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SVS: AAA surveillance comes at an emotional cost

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To survey and protect

The diagnosis of a small aortic aneurysm, whether by screening or as an incidental finding, causes anxiety in our patients. The risk of rupture of small AAA has been demonstrated to be low – less than 1% per year below 5.0 cm in males (Health Technol. Assess. 2013;41:1-108) . Therefore, appropriate counseling and surveillance intervals should optimize the management of AAA patients. This study highlights the adverse effects of a diagnosis of small AAA on a proportion of our patients, despite appropriate explanation. Frequently patients know someone who died of AAA rupture and many do not understand the risk when it is explained in routine consultations. Perhaps we should all ensure that a member of our team contacts patients with small AAA post review and perform a short Quality of Life questionnaire by phone so that we can identify those who are suffering a negative impact on their QOL. We could then intensify our counseling and reassurance for this cohort of patients. This study should make us all reflect on whether our surveillance programs need to be modified, to ensure that our patients are not adversely affected by a diagnosis of small AAA.

Dr. Robert Fitridge is professor of vascular surgery, University of Adelaide, Australia, and associate medical editor of Vascular Specialist.


AT The 2015 Vascular Annual Meeting


CHICAGO – For some patients, surveillance of low-risk abdominal aortic aneurysms is so stressful that early repair might be a better option.

Until now, though, it’s been hard to know who those patients are. There hasn’t been a way to quantify the impact of abdominal aortic aneurysm (AAA) surveillance on quality of life.

Dr. Bjoern Suckow, a vascular surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and his colleagues at the University of Massachusetts and elsewhere are working to fix that problem. “I do believe that there is a certain subset of patients who we know are” at low risk for rupture “who are so consumed by fear and anxiety during surveillance that the impact on quality of life might make us want to repair them slightly sooner. I hope this will help us weed out who that subgroup might be,” Dr. Suckow said at a meeting hosted by the Society for Vascular Surgery.

Dr. Bjoern Suckow Alexander Otto/Frontline Medical News

Dr. Bjoern Suckow

With the help of patient and physician focus groups and interviews, the team developed AAA-specific quality of life (QOL) surveys and administered them to 351 patients under surveillance for aneurysms below about 5.5 cm, and 657 who had undergone mostly endovascular AAA repair at six United States institutions.

The surveys included nine questions to assess concerns about rupture, surgery, costs, and death. The responses were averaged to give an emotional impact score (EIS) ranging from 0 to 100, with higher scores indicating worse emotional QOL. The survey also included 10 questions to assess changes in heavy lifting, strenuous activity, travel habits, and other behaviors. Those results were averaged to give a behavioral change score (BCS) that also ranged from 0 to 100, with higher scores indicating greater negative impact.

A significant portion of the surveillance patients thought it was “very likely” their aneurysm would rupture within a year; their EIS was 45 and BCS 30; patients who thought rupture was unlikely had an EIS of 12 and BCS of 13 (P less than .001). Overall, patients under surveillance had worse emotional impact sores than did those who had undergone repair.

“We routinely counsel patients with small aneurysms that the rupture risk is low” – less than 5% – “and outweighed by the higher risk of repair. We were surprised that even though we feel we do a great job counseling and educating our patients, some of them do not understand or retain what we mean.” Eventually, surveys could be used in the clinic to identify patients with “less understanding, so [we can] spend more time with them,” Dr. Suckow said.

In general, “the range of impact on QOL by AAA surveillance is broad. For most patients, the impact is minimal, but for some, especially those with a greater perceived rupture risk, it is severe. Overall, surveillance has a persistent negative impact on QOL, particularly emotional QOL. This impact appears to diminish following either open or endovascular repair,” he said.

The respondents were about 76 years old, on average. Most were white men, and about half were high school graduates.

Dr. Suckow has no relevant financial conflicts. The work was funded by the National Institutes of Health and career development awards from the Society for Vascular Surgery and the American College of Surgeons.

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