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PARIS – The usual rule that the larger an aortic aneurysm grows the greater the risk it will undergo dissection or rupture doesn’t work in patients with giant-cell arteritis. Their aortic aneurysms appear liable to dissect or rupture at any size after the diagnosis of giant-cell arteritis occurs, based on a retrospective study of 195 patients followed at a single U.S. center.
"Aortic size at diagnosis or last follow-up did not predict aortic dissection or rupture," Dr. Ashima Makol reported at the annual European Congress of Rheumatology, nor were linear, serial measurements of aortic size able to reliably predict risk for these complications in patients with GCA. Without a reliable way to identify patients with GCA at risk for dissection or rupture, the only management advice remaining is to follow GCA patients annually with imaging, said Dr. Makol, a rheumatologist at the Mayo Clinic in Rochester, Minn.
Positron emission tomography, CT angiography, or MR angiography seem to be the best ways to follow these patients, but if those are too costly to do annually, then transesophageal echocardiography or a chest x-ray are other options, Dr. Makol said in an interview.
Although 30% of patients with GCA have a vasculitis that involves the aorta and its branches and an increased risk for developing aortic aneurysms, the way these aneurysms change over time and the relationship between aneurysm size and the risk for dissection or rupture in GCA patients were not previously reported. To address this, Dr. Makol and her associates reviewed 195 patients with GCA and an aortic aneurysm seen at the Mayo Clinic during 2000-2012.
The aneurysms occurred in the ascending thoracic aorta in 161 patients (83%), the descending thoracic aorta in 21 (11%), and the abdominal aorta in the remaining 13 patients (7%). (Percentages total 101% because of rounding.) The patients averaged 74 years old, 62% were women, and 49% had a history of smoking.
During follow-up, 14 patients (7%) had an aneurysm dissection, and 1 patient (1%) had an aneurysm rupture, the investigators reported. All of the dissections and the rupture occurred in thoracic aorta aneurysms.
At the time of GCA diagnosis, the average aneurysm size in the 15 patients who developed an aneurysm complication was 51 mm, which was very similar to the average size of 49 mm in the 180 patients who did not have an aneurysm dissection or rupture during follow-up.
Patients also showed no clear link between aneurysm size at the time of dissection or rupture and the aneurysm size during follow-up of patients without these complications. The average maximum aneurysm diameter among the 15 patients with a complication at the time of their event was 54 mm, while the average aneurysm size at last follow-up among those without a dissection or rupture during follow-up was 50 mm, a difference that was not statistically significant, Dr. Makol said.
The average rate of aneurysm growth during 3 years of follow-up for all the GCA patients in the analysis was 1.59 mm/year, a rate "somewhat higher" than the average annual growth rate of 1 mm/year reported for aortic aneurysms in patients without inflammatory disease. The 54-mm average aneurysm diameter at the time of dissection or rupture in the CGA patients was "somewhat lower" than the 65-mm average aneurysm diameter seen at the time of dissection or rupture in patients without inflammatory disease, she noted.
The study is the first reported to look at the pattern of aneurysm growth and complications in GCA patients, although it is limited to the retrospective experience at one tertiary referral center and so may reflect a referral bias, Dr. Makol said. But the inability of the analysis to identify aneurysm characteristics in GCA patients that can telegraph an increased risk for complications means that all GCA patients with an aortic aneurysm need careful surveillance by annual imaging, she advised.
Dr. Makol said that she had no disclosures.
The take home message from this article can be summed up in this manner: Aneurysms in patients with, or that are the result of, giant-cell arteritis (GCA) may be at increased risk for a catastrophic event at an earlier, or at least more unpredictable point, than aneurysms that are not associated with GCA. As the article states, "the usual rule that the larger an aortic aneurysm grows the greater the risk" may not hold in this small subset of patients with GCA. Further interpretation of this article leads me to conclude, however, that the discussion centers (nearly) exclusively on pathology involving the ascending aorta. Only a very small percentage of the cohort that was studied had aneurysms distal to the subclavian artery and none of the fifteen catastrophic events that were noted occurred below the diaphragm. While not clear from the article, it is quite likely all of the catastrophic events, rupture or dissection, occurred in association with disease involving the ascending aorta. As such, the article’s content may be more appropriate for those who routinely treat patients with ascending aortic pathology and not so much for vascular surgeons who traditionally treat aortic pathology from the transverse arch down. In addition, there seems to be the inference in the article that this data can be directly translated to disease affecting the infra-renal aorta which is a conclusion that I would hold, is premature, at best. I, for one, must admit that while I have seen a number of patients with GCA, I have never had the occasion to treat an aneurysm in one of them. While this may be true for many of us, the point of the article does have merit and the information should be stored somewhere in our memory banks. Who knows, perhaps someday we may see it pop up on some board question.
Dr. Mark D. Morasch is a vascular surgeon at St Vincent Healthcare Heart and Vascular, Billings, Montana, and an associate medical editor for Vascular Specialist.
The take home message from this article can be summed up in this manner: Aneurysms in patients with, or that are the result of, giant-cell arteritis (GCA) may be at increased risk for a catastrophic event at an earlier, or at least more unpredictable point, than aneurysms that are not associated with GCA. As the article states, "the usual rule that the larger an aortic aneurysm grows the greater the risk" may not hold in this small subset of patients with GCA. Further interpretation of this article leads me to conclude, however, that the discussion centers (nearly) exclusively on pathology involving the ascending aorta. Only a very small percentage of the cohort that was studied had aneurysms distal to the subclavian artery and none of the fifteen catastrophic events that were noted occurred below the diaphragm. While not clear from the article, it is quite likely all of the catastrophic events, rupture or dissection, occurred in association with disease involving the ascending aorta. As such, the article’s content may be more appropriate for those who routinely treat patients with ascending aortic pathology and not so much for vascular surgeons who traditionally treat aortic pathology from the transverse arch down. In addition, there seems to be the inference in the article that this data can be directly translated to disease affecting the infra-renal aorta which is a conclusion that I would hold, is premature, at best. I, for one, must admit that while I have seen a number of patients with GCA, I have never had the occasion to treat an aneurysm in one of them. While this may be true for many of us, the point of the article does have merit and the information should be stored somewhere in our memory banks. Who knows, perhaps someday we may see it pop up on some board question.
Dr. Mark D. Morasch is a vascular surgeon at St Vincent Healthcare Heart and Vascular, Billings, Montana, and an associate medical editor for Vascular Specialist.
The take home message from this article can be summed up in this manner: Aneurysms in patients with, or that are the result of, giant-cell arteritis (GCA) may be at increased risk for a catastrophic event at an earlier, or at least more unpredictable point, than aneurysms that are not associated with GCA. As the article states, "the usual rule that the larger an aortic aneurysm grows the greater the risk" may not hold in this small subset of patients with GCA. Further interpretation of this article leads me to conclude, however, that the discussion centers (nearly) exclusively on pathology involving the ascending aorta. Only a very small percentage of the cohort that was studied had aneurysms distal to the subclavian artery and none of the fifteen catastrophic events that were noted occurred below the diaphragm. While not clear from the article, it is quite likely all of the catastrophic events, rupture or dissection, occurred in association with disease involving the ascending aorta. As such, the article’s content may be more appropriate for those who routinely treat patients with ascending aortic pathology and not so much for vascular surgeons who traditionally treat aortic pathology from the transverse arch down. In addition, there seems to be the inference in the article that this data can be directly translated to disease affecting the infra-renal aorta which is a conclusion that I would hold, is premature, at best. I, for one, must admit that while I have seen a number of patients with GCA, I have never had the occasion to treat an aneurysm in one of them. While this may be true for many of us, the point of the article does have merit and the information should be stored somewhere in our memory banks. Who knows, perhaps someday we may see it pop up on some board question.
Dr. Mark D. Morasch is a vascular surgeon at St Vincent Healthcare Heart and Vascular, Billings, Montana, and an associate medical editor for Vascular Specialist.
PARIS – The usual rule that the larger an aortic aneurysm grows the greater the risk it will undergo dissection or rupture doesn’t work in patients with giant-cell arteritis. Their aortic aneurysms appear liable to dissect or rupture at any size after the diagnosis of giant-cell arteritis occurs, based on a retrospective study of 195 patients followed at a single U.S. center.
"Aortic size at diagnosis or last follow-up did not predict aortic dissection or rupture," Dr. Ashima Makol reported at the annual European Congress of Rheumatology, nor were linear, serial measurements of aortic size able to reliably predict risk for these complications in patients with GCA. Without a reliable way to identify patients with GCA at risk for dissection or rupture, the only management advice remaining is to follow GCA patients annually with imaging, said Dr. Makol, a rheumatologist at the Mayo Clinic in Rochester, Minn.
Positron emission tomography, CT angiography, or MR angiography seem to be the best ways to follow these patients, but if those are too costly to do annually, then transesophageal echocardiography or a chest x-ray are other options, Dr. Makol said in an interview.
Although 30% of patients with GCA have a vasculitis that involves the aorta and its branches and an increased risk for developing aortic aneurysms, the way these aneurysms change over time and the relationship between aneurysm size and the risk for dissection or rupture in GCA patients were not previously reported. To address this, Dr. Makol and her associates reviewed 195 patients with GCA and an aortic aneurysm seen at the Mayo Clinic during 2000-2012.
The aneurysms occurred in the ascending thoracic aorta in 161 patients (83%), the descending thoracic aorta in 21 (11%), and the abdominal aorta in the remaining 13 patients (7%). (Percentages total 101% because of rounding.) The patients averaged 74 years old, 62% were women, and 49% had a history of smoking.
During follow-up, 14 patients (7%) had an aneurysm dissection, and 1 patient (1%) had an aneurysm rupture, the investigators reported. All of the dissections and the rupture occurred in thoracic aorta aneurysms.
At the time of GCA diagnosis, the average aneurysm size in the 15 patients who developed an aneurysm complication was 51 mm, which was very similar to the average size of 49 mm in the 180 patients who did not have an aneurysm dissection or rupture during follow-up.
Patients also showed no clear link between aneurysm size at the time of dissection or rupture and the aneurysm size during follow-up of patients without these complications. The average maximum aneurysm diameter among the 15 patients with a complication at the time of their event was 54 mm, while the average aneurysm size at last follow-up among those without a dissection or rupture during follow-up was 50 mm, a difference that was not statistically significant, Dr. Makol said.
The average rate of aneurysm growth during 3 years of follow-up for all the GCA patients in the analysis was 1.59 mm/year, a rate "somewhat higher" than the average annual growth rate of 1 mm/year reported for aortic aneurysms in patients without inflammatory disease. The 54-mm average aneurysm diameter at the time of dissection or rupture in the CGA patients was "somewhat lower" than the 65-mm average aneurysm diameter seen at the time of dissection or rupture in patients without inflammatory disease, she noted.
The study is the first reported to look at the pattern of aneurysm growth and complications in GCA patients, although it is limited to the retrospective experience at one tertiary referral center and so may reflect a referral bias, Dr. Makol said. But the inability of the analysis to identify aneurysm characteristics in GCA patients that can telegraph an increased risk for complications means that all GCA patients with an aortic aneurysm need careful surveillance by annual imaging, she advised.
Dr. Makol said that she had no disclosures.
PARIS – The usual rule that the larger an aortic aneurysm grows the greater the risk it will undergo dissection or rupture doesn’t work in patients with giant-cell arteritis. Their aortic aneurysms appear liable to dissect or rupture at any size after the diagnosis of giant-cell arteritis occurs, based on a retrospective study of 195 patients followed at a single U.S. center.
"Aortic size at diagnosis or last follow-up did not predict aortic dissection or rupture," Dr. Ashima Makol reported at the annual European Congress of Rheumatology, nor were linear, serial measurements of aortic size able to reliably predict risk for these complications in patients with GCA. Without a reliable way to identify patients with GCA at risk for dissection or rupture, the only management advice remaining is to follow GCA patients annually with imaging, said Dr. Makol, a rheumatologist at the Mayo Clinic in Rochester, Minn.
Positron emission tomography, CT angiography, or MR angiography seem to be the best ways to follow these patients, but if those are too costly to do annually, then transesophageal echocardiography or a chest x-ray are other options, Dr. Makol said in an interview.
Although 30% of patients with GCA have a vasculitis that involves the aorta and its branches and an increased risk for developing aortic aneurysms, the way these aneurysms change over time and the relationship between aneurysm size and the risk for dissection or rupture in GCA patients were not previously reported. To address this, Dr. Makol and her associates reviewed 195 patients with GCA and an aortic aneurysm seen at the Mayo Clinic during 2000-2012.
The aneurysms occurred in the ascending thoracic aorta in 161 patients (83%), the descending thoracic aorta in 21 (11%), and the abdominal aorta in the remaining 13 patients (7%). (Percentages total 101% because of rounding.) The patients averaged 74 years old, 62% were women, and 49% had a history of smoking.
During follow-up, 14 patients (7%) had an aneurysm dissection, and 1 patient (1%) had an aneurysm rupture, the investigators reported. All of the dissections and the rupture occurred in thoracic aorta aneurysms.
At the time of GCA diagnosis, the average aneurysm size in the 15 patients who developed an aneurysm complication was 51 mm, which was very similar to the average size of 49 mm in the 180 patients who did not have an aneurysm dissection or rupture during follow-up.
Patients also showed no clear link between aneurysm size at the time of dissection or rupture and the aneurysm size during follow-up of patients without these complications. The average maximum aneurysm diameter among the 15 patients with a complication at the time of their event was 54 mm, while the average aneurysm size at last follow-up among those without a dissection or rupture during follow-up was 50 mm, a difference that was not statistically significant, Dr. Makol said.
The average rate of aneurysm growth during 3 years of follow-up for all the GCA patients in the analysis was 1.59 mm/year, a rate "somewhat higher" than the average annual growth rate of 1 mm/year reported for aortic aneurysms in patients without inflammatory disease. The 54-mm average aneurysm diameter at the time of dissection or rupture in the CGA patients was "somewhat lower" than the 65-mm average aneurysm diameter seen at the time of dissection or rupture in patients without inflammatory disease, she noted.
The study is the first reported to look at the pattern of aneurysm growth and complications in GCA patients, although it is limited to the retrospective experience at one tertiary referral center and so may reflect a referral bias, Dr. Makol said. But the inability of the analysis to identify aneurysm characteristics in GCA patients that can telegraph an increased risk for complications means that all GCA patients with an aortic aneurysm need careful surveillance by annual imaging, she advised.
Dr. Makol said that she had no disclosures.
AT THE EULAR CONGRESS 2014
Key clinical point: Risk for aortic aneurysm dissection in patients with giant-cell arteritis showed no link to aneurysm size.
Major finding: GCA patients with dissection or rupture of an aortic aneurysm had aneurysms that were similar in size to those of GCA patients without these complications.
Data source: Retrospective study of 195 patients with GCA at one U.S. center.
Disclosures: Dr. Makol said that she had no disclosures.
