first search after deletion of duplicates: 19 studies

2. SECOND SEARCH

Search about effectiveness and adverse effects of AAA treatment, including open surgery and endovascular repair.

Inclusion criteria:

• Men and/or women aged 65 with non-ruptured AAA AND
• AAA repair performed by open or endovascular surgery over AND
• Describing harms, adverse effects and effectiveness of the AAA treatment.

Name of the database or link/reference to other source MEDLINE via OVID.

Search string or search terms

1. safety management (MeSH) OR adverse effects.fs.
2. "safety".ab.ti.tw.
3. "adverse events".ab.ti.tw.
4. 1 AND ( 2 or 3)
5. ((Blood vessel prosthesis/ OR Blood vessel prosthesis implantation/ OR (endovascular repair.mp. OR evar.mp. OR Stents/) OR (vascular surgical procedures/ OR open surgery.mp.))
6. (aortic aneurysm, abdominal).sh.
7. 4 AND 5
8. 7 AND 6
9. limit 8 to humans and published 2000-current, (case reports or classical article or clinical trial, all or comparative study or controlled clinical trial or "corrected and republished article" or evaluation studies or introductory journal article or journal article or meta analysis or multicenter study or randomized controlled trial or "review" or "scientific integrity review" or technical report or validation studies)

Date of search 23/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 67

Abstract screen:

Number included 40

Name of the database or link/reference to other source EMBASE

Search string or search terms

1. safety/
2. adverse drug reaction/ or adverse outcome/
3. 1 or 2
4. blood vessel prosthesis/ or blood vessel transplantation/
5. interventional cardiovascular procedure/
6. vascular surgery/
7. abdominal aorta aneurysm/
8. 3 or 4 or 5 or 6
9. 7 and 8
10. limit 9 to (human and (evidence based medicine or meta analysis or outcomes research or "systematic review") and (clinical trial or randomized controlled trial or controlled clinical trial or multicenter study) and yr="2000 -Current" and (article or journal or report or "review" or short survey))

Date of search 23/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 22

Abstract screen:

Number included 14

Total selection for the second search after deletion of duplicates: 54 studies

3. THIRD SEARCH

Search of clinical trials and systematic reviews about health related effects of AAA screening

Inclusion criteria:

Clinical trials or systematic review studies about:

• Population-based systematic AAA screening that includes one single invitation for men and/or women aged 64 or over to do one ultrasound scan examination OR
• An opportunistic abdominal aneurysm screening suggested by the general practitioner for population at risk: smokers, apoplexy, arteriosclerosis, hypertension or COPD.
• AND describing health related outcomes of screening AAA.

Name of the database or link/reference to other source : MEDLINE via OVID

Search string or search terms

1. controlled clinical trials.sh .
2. 2. randomized controlled trials.sh.
3. multicenter studies.sh.
4. 4. double-blind method .sh.
5. meta-analysis.sh.
6. random allocation .sh.
7. 7. single-blind method.sh .
8. controlled clinical trial. pt.
9. meta analysis.pt .
10. randomized controlled trial. pt.
11. ( meta analy* OR metaanaly*) .ab.ti
12. ( systematic* review* OR systematic* overview*).ab.ti.
13. (quantitative* review* OR quantitative* overview*).ab.ti.
14. evidence based review*.ab.ti.
15. or/1-14
16. Aortic aneurysm, abdominal .sh.
17. 15 AND 16
18. mass screening.sh.
19. screen*.ab.ti.
20. 17 AND (18 OR 19)
21. 21. Limits: Humans, Publication Date from 2000-current

Date of search 13/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 88

Abstract screen:

Number included 26

Name of the database or link/reference to other source: EMBASE

Search string or search terms

1. controlled clinical trial/
2. randomized controlled trial/
3. multicenter study/
4. double blind procedure/
5. meta analysis/
6. randomization/
7. single blind procedure/
8. (meta analy* or mataanaly*).ti,ab.
9. (systematic* review* or systematic* overview*).ti,ab.
10. (quantitative* review* or quantitative* overview*).ti,ab.
11. "evidence based review*".ti,ab.
12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11
13. abdominal aorta aneurysm/
14. 12 and 13
15. mass screening/
16. "scree*".ti,ab.
17. 15 or 16
18. 14 and 17
19. limit 18 to (human and yr="2000 -Current")

Date of search 13/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 93

Abstract screen:

Number included 3

Total selection for the third search after deletion of duplicates: 29

4. FOURTH SEARCH

Search about the relation between Health Centre’s, surgeon’s and surgery team characteristics and risks and benefits of AAA repair.

Inclusion criteria:

-

Name of the database or link/reference to other source MEDLINE via OVID

Search string or search terms

1. learning curve.sh.
2. "outcome and process assessment health care" .sh.
3. clinical competence.sh.
4. "standard of care".sh.
5. health resources.sh.
6. aortic aneurysm, abdominal.sh.
7. 1 or 2 or 3 or 4 or 5
8. 6 and 7
9. limit 8 to humans and published 2000-current, (case reports or classical article or clinical trial, all or comparative study or controlled clinical trial or "corrected and republished article" or evaluation studies or introductory journal article or journal article or meta analysis or multicenter study or randomized controlled trial or "review" or "scientific integrity review" or technical report or validation studies)

Date of search 23/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 131

Abstract screen:

Number included 28

Name of the database or link/reference to other source EMBASE

Search string or search terms

1. learning curve/
2. treatment outcome/
3. clinical competence/
4. health care planning/
5. abdominal aorta aneurysm/
6. 1 or 2 or 3 or 4
7. 5 and 6
8. limit 7 to (human and (evidence based medicine or meta analysis or outcomes research or "systematic review") and (clinical trial or randomized controlled trial or controlled clinical trial or multicenter study) and yr="2000 -Current" and (article or journal or report or "review" or short survey))

Date of search 23/06/2011

Name and affiliation of person who performed the search Javiera Valdés. AETS ISCIII.

Selection of studies

Number of references retrieved: 40

Abstract screen:

Number included 2

Total selection for the third search after deletion of duplicates: 30

LIST OF INCLUDED ARTICLES:

(1) Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002; 360(9345):1531-1539.

(2) Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA et al. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg 2007; 94(6):696-701.

(3) Beales L, Wolstenhulme S, Evans JA, West R, Scott DJ. Reproducibility of ultrasound measurement of the abdominal aorta. Br J Surg 2011; 98(11):1517-1525.

(4) Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011; 53(5):1167-1173.

(5) Brady AR, Fowkes FG, Greenhalgh RM, Powell JT, Ruckley CV, Thompson SG. Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 2000; 87(6):742-749.

(6) Chong T, Nguyen L, Owens CD, Conte MS, Belkin M. Suprarenal aortic cross-clamp position: a reappraisal of its effects on outcomes for open abdominal aortic aneurysm repair. J Vasc Surg 2009; 49(4):873-880.

(7) Coselli JS, Bozinovski J, LeMaire SA, Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg 2007; 83(2):S862-S864.

(8) Couto E, Duffy SW, Ashton HA, Walker NM, Myles JP, Scott RA et al. Probabilities of progression of aortic aneurysms: estimates and implications for screening policy. J Med Screen 2002; 9(1):40-42.

(9) Dimick JB, Stanley JC, Axelrod DA, Kazmers A,Henke PK, Jacobs LA et al. Variation in death rate after abdominal aortic aneurysmectomy in theUnited States: impact of hospital volume, gender, and age. Ann Surg 2002; 235(4):579-585.

(10) Dimick JB, Cowan JA, Jr., Stanley JC, Henke PK, Pronovost PJ, Upchurch GR, Jr. Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States. J Vasc Surg 2003; 38(4):739-744.

(11) Dimick JB, Upchurch GR, Jr. Endovascular technology, hospital volume, and mortality with abdominal aortic aneurysm surgery. J Vasc Surg 2008; 47(6):1150-1154.

(12) Egorova N, Giacovelli J, Gelijns A, Greco G, Moskowitz A, McKinsey J et al. Defining high-risk patients for endovascular aneurysm repair. J Vasc Surg 2009; 50(6):1271-1279.

(13) Holt PJ, Poloniecki JD, Hofman D, Hinchliffe RJ, Loftus IM, Thompson MM et al. Re-interventions, readmissions and discharge destination: modern metrics for the assessment of the quality of care. Eur J Vasc Endovasc Surg 2010; 39(1):49-54.

(14) Holt PJE. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg 2007; 94(4):395-403.

(15) Jamrozik K, Norman PE, Spencer CA, Parsons RW, Tuohy R, Lawrence-Brown MM et al. Screening for abdominal aortic aneurysm: lessons from a population-based study. Med J Aust 2000; 173(7):345-350.

(16) Jetty P, Hebert P, van Walraven C. Long-term outcomes and resource utilization of endovascular versus open repair of abdominal aortic aneurysms inOntario. J Vasc Surg 2010; 51(3):577-583.

(17) Jibawi A, Hanafy M, Guy A. Is there a minimum caseload that achieves acceptable operative mortality in abdominal aortic aneurysm operations? Eur J Vasc Endovasc Surg 2006; 32(3):273-276.

(18) Jim J, Rubin BG, Geraghty PJ, Criado FJ,Sanchez LA.Outcome of endovascular repair of small and large abdominal aortic aneurysms. Ann Vasc Surg 2011; 25(3):306-314.

(19) Kibbe MR, Matsumura JS, Excluder I. The Gore Excluder US multi-center trial: analysis of adverse events at 2 years. Semin Vasc Surg 2003; 16(2):144-150.

(20) Kim LG, Scott RA, Thompson SG, Collin J, Morris GE, Sutton GL et al. Implications of screening for abdominal aortic aneurysms on surgical workload. Br J Surg 2005; 92(2):171-176.

(21) Kim LG, RA PS, Ashton HA, Thompson SG, Multicentre Aneurysm Screening Study Group., Kim LG et al. A sustained mortality benefit from screening for abdominal aortic aneurysm.[Erratum appears in Ann Intern Med. 2007 Aug 7;147(3):216]. Ann Intern Med 2007; 146(10):699-706.

(22) Laheij RJ, van Marrewijk CJ, Buth J,Harris PL, EUROSTAR c. The influence of team experience on outcomes of endovascular stenting of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2002; 24(2):128-133.

(23) Lederle FA, Johnson GR, Wilson SE, Acher CW, Ballard DJ, Littooy FN et al. Quality of life, impotence, and activity level in a randomized trial of immediate repair versus surveillance of small abdominal aortic aneurysm. J Vasc Surg 2003; 38(4):745-752.

(24) Lederle FA, Kane RL, MacDonald R, Wilt TJ. Systematic review: repair of unruptured abdominal aortic aneurysm. Ann Intern Med 2007; 146(10):735-741.

(25) Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Jr., Matsumura JS, Kohler TR et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009; 302(14):1535-1542.

(26) Lee WA, Carter JW, Upchurch G, Seeger JM, Huber TS. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in theUnited Statesduring 2001. Journal of Vascular Surgery 39[3], 491-496. 1-3-2004.

(27) Lindholt JS, Juul S, Henneberg EW, Fasting H. Is screening for abdominal aortic aneurysm acceptable to the population? Selection and recruitment to hospital-based mass screening for abdominal aortic aneurysm. J Public Health Med 1998; 20(2):211-217.

(28) Lindholt JS, Vammen S, Juul S, Henneberg EW, Fasting H. The validity of ultrasonographic scanning as screening method for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 1999; 17(6):472-475.

(29) Lindholt JS, Vammen S, Fasting H, Henneberg EW. Psychological consequences of screening for abdominal aortic aneurysm and conservative treatment of small abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2000; 20(1):79-83.

(30) Lovegrove REJ. A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm. The British journal of surgery 2008; 95(6):677-684.

(31) Lucarotti ME, Heather BP, Shaw E, Poskitt KR. Psychological morbidity associated with abdominal aortic aneurysm screening. Eur J Vasc Endovasc Surg 1997; 14(6):499-501.

(32) Maher MMM. Abdominal aortic aneurysms: Elective endovascular repair versus conventional surgery - Evaluation with evidence-based medicine techniques. Radiology 2003; 228(3):647-658.

(33) Marteau TM, Kim LG, Upton J, Thompson SG, Scott AP, Marteau TM et al. Poorer self assessed health in a prospective study of men with screen detected abdominal aortic aneurysm: a predictor or a consequence of screening outcome? J Epidemiol Community Health 2004; 58(12):1042-1046.

(34) McPhee J, Eslami MH, Arous EJ, Messina LM, Schanzer A. Endovascular treatment of ruptured abdominal aortic aneurysms in theUnited States(2001-2006): a significant survival benefit over open repair is independently associated with increased institutional volume. J Vasc Surg 2009; 49(4):817-826.

(35) McPhee JT, Robinson WP, III, Eslami MH, Arous EJ, Messina LM, Schanzer A et al. Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair. J Vasc Surg 2011; 53(3):591-599.

(36) McPhee JT, Hill JS, Eslami MH. The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004. J Vasc Surg 2007; 45(5):891-899.

(37) Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A et al. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg 2006; 43(2):205-216.

(38) Polo-De Santos M, Luengo-Matos S, Munoz-Navarro B, Saz-Parkinson Z. Results from the monitoring use programme for endovascular repair of abdominal aortic aneurysms in Spain. Int Angiol 2009; 28(3):181-191.

(39) Prinssen M, Buskens E, Nolthenius RP, van Sterkenburg SM, Teijink JA, Blankensteijn JD. Sexual dysfunction after conventional and endovascular AAA repair: results of the DREAM trial. J Endovasc Ther 2004; 11(6):613-620.

(40) Schermerhorn ML, O'Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358(5):464-474.

(41) Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study. Br J Surg 1995; 82(8):1066-1070.

(42) Scott RA, Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA et al. The long-term benefits of a single scan for abdominal aortic aneurysm (AAA) at age 65. Eur J Vasc Endovasc Surg 2001; 21(6):535-540.

(43) Scott RA,BridgewaterSG, Ashton HA. Randomized clinical trial of screening for abdominal aortic aneurysm in women. Br J Surg 2002; 89(3):283-285.

(44) Spencer CA,NormanPE, Jamrozik K, Tuohy R, Lawrence-Brown M, Spencer CA et al. Is screening for abdominal aortic aneurysm bad for your health and well-being? ANZ J Surg 2004; 74(12):1069-1075.

(45) TheUKSmall Aneurysm Trial Participants. Long-Term Outcomes of Immediate Repair Compared with Surveillance of Small Abdominal Aortic Aneurysms. N Engl J Med 2002; 346(19):1445-1452.

(46) Thomas SM, Beard JD,IrelandM, Ayers S, Vascular Society ofGreat BritainandIreland, British Society of Interventional Radiology. et al. Results from the prospective registry of endovascular treatment of abdominal aortic aneurysms (RETA): mid term results to five years. Eur J Vasc Endovasc Surg 2005; 29(6):563-570.

(47) Thompson SG, Ashton HA, Gao L, Scott RA, Multicentre Aneurysm Screening Study Group., Thompson SG et al. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 2009; 338:b2307.

(48) Tu JV,AustinPC, Johnston KW, Tu JV, Austin PC, Johnston KW. The influence of surgical specialty training on the outcomes of elective abdominal aortic aneurysm surgery. J Vasc Surg 2001; 33(3):447-452.

(49) van Marrewijk CJ, Leurs LJ, Vallabhaneni SR,Harris PL, Buth J, Laheij RJ et al. Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair in a large population: how do stent-grafts compare? J Endovasc Ther 2005; 12(4):417-429.

(50) Vardulaki KA, Walker NM, Couto E, Day NE, Thompson SG, Ashton HA et al. Late results concerning feasibility and compliance from a randomized trial of ultrasonographic screening for abdominal aortic aneurysm. Br J Surg 2002; 89(7):861-864.

(51) Walschot LHB. Outcome after endovascular abdominal aortic aneurysm repair: A meta-analysis. J Endovasc Ther 2002; 9(1):82-89.

(52) Wilmink AB, Forshaw M, Quick CR, Hubbard CS, Day NE, Wilmink ABM et al. Accuracy of serial screening for abdominal aortic aneurysms by ultrasound. J Med Screen 2002; 9(3):125-127.

LIST OF EXCLUDED ARTICLES:

(1)Abbruzzese TA, Kwolek CJ, Brewster DC, Chung TK, Kang J, Conrad MF et al. Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): an anatomic and device-specific analysis. J Vasc Surg 2008; 48(1):19-28.

(2)Abularrage CJ, Sheridan MJ, Mukherjee D, Abularrage CJ, Sheridan MJ, Mukherjee D. Endovascular versus "fast-track'' abdominal aortic aneurysm repair. Vasc Endovascular Surg 2005; 39(3):229-236.

(3)Alonso-Perez M, Segura RJ, Sanchez J, Sicard G, Barreiro A, Garcia M et al. Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms. Ann Vasc Surg 2001; 15(6):601-607.

(4)Becker GJ, Kovacs M, Mathison MN, Katzen BT, Benenati JF, Zemel G et al. Risk stratification and outcomes of transluminal endografting for abdominal aortic aneurysm: 7-year experience and long-term follow-up. J Vasc Interv Radiol 2001; 12(9):1033-1046.

(5)Becquemin JP, Allaire E, Desgranges P, Kobeiter H, Becquemin JP, Allaire E et al. Delayed complications following EVAR. Tech Vasc Interv Radiol 2005; 8(1):30-40.

(6)Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, van Sterkenburg SM et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005; 352(23):2398-2405.

(7)Bosch JLK. Abdominal aortic aneurysms: Cost-effectiveness of elective endovascular and open surgical repair. Radiology 2002; 225(2):337-344.

(8)Bown MJS. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg 2002; 89(6):714-730.

(9)Buth J, Laheij RJ, Buth J, Laheij RJ. Early complications and endoleaks after endovascular abdominal aortic aneurysm repair: report of a multicenter study. J Vasc Surg 2000; 31(1 Pt1):134-146.

(10) Cau JR. Total Laparoscopic Aortic Repair for Occlusive and Aneurysmal Disease: First 95 Cases. Eur J Vasc Endovasc Surg 2006; 31(6):567-574.

(11) Chaikof EL, Chaikof EL. Caring for patients with an abdominal aortic aneurysm: data, knowledge, and wisdom. J Vasc Surg 2009; 50(4 Suppl):S1.

(12) Cho JS, Kim JY, Rhee RY, Gupta N, Marone LK, Dillavou ED et al. Contemporary results of open repair of ruptured abdominal aorto-iliac aneurysms: effect of surgeon volume on mortality. J Vasc Surg 2008; 48(1):10-17.

(13) Cuypers PW, Gardien M, Buth J, Charbon J, Peels CH, Hop W et al. Cardiac response and complications during endovascular repair of abdominal aortic aneurysms: a concurrent comparison with open surgery. J Vasc Surg 2001; 33(2):353-360.

(14) Davenport DL, O'Keeffe SD, Minion DJ, Sorial EE, Endean ED, Xenos ES et al. Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2010; 51(2):305-309.

(15) De Rango PC. Outcome after Endografting in Small and Large Abdominal Aortic Aneurysms: A Metanalysis. Eur J Vasc Endovasc Surg 2008; 35(2):162-172.

(16) Dzieciuchowicz L, Majewski W, Slowinski M, Krasinski Z, Jawien AA, Bieda K et al. Improved outcome after rupture of abdominal aortic aneurysm over an 18-year period. Ann Vasc Surg 2008; 22(1):25-29.

(17) Eckstein HH, Bockler D, Flessenkamper I, Schmitz-Rixen T, Debus S, Lang W et al. Ultrasonographic screening for the detection of abdominal aortic aneurysms. Dtsch 2009; 106(41):657-663.

(18) Enzler MA, van Marrewijk CJ, Buth J, Harris PL, Enzler MA, van Marrewijk CJ et al. [Endovascular therapy of aneurysms of the abdominal aorta: report of 4,291 patients of the Eurostar Register]. [German]. Vasa 2002; 31(3):167-172.

(19) Fassiadis NR. Is screening of abdominal aortic aneurysm effective in a general practice setting? International Angiology 2005;24(2):185-8.

(20) Flu WJ, van Kuijk JP, Merks EJ, Kuiper R, Verhagen HJ, Bosch JG et al. Screening for abdominal aortic aneurysms using a dedicated portable ultrasound system: early results. Eur J Echocardiogr 2009; 10(5):602-606.

(21) Forbes TL, DeRose G, Kribs SW, Harris KA, Forbes TL, DeRose G et al. Cumulative sum failure analysis of the learning curve with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004; 39(1):102-108.

(22) Forbes TL, DeRose G, Lawlor DK, Harris KA, Forbes TL, DeRose G et al. The association between a surgeon's learning curve with endovascular aortic aneurysm repair and previous institutional experience. Vasc Endovascular Surg 2007; 41(1):14-18.

(23) Giles KA, Hamdan AD, Pomposelli FB, Wyers MC, Dahlberg SE, Schermerhorn ML et al. Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms. J Endovasc Ther 2009; 16(5):554-564.

(24) Greenberg R, Zenith I, Greenberg R, Zenith I. The Zenith AAA endovascular graft for abdominal aortic aneurysms: clinical update. Semin Vasc Surg 2003; 16(2):151-157.

(25) Hamerlynck JV, Legemate DA, Hooft L, Hamerlynck JVTH, Legemate DA, Hooft L. [From the Cochrane Library: ultrasonographic screening for abdominal aortic aneurysm in men aged 65 years and older: low risk of fatal aneurysm rupture]. [Dutch]. Ned Tijdschr Geneeskd 2008; 152(13):747-749.

(26) Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP, van Marrewijk C, Laheij RJ et al. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair. J Vasc Surg 2000; 32(4):739-749.

(27) HobbsS.Claridge. Strategies to improve the effectiveness of abdominal aortic aneurysm screening programmes. J Med Screen 2004; 11(2):93-96.

(28) Hogh AG. False-positive findings in screening for abdominal aortic aneurysm. Ugeskr Laeger 2009; 171(43):3101-3102.

(29) IrvineCDS. A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally. Eur J Vasc Endovasc Surg 2000; 20(4):374-378.

(30) Jim J, Rubin BG, Geraghty PJ, Criado FJ, Fajardo A, Sanchez LA. A 5-year comparison of EVAR for large and small aortic necks. J Endovasc Ther 2010; 17(5):575-584.

(31) Jordan WD, Jr., Moore WM, Jr., Melton JG, Brown OW, Carpenter JP, Endologix I, et al. Secure fixation following EVAR with the Powerlink XL System in wide aortic necks: results of a prospective, multicenter trial. J Vasc Surg 2009 Nov;50(5):979-86.

(32) Karthikesalingam A, Hinchliffe RJ, Loftus IM, Thompson MM, Holt PJ, . Volume-outcome relationships in vascular surgery: the current status. J Endovasc Ther 2010; 17(3):356-365.

(33) Lawrence-Brown MM, Norman PE, Jamrozik K, Semmens JB,DonnellyNJ, Spencer C et al. Initial results of ultrasound screening for aneurysm of the abdominal aorta inWestern Australia: relevance for endoluminal treatment of aneurysm disease. Cardiovasc Surg 2001; 9(3):234-240.

(34) Lederle FA, Johnson GR, Wilson SE, Chute EP, Hye RJ, Makaroun MS et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 2000; 160(10):1425-1430.

(35) Lee ES, Pickett E, Hedayati N, Dawson DL, Pevec WC, Lee ES et al. Implementation of an aortic screening program in clinical practice: implications for the Screen For Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. J Vasc Surg 2009; 49(5):1107-1111.

(36) Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ, Lesperance K et al. Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective. J Vasc Surg 2008; 47(6):1165-1170.

(37) Lin PH, Bush RL, Milas M, Terramani TT, Dodson TF, Chen C et al. Impact of an endovascular program on the operative experience of abdominal aortic aneurysm in vascular fellowship and general surgery residency. Am J Surg 2003; 186(2):189-193.

(38) Lindholt JS, Vammen S, Henneberg EW, Fasting H, Juul S, Lindholt JS et al. [Optimal interval screening and observation of abdominal aortic aneurysms]. [Danish]. Ugeskr Laeger 2001; 163(37):5034-5037.

(39) Lindholt JS, Juul S, Fasting H, Henneberg EW, Lindholt JS, Juul S et al. Screening for abdominal aortic aneurysms: single centre randomised controlled trial.[Erratum appears in BMJ. 2005 Oct 15;331(7521):876]. BMJ 2005; 330(7494):750.

(40) Lindholt JS, Juul S, Fasting H, Henneberg EW. [Screening reduced abdominal aortic aneurysm mortality--secondary publication. Results from a Danish randomized screening trial]. Ugeskr Laeger 2005; 167(15):1641-1644.

(41) Lindholt JS, Juul S, Fasting H, Henneberg EW, Lindholt JS, Juul S et al. Preliminary ten year results from a randomised single centre mass screening trial for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2006; 32(6):608-614.

(42) Lobato AC, Rodriguez-Lopez J, Diethrich EB, Lobato AC, Rodriguez-Lopez J, Diethrich EB. Learning curve for endovascular abdominal aortic aneurysm repair: evaluation of a 277-patient single-center experience. J Endovasc Ther 2002; 9(3):262-268.

(43) Londero H, Lev G, Bertoni H, Mendaro E, Santaera O, Martinez RL et al. Safety and feasibility of balloon-expandable stent implantation for the treatment of type I endoleaks following endovascular aortic abdominal aneurysm repair. Eurointervention 2011; 6(6):740-743.

(44) LottmanPE, Laheij RJ, Cuypers PW, Bender M, Buth J, Lottman PEM et al. Health-related quality of life outcomes following elective open or endovascular AAA repair: a randomized controlled trial. J Endovasc Ther 2004; 11(3):323-329.

(45) Mastracci TMG. Endovascular repair of ruptured abdominal aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg 2008; 47(1):214-221.

(46) Matsumoto AH. What Randomized Controlled Trials Tell Us About Endovascular Repair of Abdominal Aortic Aneurysms. Journal of Vascular and Interventional Radiology 2008; 19(6 SUPPL.):S18-S21.

(47) Montreuil B, Brophy J, Montreuil B, Brophy J. Screening for abdominal aortic aneurysms in men: a Canadian perspective using Monte Carlo-based estimates. Can J Surg 2008; 51(1):23-34.

(48) Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. BMJ 2002; 325(7373):1135.

(49) Muszbek NT. Systematic Review of Utilities in Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2008; 36(3):283-289.

(50) Nordon IMH. Modern Treatment of Juxtarenal Abdominal Aortic Aneurysms with Fenestrated Endografting and Open Repair - A Systematic Review. Eur J Vasc Endovasc Surg 2009; 38(1):35-41.

(51) Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm.[Erratum appears in BMJ. 2005 Mar 12;330(7491):596]. BMJ 2004; 329(7477):1259.

(52) Ouriel K. Randomized clinical trials of endovascular repair versus surveillance for treatment of small abdominal aortic aneurysms. J Endovasc Ther 2009; 16 Suppl 1(pp I94-105):Feb.

(53) Pande RLB. Abdominal Aortic Aneurysm: Populations at Risk and How to Screen. Journal of Vascular and Interventional Radiology 2008; 19 (6 SUPPL):S2-S8.

(54) Rafii BY, Abilez OJ, Benharash P, Zarins CK, Rafii BY, Abilez OJ et al. Lateral movement of endografts within the aneurysm sac is an indicator of stent-graft instability. J Endovasc Ther 2008; 15(3):335-343.

(55) Reilly LM. Endovascular Repair of Abdominal Aortic Aneurysms Reduces Perioperative Morbidity and Mortality. Journal of Cardiothoracic and Vascular Anesthesia 2003; 17(5):655-658.

(56) Ricco JB, InterGard Silver Study Group., Ricco JB, InterGard Silver Study Group. InterGard silver bifurcated graft: features and results of a multicenter clinical study. J Vasc Surg 2006; 44(2):339-346.

(57) Rosenthal R, von Kanel O, Eugster T, Stierli P, Gurke L, Rosenthal R et al. Does specialization improve outcome in abdominal aortic aneurysm surgery?.[Erratum appears in Vascular. 2006 Jan-Feb;14(1):54]. Vascular 2005; 13(2):107-113.

(58) Roshanali F, Mandegar MH, Yousefnia MA, Mohammadi A, Baharvand B, Roshanali F et al. Abdominal aorta screening during transthoracic echocardiography. Echocardiography 2007; 24(7):685-688.

(59) Sadat UB. Endovascular vs open repair of acute abdominal aortic aneurysms-A systematic review and meta-analysis. J Vasc Surg 2008; 48(1):227-236.

(60) Salhab M, Farmer J, Osman I, Salhab M, Farmer J, Osman I. Impact of delay on survival in patients with ruptured abdominal aortic aneurysm. Vascular 2006; 14(1):38-42.

(61) Schmidt T, Muhlberger N, Chemelli-Steingruber IE, Strasak A, Kofler B, Chemelli A et al. Benefit, risks and cost-effectiveness of screening for abdominal aortic aneurysm. ROFO Fortschr Geb Rontgenstr Nuklearmed 2010; 182(7):573-580.

(62) Schmiedt W, Duber C, Pitton M, Neufang A, Dorweiler B, Herber S et al. [Endovascular aneurysm therapy--long-term treatment outcomes after 7 years]. [German]. Med Klin 2002; 97(4):204-208.

(63) Schunn CD, Krauss M, Heilberger P, Ritter W, Raithel D, Schunn CD et al. Aortic aneurysm size and graft behavior after endovascular stent-grafting: clinical experiences and observations over 3 years. J Endovasc Ther 2000; 7(3):167-176.

(64) Stella A, Freyrie A, Gargiulo M, Faggioli GL, Stella A, Freyrie A et al. The advantages of Anaconda endograft for AAA. J Cardiovasc Surg (Torino) 2009; 50(2):145-152.

(65) Stolberg HO. Treatment of abdominal aortic aneurysms: review with evidence-based methods. Radiology 2003; 228(3):614-616.

(66) Subramanian K, Woodburn KR, Travis SJ, Hancock J, Subramanian K, Woodburn KR et al. Secondary interventions following endovascular repair of abdominal aortic aneurysm. Diagn Interv Radiol 2006; 12(2):99-104.

(67) Sultan S, Hynes N. Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair. J Endovasc Ther 2011 Apr;18(2):181-96.

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Appendix SAF-2. Table on complications from intact abdominal aortic aneurysm repairs

Table. Medicare reported complications data from 45,660 intact abdominal aortic aneurysm repairs performed by EVAR (endovascular aneurysm repair) and OAR (open aneurysm repair)*. With author’s permission.

	EVAR (N=22,830)	OAR (N=22,830)
Medical Complications (% of patients)
Myocardial infarction	7	9.4
Pneumonia	9.3	17.4
Acute renal failure	5.5	10.9
Renal failure requiring dialysis	0.4	0.5
Deep-vein thrombosis or pulmonary embolism	1.1	1.7
Surgical complications (% of patients)
Conversion to open repair	1.6	-
Acute mesenteric ischemia	1.0	2.1
Reintervention for bleeding	0.8	1.2
Tracheostomy	0.2	1.5
Thrombectomy	0.4	0.2
Embolectomy	1.3	1.7
Repair of infected graft of graft-enteric fistula	0.01	0.09
Major amputation	0.04	0.13
Complications related to laparatomy
Lysis of adhesions without resection	0.1	1.2
Bowel resection	0.6	1.3
Ileus of bowel obstruction without resection of lysis of adhesions	5.1	16.7
Mean length of hospital stay (nº of days)	3.4 + 4.7	9.3 + 8.1
Discharge home (% of survivors)	94.5	81.6

• Schermerhorn ML, O'Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358(5):464-474.

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