Abdominal aortic aneurysm in patients affected by intermittent claudication: prevalence and clinical predictors

  • Giuseppe Giugliano1,

    Affiliated with

    • Eugenio Laurenzano1,

      Affiliated with

      • Carlo Rengo1,

        Affiliated with

        • Giovanna De Rosa1,

          Affiliated with

          • Linda Brevetti1,

            Affiliated with

            • Anna Sannino1,

              Affiliated with

              • Cinzia Perrino1,

                Affiliated with

                • Lorenzo Chiariotti2,

                  Affiliated with

                  • Gabriele Giacomo Schiattarella1,

                    Affiliated with

                    • Federica Serino1,

                      Affiliated with

                      • Marco Ferrone1,

                        Affiliated with

                        • Fernando Scudiero1,

                          Affiliated with

                          • Andreina Carbone1,

                            Affiliated with

                            • Antonio Sorropago1,

                              Affiliated with

                              • Bruno Amato3,

                                Affiliated with

                                • Bruno Trimarco1 and

                                  Affiliated with

                                  • Giovanni Esposito1Email author

                                    Affiliated with

                                    BMC Surgery201212(Suppl 1):S17

                                    DOI: 10.1186/1471-2482-12-S1-S17

                                    Published: 15 November 2012

                                    Abstract

                                    Background

                                    Abdominal aortic aneurysm (AAA) is a frequent cause of death among elderly. Patients affected by lower extremity peripheral arterial disease (LE-PAD) seem to be particularly at high risk for AAA. We aimed this study at assessing the prevalence and the clinical predictors of the presence of AAA in a homogeneous cohort of LE-PAD patients affected by intermittent claudication.

                                    Methods

                                    We performed an abdominal ultrasound in 213 consecutive patients with documented LE-PAD (ankle/brachial index ≤0.90) attending our outpatient clinic for intermittent claudication. For each patient we registered cardiovascular risk factors and comorbidities, and measured neutrophil count.

                                    Results

                                    The ultrasound was inconclusive in 3 patients (1.4%), thus 210 patients (169 males, 41 females, mean age 65.9 ± 9.8 yr) entered the study. Overall, AAA was present in 19 patients (9.0%), with a not significant higher prevalence in men than in women (10.1% vs 4.9%, p = 0.300). Patients with AAA were older (71.2 ± 7.0 vs 65.4 ± 9.9 years, p = 0.015), were more likely to have hypertension (94.7% vs 71.2%, p = 0.027), and greater neutrophil count (5.5 [4.5 – 6.2] vs 4.1 [3.2 – 5.5] x103/μL, p = 0.010). Importantly, the c-statistic for neutrophil count (0.73, 95% CI 0.60 – 0.86, p =0.010) was higher than that for age (0.67, CI 0.56–0.78, p = 0.017). The prevalence of AAA in claudicant patients with a neutrophil count ≥ 5.1 x103/μL (cut-off identified at ROC analysis) was as high as 29.0%.

                                    Conclusions

                                    Prevalence of AAA in claudicant patients is much higher than that reported in the general population. Ultrasound screening should be considered in these patients, especially in those with an elevated neutrophil count.

                                    Introduction

                                    Systemic atherosclerosis represents the leading cause of morbidity and mortality in the western countries [13], with increased prevalence in the elderly population [4, 5]. The atherosclerotic disease may involved different part of vascular tree, in particular coronary arteries, carotid arteries and peripheral arteries [6, 7] .

                                    Abdominal aortic aneurysm (AAA) is a frequent cause of death in the elderly and its incidence has increased during last decades because of the increasing life-expectancy and the development of easy and low-cost diagnostic tools like ultrasound [5, 812]. The rising incidence of AAA and the severe prognosis in case of rupture with a mortality rate that can be as high as 90% [13] call for early identification and elective repair. However, opposing views have been published on the importance of ultrasound screening for AAA and there is still debate on the high-risk populations who need to be screened [14, 15].

                                    Lower extremity peripheral arterial disease (LE-PAD), one of the main expressions of atherosclerosis, affects about 27 million people in Europe and the United States [16] and is associated with a high risk of developing fatal and non-fatal ischemic cardiovascular events [2, 1719]. Patients affected by LE-PAD seem to be at particularly high risk for AAA development [2022]. Accordingly, we aimed this study at assessing the prevalence and the clinical predictors of the presence of AAA in a homogeneous cohort of LE-PAD patients affected by intermittent claudication, the most frequent clinical expression of LE-PAD.

                                    Methods

                                    We performed an abdominal ultrasound in 213 consecutive patients with documented LE-PAD attending our outpatient complaining intermittent claudication. Using an Image Point Hx ultrasound system (Hewlett Packard) and a 3.0 MHz transducer, we measured in each patient both antero-posterior and transverse outer diameters at the largest portion of the infrarenal abdominal aorta. AAA was defined by an infrarenal abdominal aorta diameter ≥ 3 cm [23]. Infrarenal abdominal aortas 2.6 to 2.9 cm were defined ectatic.

                                    The diagnosis of PAD was based on the presence of an ankle brachial index (ABI) ≤ 0.90. ABI was measured after participants had rested supine for 5 minutes. The systolic blood pressure in both brachial arteries, and the ankle systolic blood pressure in the right and left posterior tibial and dorsalis pedis arteries were measured using a Doppler probe. The ABI for each leg was then determined using the higher of the two readings from either the posterior tibial or dorsalis pedis arteries, and the higher of the two brachial readings. The lower ABI of the two legs was used for diagnostic purposes.

                                    In each patient, clinical history and risk factors were assessed. Smokers included current and former smokers. Hypertension was diagnosed if systolic arterial pressure exceeded 140 mmHg and/or diastolic arterial pressure exceeded 90 mmHg, or if the patient used antihypertensive drugs. Hypercholesterolemia was diagnosed if plasma total cholesterol exceeded 200 mg/dL, plasma low-density lipoprotein cholesterol exceeded 130 mg/dL, or if the patient used lipid-lowering drugs because of a history of hypercholesterolemia. Diabetes mellitus was diagnosed if plasma fasting glucose exceeded 126 mg/dL or if the patient used hypoglycaemic agents. A history of coronary artery disease, previous myocardial infarction, or ischemic stroke was documented by hospital records. All patients underwent ultrasound examination of carotid arteries.

                                    All participants gave written informed consent to the study, which was approved by our institutional Ethics Committee.

                                    Blood samples and laboratory assay

                                    Blood was drawn from an antecubital vein using a 19-gauge needle in a Vacutainer system (Becton-Dickson, Franklin Lakes, NJ). Neutrophil count was measured with the Bayer H*2 hematology analyzer (Bayer Diagnostic Division, Tarrytown, NY).

                                    Statistical analysis

                                    Statistical analyses were performed using SPSS 12.0 (SPSS, Inc., Chicago, IL, USA). Variables were expressed as absolute numbers and percentage or mean ± SD, with the exception of neutrophil count, which was expressed as median and inter-quartile range because of their skewed distribution. Comparisons were made by t-test for unpaired samples, χ2 test, or Mann–Whitney U test, as appropriate. For continuous variables, receiver-operating characteristic (ROC) curve analysis was used to identify the threshold levels that provided the best cut-off for the prediction of the presence AAA. Correlations between continuous variables were evaluated by Spearman analysis.

                                    All statistical tests were two-sided. For all tests, a p-value <0.05 was considered statistically significant.

                                    Results

                                    The ultrasound was inconclusive in 3 patients (1.4%), thus 210 patients (169 males, 41 females, mean age 65.9 ± 9.8 yr) completed the study. Table 1 shows baseline characteristics of the study population. Overall, AAA was present in 19 patients (9.0%), with a not significant higher prevalence in men than in women (10.1% vs 4.9%, p = 0.300). Furthermore, patients with AAA were older (71.2 ± 7.0 vs 65.4 ± 9.9 years, p = 0.015), were more likely to have hypertension (94.7% vs 71.2%, p = 0.027), and greater neutrophil count (5.5 [4.5 – 6.2] vs 4.1 [3.2 – 5.5] x103/μL, p = 0.010) (Table 2). The prevalence progressively increased with age (p for trend = 0.013), with a maximum of 15.8% in over 75-year-subjects (Table 3). Of note, in our population we observed a higher prevalence of carotid stenosis >50% in claudicant patients with AAA, although not significant (47.4 vs 29.3%, p = 0.105). No relationship was found between the ankle/brachial index and the presence of AAA. For continuous variables, which are associated to the presence of AAA at univariate analysis (i.e. age and neutrophil count), ROC curve analysis was performed to evaluate the best cut-offs to predict the presence of the disease (Figure 1). The best cut-offs were ≥ 66 years for age and ≥ 5.1 x103/μL for neutrophil count. Importantly, the c-statistic for neutrophil count (0.73, 95% CI 0.60 – 0.86, p = 0.010) was higher than that for age (0.67, CI 0.56–0.78, p = 0.017) (Figure 1). In our population the prevalence of AAA in claudicant patients with a neutrophil count ≥ 5.1 x103/μL (cut-off identified at ROC analysis) was as high as 29.0%. Of note, Spearman analysis showed that neutrophil count and age are not correlated (ρ = -0.123, p = 0.230).
                                    Table 1

                                    Baseline characteristics of the study population (n=210)

                                     

                                    Number

                                    Percentage or mean (SD) or median [25th-75th percentiles]

                                    Age (years)

                                     

                                    65.9 (9.8)

                                    Males

                                    169

                                    80.5

                                    Height (cm)

                                     

                                    167.4 (7.5)

                                    Weight (Kg)

                                     

                                    73.9 (11.7)

                                    Risk factors

                                      

                                    Smoking

                                    188

                                    89.5

                                    Hypertension

                                    154

                                    73.3

                                    Hypercholesterolemia

                                    137

                                    65.2

                                    Diabetes mellitus

                                    75

                                    35.7

                                    BMI (kg/m2)

                                     

                                    26.2 (3.4)

                                    WC (cm)

                                     

                                    97.6 (9.4)

                                    Metabolic syndrome

                                    96

                                    45.7

                                    Comorbidity

                                      

                                    CAD

                                    106

                                    50.5

                                    Previous MI

                                    76

                                    36.2

                                    Previous stroke

                                    8

                                    3.8

                                    Medications

                                      

                                    Antiplatelets

                                    191

                                    91.0

                                    Beta blockers

                                    47

                                    22.4

                                    ACE-inhibitors

                                    104

                                    49.5

                                    Statins

                                    130

                                    61.9

                                    Carotid status

                                      

                                    Carotid stenosis >50%

                                    65

                                    31

                                    LE-PAD severity

                                      

                                    Bilateral LE-PAD

                                    131

                                    62.4

                                    ABI

                                     

                                    0.69 (0.22)

                                    Aortic features

                                      

                                    Aortic diameter (mm)

                                     

                                    20.7 (6.8)

                                    Ectatic aorta

                                    13

                                    6.2

                                    AAA

                                    19

                                    9.0

                                    Inflammatory status

                                      

                                    Neutrophil count (x103/μL)

                                     

                                    4.4 [3.3-5.7]

                                    SD = standard deviation; BMI = body mass index; WC = waist circumference; CAD = coronary artery disease; MI = myocardial infarction; ACE = angiotensin converting enzyme; LE-PAD = lower extremity-peripheral arterial disease; ABI = ankle/brachial index; AAA = abdominal aortic aneurysm.

                                    Table 2

                                    Characteristics of claudicants according to the presence or absence of AAA.

                                     

                                    AAA

                                    No AAA

                                    p

                                     

                                    (n = 19)

                                    (n = 191)

                                     

                                    Age (years)

                                    71.2 ± 7.0

                                    65.4 ± 9.9

                                    0.015

                                    Age ≥ 65 years

                                    16 (84.2)

                                    110 (57.6)

                                    0.024

                                    Males

                                    17 (89.5)

                                    152 (79.6)

                                    0.300

                                    Risk factors

                                       

                                    Smoking

                                    18 (94.7)

                                    170 (89.0)

                                    0.437

                                    Hypertension

                                    18 (94.7)

                                    136 (71.2)

                                    0.027

                                    Hypercholesterolemia

                                    15 (78.9)

                                    122 (63.9)

                                    0.188

                                    Diabetes Mellitus

                                    4 (21.1)

                                    71 (37.2)

                                    0.162

                                    BMI (kg/m2)

                                    26.5 ± 3.7

                                    26.2 ± 3.4

                                    0.742

                                    WC (cm)

                                    96.7 ± 9.6

                                    97.7 ± 9.4

                                    0.708

                                    Metabolic syndrome

                                    9 (47.4)

                                    87 (45.5)

                                    0.879

                                    Comorbidity

                                       

                                    CAD

                                    10 (52.6)

                                    96 (50.3)

                                    0.844

                                    Previous MI

                                    5 (26.3)

                                    71 (37.2)

                                    0.348

                                    Previous stroke

                                    1 (5.2)

                                    7 (3.7)

                                    0.729

                                    Medications

                                       

                                    Antiplatelets

                                    18 (94.7)

                                    173 (90.6)

                                    0.547

                                    Beta blockers

                                    2 (10.5)

                                    45 (23.6)

                                    0.194

                                    ACE-inhibitors

                                    11 (57.9)

                                    93 (48.7)

                                    0.444

                                    Statins

                                    10 (52.6)

                                    120 (62.8)

                                    0.383

                                    Carotid status

                                       

                                    Carotid stenosis >50%

                                    9 (47.4)

                                    56 (29.3)

                                    0.105

                                    LE-PAD severity

                                       

                                    Bilateral LE-PAD

                                    13 (68.4)

                                    118 (61.8)

                                    0.569

                                    ABI

                                    0.64 ± 0.11

                                    0.69 ± 0.23

                                    0.315

                                    Inflammatory status

                                       

                                    Neutrophil count (x103/μL)

                                    5.5 [4.5 – 6.2]

                                    4.1 [3.2 – 5.5]

                                    0.010

                                    Values are n (%) or mean ± SD or median [interquartile range].

                                    AAA = abdominal aortic aneurysm; BMI = body mass index; WC = waist circumference; CAD = coronary artery disease; MI = myocardial infarction; ACE = angiotensin converting enzyme; LE-PAD = lower extremity-peripheral arterial disease; ABI = ankle/brachial index; SD = standard deviation.

                                    Table 3

                                    Distribution of AAA by age.

                                     

                                    Total

                                    AAA

                                    Prevalence

                                    Age < 55 years

                                    25

                                    0

                                    0%

                                    Age 55 – 64 years

                                    59

                                    3

                                    5.1%

                                    Age 65 – 74 years

                                    88

                                    10

                                    11.4%

                                    Age ≥ 75 years

                                    38

                                    6

                                    15.8%

                                    p for trend = 0.013

                                    http://static-content.springer.com/image/art%3A10.1186%2F1471-2482-12-S1-S17/MediaObjects/12893_2012_258_Fig1_HTML.jpg

                                    Figure 1

                                    Discussion

                                    The present study demonstrates that prevalence of AAA in claudicant patients is much higher than that reported in the general population, with the highest clinical predictors being advanced age and an elevated inflammatory status.

                                    To decrease the number of deaths from ruptured AAA, early detection by screening subjects at high risk is needed. Physical examination is not effective in identifying the presence of an AAA, while abdominal ultrasound is an accurate test to detect the presence of this life-threatening disease [23]. Elderly males are those who show the highest prevalence of the disease in the general population. Indeed there is evidence that screening programs involving males with > 65 years are cost-effective [14, 24, 25]. The strong association with age has been confirmed also in our population of claudicant patients. Indeed, we observed that the prevalence of AAA dramatically increases after 65 years (optimal cut-off identified at ROC analysis being ≥ 66 years) and no AAA was found in patients younger than 55 years of age. Thus age cut-off to initiate screening for AAA in patients with intermittent claudication seems to be the same than in general population. These results might suggest that performing an abdominal ultrasound in all claudicant patients may not be advisable. However, in our study, we found that an elevated inflammatory status, evaluated by neutrophil count, is a powerful predictor of the presence of AAA in patients with intermittent claudication, and that the neutrophil count did not correlate with age. Initiating the screening in patients ≥ 65 years with intermittent claudication might consequently lead to miss some diagnosis of AAA, and therefore in claudicant patients with an elevated inflammatory status the ultrasound screening should be performed irrespective of age. At this regard, pathophysiological studies are needed to evaluate whether the increased inflammation observed in our population of intermittent claudication patients affected by AAA is a cause or a consequence of the presence of AAA [19, 26, 27].

                                    Conclusions

                                    The high prevalence of AAA among patients affected by intermittent claudication makes them a suitable target population for AAA screening. In our opinion ultrasound screening should be considered in these patients, especially in those with an elevated neutrophil count. However, further studies are warranted to elucidate if screening all patients with intermittent claudication for of this life-threatening condition is cost-effective.

                                    List of abbreviations

                                    LE-PAD: 

                                    Lower Extremity Peripheral Arterial Disease

                                    AAA: 

                                    Abdominal Aortic Aneurysm

                                    ABI: 

                                    ankle/brachial index.

                                    Declarations

                                    Acknowledgements

                                    This article has been published as part of BMC Surgery Volume 12 Supplement 1, 2012: Selected articles from the XXV National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://​www.​biomedcentral.​com/​bmcsurg/​supplements/​12/​S1.

                                    Authors’ Affiliations

                                    (1)
                                    Department of Clinical Medicine and Cardiovascular and Immunological Sciences, “Federico II” University”
                                    (2)
                                    Department of Biology and Cellular and Molecular Pathology, Federico II University
                                    (3)
                                    Department of General, Geriatric, Oncologic Surgery and Advanced Technologies, “Federico II” University”

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                                    Copyright

                                    © Giugliano et al; licensee BioMed Central Ltd. 2012

                                    This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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