 |
|
Management of Small Abdominal Aortic AneurysmsEarly Surgery vs Watchful Waiting
David A. Katz, MD;
Benjamin Littenberg, MD;
Jack L. Cronenwett, MD
JAMA. 1992;268(19):2678-2686.
Abstract
| |
Objective.
—To compare two clinical strategies for the management of small abdominal aortic aneurysms (AAAs) less than 5 cm in diameter: early surgery (repair small AAAs when diagnosed) and watchful waiting (measure AAA size every 6 months and repair when the diameter reaches 5 cm).
Data Sources.
—We reviewed data from an earlier longitudinal study of patients with small AAAs to estimate incidence rates of rupture or acute expansion. Estimates for other parameters in the model were obtained by searching the medical literature (MEDLINE, 1966 to present).
Data Synthesis.
—We constructed a Markov decision tree to compare early surgery with watchful waiting in patients with asymptomatic AAAs less than 5 cm in diameter, with respect to long-term survival in quality-adjusted life years. The average annual rates of rupture or acute expansion for AAAs with a maximal transverse diameter of less than 4.0,4.0 to 4.9, and at least 5.0 cm, are 0, 3.3, and 14.4 events per 100 patient-years of observation, respectively. At an average rupture rate of 3.3 events per 100 patient-years and an average operative risk for elective surgery (4.6%, 30-day mortality), our model predicts that early surgery improves survival in patients who present with a 4-cm AAA. The benefit of early surgery decreases with increased age at presentation. If the average rupture rate for AAAs less than 5 cm is assumed to be low (eg, 0.4 event per 100 patient-years), watchful waiting is favored, particularly as operative risk increases. The decision in this subgroup, however, is sensitive to possible future increases in operative risk.
Conclusions.
—In the majority of scenarios that we examined, early surgery is preferred to watchful waiting for patients with AAAs less than 5 cm in diameter. Watchful waiting is generally favored, however, for patients with a low risk of AAA rupture or acute expansion, including those patients who present with very small AAAs (eg, <4 cm). More accurate data concerning the rupture risk of AAAs less than 5 cm would improve clinical decision making.
(JAMA. 1992;268:2678-2686)
Author Affiliations
From the Department of Medicine, White River Junction (Vt) Veterans Administration Medical Center (Dr Katz), and Technology Assessment Program, Department of Medicine (Drs Katz and Littenberg), and Section of Vascular Surgery (Dr Cronenwett), Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Footnotes
Dr Katz is supported by a Veterans Administration fellowship in ambulatory care. Dr Littenberg is the American College of Physicians George Morris Piersol Teaching and Research Scholar.
Reprint requests to Department of Medicine (111B), Veterans Administration Medical Center, White River Junction, VT 05001 (Dr Katz).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
A Real Options Approach to Watchful Waiting: Theory and an Illustration
Driffield and Smith
Med Decis Making 2007;27:178-188.
ABSTRACT
Prospects for the Medical Management of Abdominal Aortic Aneurysms
Steinmetz et al.
VASC ENDOVASCULAR SURG 2003;37:151-163.
ABSTRACT
Small Abdominal Aortic Aneurysms
Kertai et al.
NEJM 2002;347:1112-1115.
FULL TEXT
Plasma Levels of Metalloproteinases-3 and -9 as Markers of Successful Abdominal Aortic Aneurysm Exclusion After Endovascular Graft Treatment
Sangiorgi et al.
Circulation 2001;104
:I-288-I-295.
ABSTRACT
| FULL TEXT
A 75-Year-Old Woman With an Abdominal Aortic Aneurysm and Emphysema
Goldman
JAMA 1998;280:366-372.
FULL TEXT
The Use of Multisite High Resolution Arterial Imaging to Assess Arteriosclerosis
Vagnini et al.
ANGIOLOGY 1997;48:1023-1030.
ABSTRACT
Learning From the Last Ultrasound: A Population-Based Study of Patients With Abdominal Aortic Aneurysm
Reed et al.
Arch Intern Med 1997;157:2064-2068.
ABSTRACT
Risk Factors for Abdominal Aortic Aneurysms in Older Adults Enrolled in the Cardiovascular Health Study
Alcorn et al.
Arterioscler. Thromb. Vasc. Bio. 1996;16:963-970.
ABSTRACT
| FULL TEXT
Perioperative Mortality of Elective Abdominal Aortic Aneurysm Surgery: A Clinical Prediction Rule Based on Literature and Individual Patient Data
Steyerberg et al.
Arch Intern Med 1995;155:1998-2004.
ABSTRACT
Users' Guides to the Medical Literature: VII. How to Use a Clinical Decision Analysis A. Are the Results of the Study Valid?
Richardson et al.
JAMA 1995;273:1292-1295.
ABSTRACT
Abdominal Aortic Aneurysm
Ernst
NEJM 1993;328:1167-1172.
FULL TEXT
|
