FOR THE VASCULAR COMMUNITY

DESPITE RECENT GUIDELINES recommending that women of childbearing age have interventions on their splenic aneurysms, only a minority in a recent study did so, according to first-named author Jason Zhang, MD, an integrated vascular surgery resident at New York University Grossman School of Medicine, who raised the need for inquiry into prior smoking history in the patient cohort. Zhang was presenting at VAM 2023, shedding light on the findings of a retrospective analysis of splenic aneurysms in pregnant women.

“Splenic-type aneurysms are the most common type of visceral aneurysms, and pregnancy is a known risk factor, with pregnant women having a higher mortality rate from rupture,” Zhang began. The headline findings, he said, suggested the guidelines “might not be known among the greater medical community.”

To achieve better outcomes for this patient cohort, Zhang argued that the vascular specialty as a whole must work on updating guidelines across the board.

To better understand the study group, Zhang explained that the analysis focused on the incidence of enlargement, intervention, and rupture of aneurysms. Pulling from the New York University Grossman School of Medicine’s radiology database from 2015 to 2020, a total of 853 patients were analyzed, with 514 having had both clinical and imaging follow-ups at a mean of 3.8 years.

Zhang noted that the most common indications for imaging were abdominal overall survival at five years similar between the two cohorts, with 59.2% in the RSD group and 59% in the CAA group. Freedom from graft-related reintervention at one and five years was 81.3% and 66.2% in CAA patients compared to 95.6% and 92.5% in RSD patients.

From The Floor

Keith Calligaro, MD, Philadelphia: “I applaud your effort but I don’t know if we’re ever going to get a good answer on this—it’s all retrospective … I personally take a different attitude about the use of cryograft. When it's a younger patient, I tend to use the cryograft because I'm more worried about recurrent infection, but every series has shown that cryograft is more likely to develop recurrent stenosis. That's the advantage of rifampin—you're pain or follow-up of an unrelated pathology.

Tabiei went on to describe that indications for reintervention in the CAA group included five patients with stenosis, four with pseudoaneurysm, two occlusion patients, one with graft-limb kinking, and one patient who experienced rupture.

In the RSD group, indications for reintervention included three patients with reinfection, one occlusion patient, one endoleak patient, one with omental coverage, and one incidence of rupture. Freedom from reinfection at one and five years was 98.3% and 94.9% in the CAA cohort compared to 92.5% and 87.2% for the RSD group.

Wrapping up, Tabiei concluded that the study found both CAA and RSD to be suitable interventions, but noted that reintervention was more common with CAA—ultimately reaffirming that individualized treatment and long-term follow-up are most appropriate with aortic and iliac graft-infected patients.

Tabiei added that at his institution, CAA are considered in older patients, and in cases of highly virulent microorganisms and such instances as intra-abdominal abscesses. RSD tends to be used in younger patients and in urgent cases.

Of the patients with imaging follow-up, 23% experienced growth, with an average increase of 2.5mm. The most common size of aneurysm was between 10mm and 19mm, with an annual growth rate of 0.17mm. Notably, there was no difference between the size cohorts.

Shifting focus to the childbearing cohort of the analysis, Zhang explained that 37 women of childbearing age were included in the study, with a mean aneurysm size of 16mm. In the entire study, only one patient presented with a rupture, measuring 23mm in size, and the aneurysm was closed successfully.

“What we found, actually, was that the large majority of these patients were never referred to a vascular surgeon. We found these aneurysms through the radiology report, which we then verified. So, most of the women who had aneurysms actually never saw a vascular surgeon,” Zhang noted when asked about the current guidelines for aneurysm treatment in women of childbearing age.

Zhang was also asked about incidental diagnoses and the opportunity for those patients to be referred sooner to a vascular surgeon by Dawn Coleman, MD, chief of vascular surgery at Duke University in Durham, North Carolina. “What are you going to do about that at a local level?” she added.

Zhang referred to potential “quality initiatives”—such as an automatic flag in the electronic medical record (EMR) when a patient has an aneurysm—but said the point was a “good consideration.”

The real conclusion, Zhang said, is that there needs to be more research done on splenic aneurysms in this patient cohort, and his team’s retrospective analysis is “just a starting point.”

To better treat women of childbearing age, the vascular community must prioritize the creation of uniform guidelines and follow up with continued research and analysis, he added.—Marni Davimes and Bryan Kay