Diabetes and Abdominal Aortic Aneurysms

19 Pages·2014·3.34 MB·English

by  P. De Rango

REVIEW
Diabetes and Abdominal Aortic Aneurysms
P. De Rango *, L. Farchioni, B. Fiorucci, M. Lenti
VascularandEndovascularSurgeryUnit,HospitalS.MariaMisericordia,UniversityofPerugia,Perugia,Italy
WHAT THIS PAPER ADDS
The systematic review (and meta-analysis) of current evidence focuses on clinical outcomes that support an
inverse relationship between diabetes and abdominal aortic aneurysms (AAA), and higher mortality in diabetic
patients with AAA either in the operative period or in the longterm.The increased cardiovascular burden and
the decreased risk for AAA developmentand expansion suggestcarefuland individualized selection ofdiabetic
patients for treatment of AAA in the future.
Epidemiologic evidence suggests that patients with diabetes may have a lower incidence of abdominal aortic
aneurysm(AAA);however,thelinkbetweendiabetesandAAAdevelopmentandexpansionisunclear.Theaimof
thisreviewistoanalyzeupdatedevidencetobetterunderstandtheimpactofdiabetesonprevalence,incidence,
clinicaloutcome,andexpansionrateofAAA.Asystematicreviewofliteraturepublishedinthelast20yearsusing
thePubMedandCochranedatabaseswasundertaken.Studiesreportingappropriatedatawereidentifiedanda
meta-analysis performed using the generic inverse variance method. Sixty-four studies were identified.
Methodological quality was “fair” in 16 and “good” in 44 studies according to a formal assessment checklist
(NewcastleeOttawa). In 17 large population prevalence studies there was a significant inverse association
betweendiabetesandAAA:pooledoddsratio(OR)0.80;95%confidenceintervals(CI)0.70e0.90(p¼.0009).An
inverse association was also confirmed by pooled analysis of data from smaller prevalence studies on selected
populations (OR 0.59; 95% CI 0.35e0.99; p ¼ .05), while no significant results were provided by case-control
studies.AsignificantlowerpooledincidenceofnewAAAindiabeticswasfoundoversixprospectivestudies:OR
0.54; 95% CI 0.31e0.91; p ¼ .03. Diabetic patients showed increased operative (30-day/in-hospital) mortality
afterAAArepair:pooledOR1.26;95%CI1.10e1.44;p¼.0008.Theincreasedoperativeriskwasmoreevidentin
studieswith30-dayassessment.Inthelong-term,diabeticsshowedlowersurvivalratesat2e5years,whilethere
was general evidence of lower growth rates of small AAA in patients with diabetes compared to non-diabetics.
There is currently evidence to support an inverse relationship between diabetes and AAA development and
enlargement,eventhoughfairmethodologicalqualityorunclearriskofbiasinmanyavailablestudiesdecreases
the strength of the finding. At the same time, operative and long-term survival is lower in diabetic patients,
suggesting increased cardiovascular burden.The higher mortality in diabetics raises the question as to whether
AAA repair should be individualized in selected diabetic populations at higher AAA rupture risk.
(cid:1) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Article history: Received 13 August 2013, Accepted 1 December 2013, Available online 18 January 2014
Keywords: Abdominal aortic aneurysm, Aneurysm growth, Aortic aneurysm development, Aortic aneurysm
incidence, Aortic aneurysm prevalence, Diabetes
INTRODUCTION formation of a degenerative AAA is complex, involving up-
regulation of proteolytic pathways, apoptosis, oxidative
The epidemiology of abdominal aortic aneurysms (AAA) is
becoming more clearly defined with data emerging from stress, inflammation, and loss of arterial wall matrix.1e3
Specifically, matrix loss is seen in the walls of aneurysmal
screeningstudiesandvascularbiologyresearch.Ithasbeen
aorta,while, on the contrary, an excessvascular matrix is a
suggested that AAAs arise when genetically susceptible in-
characteristic of diabetes. For individuals developing dia-
dividuals are exposed to additional risk, such as smoking
betes, it is possible that increases in matrix due to their
and increasing age.The pathologic process involved in the
diabetes compensate for any decrease related to suscepti-
*Corresponding author. P. De Rango,Vascular and Endovascular Unit, bility to AAA. Epidemiologic evidence therefore suggests
UniversityofPerugia,HospitalS.MariaMisericordia,Loc.S.Andreadelle that patients with diabetes may have a lower incidence of
Fratte,06134Perugia,Italy. AAA. However, the precise mechanisms of this inverse as-
E-mailaddress:[email protected](P.DeRango).
sociation are unknown, and the link between diabetes and
1078-5884/$eseefrontmatter(cid:1)2013EuropeanSocietyforVascular
AAA development and expansion is unclear. There is also
Surgery.PublishedbyElsevierLtd.Allrightsreserved.
http://dx.doi.org/10.1016/j.ejvs.2013.12.007 limited information on clinical outcome in patients with
244 P.DeRangoetal.
diabetesandAAAreceivingornotreceivingtreatment.The Assessment of methodological quality and risk of bias
aim of this review was to analyze updated evidence to
Alltheincludedstudieswerenon-randomizedforthestudy
better understand the impact of diabetes on prevalence,
populations (diabetics, non-diabetics), with no level 1 evi-
incidence, and clinical outcome of AAA. The effect of dia-
dence. The quality of these observational studies was
betes on AAA expansion was also reviewed. evaluatedusingthe“NewcastleeOttawaScale”(adoptedby
Wells et al.5), including assessment of selection, compara-
bility,andoutcome/exposureofpatientsincohortandcase-
METHODS
controlstudies.Inaddition,theUSPreventiveServicesTask
A literature search of published studies on diabetes and Forces checklist (adopted by Sawaya et al.6), including
AAA was performed following quality reporting guidelines assessment of quality in reporting, confounding bias, and
setbythePreferredReportingItemsforSystematicReviews external validity was used to score included studies.
and Meta-Analyses.4
MEDLINE,CochraneDatabaseofSystematicReviews,and Risk of bias assessment.The main scoring of the included
Cochrane Central Register of Controlled Trials were studies in this systematic review was based on assessment
searched to identify studies published in the last 20 years of “riskof bias”more than generic “methodological quality
(between 1 January 1993 and 20 July 2013) using the “assessment. Bias may be distinguished from quality.7
following key search words: “diabetes” OR “glycemia” AND “Assessment of methodological quality” has been used
“abdominal aortic aneurysms”, “prevalence”, “incidence”, extensively to refer to the critical appraisal of included
“growth”, “enlargement”, and “outcomes”. No filters were studies.Thetermsuggestsaninvestigationoftheextentto
used to restrict study designs. In addition, reference lists which study authors conducted their research to the high-
were searched for further studies to be included. est possible standards. A study may be performed to the
Two researchers (P.D.R., L.F.) independently performed highestpossiblestandardsyetstillhaveanimportantriskof
abstract, title, and full-text screening. Studies were bias. For example, in randomized trials, it could be that no
included if they reported on AAA with a baseline diameter random allocation was allowed for the populations of in-
of at least 3 cm and provided data for diabetic patients terestinthepresentreview(i.e.,diabeticpatients).Inmany
(distribution of disease, and clinical/morphology outcomes situations, despite the incidence of AAA being tested with
as mortality, morbidity after repair, and aneurysm adjustments for several confounders, no blinding in testing
enlargement). Studies reporting on aortic aneurysms the association with diabetes was clearly used or
involving the thoracoabdominal or thoracic aorta were mentioned.Riskofbiaswasratedas“low”,“unclear”(items
excluded unlessthoracic aneurysms wereused as a control not-knownornot-reported),or“higher”asintheCochrane
group for AAA. In addition, the following were excluded: checklist.7
review articles, studies in which patient data were dupli- Asummaryofthemaincharacteristicsofbiasandquality
cated (in which case, the most recent or comprehensive scoresystemsisshowninSupplementaryTables1Aand1B.
study was used), nonhuman studies, editorials, letters, and
case reports.
Statistical analysis
Where possible, the following data were extracted from
each report: study period, study design, country of origin, Studieswereseparatelyanalyzedaccordingtowhetherthey
source of patients (population screening, hospital reported on prevalence, clinical outcomes, or aneurysm
screening, case-control), defined diabetic patients, sex, growth using RevMan v.5.1 (The Cochrane Collaboration,
intervention policy, duration of follow-up (mean, median), http://ims.cochrane.org/revman).7
outcomes(e.g.,30-dayinhospitalmortality,aorticdiameter For dichotomous outcomes such as mortality and the
measurement), analysis (statistical methods used, employ- prevalence/incidence of AAA, studies with estimates from
ment of univariate or adjusted calculations). twotreatmentarmswerepooledtoobtainanoverallstudy
Thesametwoauthorsindependentlyextracteddatafrom estimate.Theoverallestimates(oneforeachstudy),suchas
the potentially eligible primary studies and cross-checked risk ratio (RR), hazard ratio (HR), or odds ratio (OR) with
their results. Any disagreements between the two re- corresponding confidence intervals (CIs), were then com-
viewers were settled with discussion and re-analysis of the bined in a conventional meta-analysis using the generic
paper data, and resolved by mutual consent. inverse variance option in RevMan where the log RRs for
Studies that failed to provide essential variables (e.g., cohort studies or log ORs for case-control studies and cor-
diabetic patients or AAA) were rejected. responding standard errors (SE) were weighted to obtain a
The effect of diabetes on patients with AAA was inves- pooled estimate.7 As in other meta-analyses, ORs were
tigated for the following outcome measures: considered as approximations of RRs.8 Both random- and
fixed-effect models were used depending on the level of
1. Prevalence and incidence of AAA in patients with heterogeneity among studies. Adjusted estimates of risk
diabetes wereemployedwhenavailable.Ifdatahadbeenpresented
2. Mortality in patients with diabetes and AAA in other forms, we entered total and number of events,
3. Riskofaneurysmenlargementinpatientswithdiabetes respectively, into RevMan 5.1 and first calculated study
and small AAA. estimates (OR with corresponding SE) and then used the
EuropeanJournalofVascularandEndovascular Surgery Volume47Issue 3p.243e261March/2014 245
generic inverse variance method with random- or fixed- For continuous measures, such as aneurysm growth, we
effects weighting. aimed to analyze weighted mean differences using means
Interstudy heterogeneity was assessed by Cochrane’s Q and SDs.When these datawere notavailable, we reported
(chi-squarep<.10)andquantifiedbyI2.TheI2statisticwas summary data with means and ranges, but did not include
used to estimate the percentage of variability between these results in a meta-analysis.
studies because of between-study heterogeneity.7 An I2
(cid:2)50% indicated “substantial” heterogeneity and (cid:2)75% RESULTS
indicated “considerable” heterogeneity.7,8
Search results
To assess the association of diabetes and AAA, large ul-
trasoundcase-cohortstudies,case-cohortscreeningstudies Fig.1showstheflowoftheliteratureselectionapplyingthe
in selected populations, and case-control studies were systematic search and selection strategies to identify
assessed separately. Subgroup analyses were performed to eligible reports. Three hundred and eighty-nine reports
investigate the effect of diabetes in specific settings with were identified. Of these, 228 were found to be irrelevant
informationavailable(e.g.,womenandmen,studydesign). on a review of the titles and abstracts.
Figure1.Flowchart ofselection ofarticles.
246 P.DeRangoetal.
Of the remaining 161 reports that were retrieved and Depending on the availability of required information,
reviewed in full, 12 were excluded because they did not two studies providing incomplete data could not be
contain original data and 23 because they were separate included27,28 in the cumulative analysis of the association
publications at different times of the same study/authors between diabetes and AAA that involved a total 38,900
group. Only the most recent or the most comprehensive patients with AAA and 3,296,269 without AAA.
publication of the results was included in the analyses as Lederle et al.13,14 performed two cohort studies. Com-
representing the cumulative experience of the overall bined data of the two cohorts, provided by the authors in
cohort. After full-text evaluation, 64 articles that provided their most recent article, were used.14 Furthermore, the
information on the association between diabetes and AAA studies of Lederle et al.13,14 provided separate information
wereselected(Tables 1e4).9e72 The RESCAN publication,65 for AAA with a diameter of 3e3.9 cm and those with a
even though it is a review including data from previous diameter of >4 cm, and data were analyzed accordingly.
studies, was retained because of relevant information pro- Cumulative analysis of overall prevalence studies sug-
vided within.The results of this review were notcombined gested lower AAA rates in diabetic patients (pooled OR
with other data already included. 0.79; 95% CI 0.70e0.89; p ¼ .0001). Separate data were
Oftheselected64articles,31reportedontheprevalence provided for large cohort screening, selected populations
of AAA in diabetic patients9e39 and six were prospective screening, and case-control studies.
studies analyzing the incidence of AAA in diabetics.40e45 According to all cohort studies (large screening and
Nineteen provided information on clinical outcome of dia- selected population) a significantly lower association be-
betic patients with AAA undergoing surgery or not or tweenAAAanddiabeteswasfound(OR0.79;95%CI0.69e
endovascular repair (EVAR).46e64 Eight additional studies 0.89; p ¼ .002).
provided data on the morphology outcome of small AAA Specifically, cumulative analysis from the 17 large
andanalyzedtheaneurysmgrowthwithdiabetic status.65e screening population studies9e25 showed a significant in-
72 Cumulative quantitative analyses were possible on 54 verseassociationbetweendiabetesandAAAamong33,407
studies. patients with AAA and 3,290,604 without AAA (OR 0.80;
95% CI 0.70e0.90; p ¼ .0009) (Fig. 2). A significant inverse
associationbetweendiabetesandAAAprevalencewasalso
Quality and risk of bias score results confirmed when the pooled analysis was restricted to the
Overall score risk of bias for each of the 64 individual five screening population studies with lower risk of
studieswasjudgedtobe“unclear”in23and“lower”in38 bias12,14,20e22 (OR 0.66; 95% CI 0.57e0.75; p < .00001)
studies (Supplementary Figs. 1A, B). No studies at higher (Fig. 2B).
bias risk were included in quantitative analysis of data. The overall risk of bias of the three26,29,30 studies
The overall methodological quality of most of the analyzing the association between diabetes and AAA in
included studies was rated as “fair” (n ¼ 16) or “good” selected populations (e.g., patients undergoing cardiac
(n ¼ 44) according to the formal assessment checklist. surgery or with acute coronary syndromes) was “unclear”.
Details of bias and quality score assessment of included Cumulative analysis of the data from the three studies
studies is shown in Supplementary Tables 1A and 1B. showed a borderline inverse association between diabetes
and AAA prevalence (OR 0.59; 95% CI0.35e0.99;p ¼ .05).
Inter-study heterogeneity was <75%, and a fixed-effect
Results on prevalence of AAA and diabetes
model was used (Fig. 3).
Most of the retrieved papers were ultrasound screening According to cumulative data from case-control studies,
AAA studies that reported on the association between including 5,390 patients with AAA and 4,873 controls with
diabetesandAAA.Table1showsthemaincharacteristicsof other diseases or healthy population,31e39 there was no
the 31 selected studies, which included 17 large screening significant association between diabetes and AAA either in
populations,9e25 five selected screening populations (e.g., all studies (OR 0.69; 95% CI 0.40e1.18; p ¼ .17) or when
AAA screening in patients undergoing cardiac surgery)26e30 only the four studies at low risk of bias were combined
and nine case-control studies.31e39 (Fig. 4A, B).
Nineofthesestudieswereratedat“low”riskofbias,and Large cohort screening studies weighted for most of the
multivariateassessmentofconfoundersotherthandiabetes overall effect on prevalence of AAA in diabetics. The dif-
was available.12,14,20e22,31,32,34,38 ference among the effects of different study design is
Overall,in10studiesasignificantinverseassociationwas shown in Supplementary Figs. 2A and 2B, where compari-
recorded betweendiabetesand AAA. Mostof the opposite son between large screening studies versus selected pop-
relationship supporters were large screening population ulation studies and all cohort prevalence studies versus
studies14,20e22 or case-control studies,31e35 whereas case-control studies are displayed.
screening studies with smaller samples were often incon-
clusive,27,29,30 and only one sustained the inverse associa-
tion.26 Three studies provided an opposite positive Results on incidence of AAA and diabetes
association between AAA and diabetes,28,38,39 but only in Six prospective large population studies evaluating the risk
one were adjusted data provided.38 of long-term AAA occurrence in diabetic and non-diabetic
Table1.Abdominal aorticaneurysms(AAA) anddiabetes.Prevalence studies.
E
Study Diabetes AAA Diabetes WithoutAAA Total OR 95%CI p Comments u
r
o
withAAA noAAA p
e
Screening studies:largepopulations a
n
Smithetal.,19939 11 219 143 2,378 2,597 Population. Nosignificantassociationof Jo
u
diabetes/AAA r
n
Pleumeekersetal.,199510 8 112 509 5,192 5,304 Rotterdamstudy. al
Nosignificantassociationofdiabetes/AAA of
Simonietal.,199611 10 70 212 1,504 1,574 .964 Genoapopulation. Nosignificantassociation of Va
s
diabetes/AAA cu
Kanagasabayetal.,199612,a 11 218 234 5,122 5,340 Adj.a0.80a 0.41e1.58a .50 PopulationNosignificantassociationofdiabetes/ lar
a
AAA n
d
Lederleetal.,199713,b 73,451 ADAMpopulationearlycohort. Significant E
n
3.0e3.9cm 2,217 0.68 0.60e0.77 negative associationofdiabetes/AAA d
o
>4.0cm 985 0.54 0.44e0.65 va
s
Lederle,etal.200014,a,b 52,745 Adj.a ADAMpopulationnewcohort. Significant cu
3.0e3.9cm 1,237 0.60a 0.50e0.71a negative associationofdiabetes/AAA lar
>4.0cm 583 0.50a 0.39e0.65a Su
Ishikawa etal.,199915 8 43 173 2,471 2,514 NS Population. Nosignificantassociationof rge
r
diabetes/AAA y
Lederleetal.,combined 5,023 114,419 119,442 Adj.a ADAMpopulation.Cumulative significant
V
199713þ200014,a,c negative associationofdiabetes/AAA olu
3.0e3.9cm 3,455 0.65a 0.59e0.72a m
e
>4.0cm 1,568 0.52a 0.45ea0.61 4
7
Newmanetal.,200116 43 416 505 4,318 4,734 Cardiovascular healthstudy.Medicare. Small Is
AAA. Nosignificantassociationofdiabetes/AAA su
e
Singh200117men 14 263 148 2,699 2,962 .7 Tromsostudy.Men.Nosignificantassociation of 3
(HbA1cþ) HbA1c/AAA p
.
Singhetal.,200117 4 74 184 3,350 3,424 .4 Tromsostudy.Women.Nosignificantassociation 24
women(HbA1cþ) ofHbA1c/AAA 3e
Waterhouse,etal.200618 2 30 39 1,202 1,032 PopulationMen.Nosignificantassociationof 26
1
diabetes/AAA M
DeRubertis etal.,200719 10 74 1,312 9,938 10,012 1.20 0.60e2.36 .61 Women.Nosignificantassociation ofdiabetes/ ar
c
AAA h/
2
Leetal.,200720,a 103 933 1,375 11,270 12,203 Adj.0.79a 0.63e0.98 Healthinmenstudy 0
1
Men.Significantnegativeassociationofdiabetes/ 4
AAA
Baumgartneretal.,200821,a 507 1,722 29,539 66,514 68,236 Adj.0.59a 0.53e0.66 <.0001 REACHRegistryPopulationwiththromboticrisks
Significantnegative associationofdiabetes/AAA
Kentetal.,201022,a 3,236 2,3446 324,532 3,033,009 3,056,455 Adj.0.75a 0.73e0.77 <.0001a Lifelinescreening.Significantnegativeassociation
ofdiabetes/AAA
Palombo etal.,201023 66 512 809 7,722 8,234 .15 Nosignificantassociationofdiabetes/AAA
Svensjöetal.,201124 25 233 1,754 14,378 14,611 .51 National population registrySweden.No
significantassociationofdiabetes/AAA
Svensjöetal.,201225 2 19 498 5,120 5,139 1.09 0.25e4.74 .907 Women.NationalpopulationregistrySweden.No
(women) significantassociationofdiabetes/AAA 2
4
Continuedonnextpage 7
Table1-continued 2
4
Study Diabetes AAA Diabetes WithoutAAA Total OR 95%CI p Comments 8
withAAA noAAA
Screeningstudies:selected populations
Kangetal.,199926 10 68 98 306 374 Adj.a Screeningincarotidstenosis.Significantnegative
>3cma 2,990a 0.58a .002a associationofdiabetes/AAA
>4cma 0.32a .002a
Hanlyetal.,200627,b 41 374 415 1.22 .65 ScreeninginCADpopulation.Nosignificant
associationofdiabetes/AAA
Shiranietal.,200928,b 53 1,907 1,960 2.32 .033 ScreeninginCABGpopulation.Positive
associationofdiabetes/AAA
Dupontetal.,201029 6 15 57 202 217 .38 ScreeninginCABG.Nosignificantassociationof
diabetes/AAA
Longetal.,201030 4 20 87 284 304 .31 ScreeninginACS.Nosignificantassociationof
diabetesAAA
Case-control studies
LaMorteetal.,199531,a 4,682 3,188 Adj.0.78a Adj.0.62e0.98a .03 AAAvs.appendectomy.Significantnegative
appendectomy associationofdiabetesinAAAvs.appendectomy
Blanchardetal.,200032,a 12 98 17 102 200 0.70 0.31e1.55 Case-controlstudy.Significantnegative
Adj.0.32a 0.12e0.88a associationofdiabetesinAAAvs.control
Shteinbergetal.,200033 5 82 26PAOD 73PAOD 155 <.001 AAAvs.PAOD.Significantnegativeassessment.
DiabetesinAAAvsPAOD
Barbaetal.,200534 29 151 279PAOD 1,015PAOD 1,166 RR0.63 0.41e0.96 .0031 AAAvs.PAOD.Significantnegativeassociationof
diabetesinAAAvs.PAOD
Madaricetal.,200535,a 1 16 36noCAD 93noCAD 109 0.11 0.01e0.83 AAAþCADvs.noCAD.Significantnegative
Adj.0.12a 0.01e1.03a associationofdiabetesinAAAvs.control
univariate.Trend multivariate
Wanhainenetal.,200536 3 35 17 140 175 .77 Cross-sectionalAAAvs.age-andsex-matched
control.
NosignificantassociationofdiabetesinAAAvs.
control
Koksaletal.,200737 5 40 7PAOD 40PAOD 80 AAAvs.PAOD.
NosignificantassociationofdiabetesinAAAvs.
PAOD
Itoetal.,200838,a 83 211 30TAA 132TAA 343 2.20 1.36e3.64 .002 AAAvs.TAA.Positiveassociation ofdiabetesin
Adj.1.85a 1.06e3.30a .033a AAAvs.TAA
Parryetal.,201039 13 75 2 90 165 .002 SmallAAAmenvs.age-andsex-matchedcontrol.
PositiveassociationofdiabetesinAAAvs.
controls
Note.OR¼oddsratio;CI¼confidenceintervals;HbA1c¼glycosylatedhemoglobin;PAOD¼peripheralarteryobstructivedisease;CAD¼coronaryarterydisease;TAA¼thoracicaortic
P
aneurysm; Adj. ¼ adjusted; RR ¼ relative risk; NS ¼ not significant; ADAM ¼ Aneurysm Detection and Management; CABG ¼ coronary artery bypass surgery; ACS ¼ acute coronary .
D
syndrome. e
R
a Adjusteddataavailable. a
n
b Data notusedformeta-analysis (cumulative analysis). go
cDatausedformeta-analysis. et
a
l.
E
u
r
o
p
e
a
n
Jo
u
r
n
a
l
o
f
V
a
Table2.Abdominal aorticaneurysms(AAA) anddiabetesmellitus(DM).Incidencestudies. sc
u
Study DMwith NewAAA NoDMwith Without Total OR 95%CI p Follow-up Comments la
r
AAA AAA AAA an
d
Prospectivestudies:incidenceofAAA
E
Törnwalletal., 4 181 NA 28,952 29,133 RR0.43a 0.16e1.15a 5.8ymean Men.Alpha-tocopherol,beta-carotenecancer nd
o
200140,a prevalence study.Nosignificantassociation of v
a
diabetes/AAA sc
u
Rodinetal., 72 418 2,515 18,856 19,274 30ymean ChicagoHeartAssociation DetectionProject la
r
200341 Industry. S
u
Nosignificantassessmentofdiabetes/AAA rg
e
Wongetal., 7 376 NA 38,976 39,352 0.58 0.27e1.22 0.15 16yover Men.Health professionalfollow-upstudy.No ry
200742,a 0.55a 0.26e1.17a 0.12a significantassociationofdiabetes/AAA
V
Iribarrenetal., NA 605 NA 104,208 104,813 0.64 0.38e1.09 13ymedian Multiphasic healthcheckups.Nosignass. o
200743,a Total 0.62a 0.36e1.05a diabetes/AAA lum
e
diabetes
4
3,321 7
Lederleetal., 8 184 9,536 161,624 161,808 0.29a 0.13e0.68a 7.8ymean Women’shealth initiative. Issu
200844,a Postmenopausalwomen.Significantnegative e
3
associationofdiabetes/AAA p
.
Ohrlander NA 3,335; NA 243,223; 246,558; Adj.a Adj.a 13yover LongitudinalMultilevelAnalysis Scania(LOMAS) 2
4
etal.,201245,a 2,351 104,425 106,776 0.38a 0.24e0.61a cohortSignificantnegative associationof 3e
men, men, men, diabetes/AAA inwomenandmen 26
984 138,798 139,782 0.41a 0.19e1.88a 1M
women women women a
r
c
Note.OR¼Oddsratio;CI¼confidence intervals; RR¼relativerisk;Adj.¼adjusted;NA¼ notavailable. h/
2
a Adjusteddataavailable. 0
1
4
2
4
9
Table3.Outcomesindiabeticandnon-diabetic patientswithabdominal aorticaneurysms(AAA). 2
5
Study AAA 30-dmortality Comment 1-yearsurvival 3-yearsurvival Otheroutcomes 0
Katzetal.,199446,a 8,185electiveopen In-hospital Nosignin-hospitalmortalityindiabetics.confirmedinadjusteddata
Diabetes:507 34(6.7%) (data notshown).a
Nodiabetes:7678 584(7.6%) Nolong-termdata.
p¼.6
Treiman etal.,199447 568AAAelectiveopen 30-d Nosignof30-dmortality indiabetics. HigherMIandwound
Diabetes:38 2(5.3%) Nolong-termdata. infection30-dayin
Nodiabetes:530 17(3.2%) diabetics withAAA
p¼NS andPAOD
Dardiketal.,199948,a 2,335electiveopen In-hospital Nosignofin-hospitalmortality indiabetics.
Diabetes:168 5(3.0%) Nolong-termdata.
Nodiabetes:2,167 76(3.5%)
p¼.99a
Sasakietal.,199949,a 79electiveopen repairs In-hospital Nosignofin-hospitalmortality in>75-y-olddiabetics.No
in>75-y-olds 2(16.7%) long-termdata.
Diabetes:12 6(9.0%)
Nodiabetes:67 p¼.268
p¼.082a
Finlaysonetal.,200250 Electiveopen AAA140,577 In-hospital HigherRRindiabeticsbased onprioradmission;lower
(Medicare) Diabetes:11,246(8%) RRprior RRindiabetics basedonindexadmission.
Nodiabetes:129,331 admission: Nolong-termdata.
1.4195%CI
1.25e1.59a
RRindex
admission:
0.76;95%CI
0.64e0.84a
Rayan etal.,200251 422electiveopen 30-d Nosignof30-dmortality 1-y: 3-y: Complicationshigher
(VascularSurgeryRegistry) Diabetes:52 2(3.8%) indiabetics. 91.0% 70.0% indiabetics.
Nodiabetes:370 5(1.4%) Nosignoflong-term 92.6% 73.5%
p¼.19 survival1e5year 5-y:
(p¼.21). 25.0%
50.9%;
p¼.21
Gioiaetal.,200552,a 183open repairsurviving Nodata Onlydataonreadmission 6-moreadmission
afterdischarge at6-months. rateshigherin
Diabetes:5 diabetics
Nodiabetes:178 OR6.6;95%
CI1.02e42.4;
p¼0.047a P.
D
Diehmetal.,200754,a 6383EVAR 30-d Nosignofmortalityat 4-ya: Rupture e
(EUROSTAR) Diabetes:810 31(3.8%)a 30dand4yindiabetics. diabetes27.7% conversion; Ra
n
Nodiabetes:5,573 212(2.7%); vs.nodiabetes p¼NS g
o
p¼.270a 23.4%;p¼NS 30-dand4-y e
t
a
l.
McFallsetal.,200755,a 1,598AAAsurgery Nodata No30-dmortalitydata. 2e5-y: E
u
(CARP) Diabetes:226 Higher2e5 ymortality 77% ro
p
Nodiabetes:1372 indiabeticsinunivariate. HR:1.38; 95% ea
NotconfirmedinCox CI:1.03e1.85; n
(data notshown)a p¼.0 Jou
r
Bergeetal.,200856,a 1,041open orEVAR 30-d Nosignof30-dmortality 5-y: na
l
EVAR:136 HR1.3;95% indiabetics.Higher5-y HR:1.79; 95% o
f
Open:905 CI0.6e2.8); mortalityindiabetics. CI:1.27e2.53 V
a
Diabetes:67(12EVAR) p¼.45a p¼.001a sc
u
Nodiabetes:974(124EVAR) la
r
Wanhainenetal.,200857,a 10,691AAArepair 30-d Higher30-dmortalityindiabetics inrupturedAAA. a
n
(SwedishRegistry) elective(7,175)and Elective AAA: Nohigh30-dmortalityindiabeticsinelectiveAAA. d
E
ruptured(3,516) OR1.4;95% Nolong-termdata. n
d
Diabetes:823(7.7%) CI0.9e2.2; ov
a
Nodiabetes:9,868 p¼0.15a sc
u
RupturedAAA: la
r
OR1.7;95% S
u
CI1.2e2.3; rg
e
p¼.001a ry
Wassinketal.,200853,a 373AAAscreeningstudy No30-ddata Nosignof3-yearmortalityinMetS
(SMART) Diabetes(NCEPMetS):198 Screeningstudy HRat3.2y:1.32;95%CI:0.88e1.97)a Vo
Nodiabetes:175 lum
(diabetesdefinedasNCEP e
4
revised MetS) 7
Gilesetal.,200958,a 22,830electiveAAA 30-d Higher30-dmortalityindiabetics foropen AAAandunivariate. Iss
u
(MedicarePropensity 11,415EVAR EVAR:OR1; Nosignof30-dmortality indiabeticsforEVAR andadjusted e
3
match) 11,415open 95%CI0.7e1.5; data (datanotshown).a p
Diabetes:3,538(1,746 p¼.91 Nolong-termdata. .2
4
EVARþ1,792open) Open;OR1.3; 3
e
Nodiabetes:19,292 95%CI1.1e1.6; 2
6
(9,669EVARþ9,623 p<.01 1
M
open) Noincreased risk a
r
inadjusteda ch
/
Grantetal.,201159,a 1,936electiveopen or 30-d Higher30-dmortalityindiabetics. 2
0
1
EVAR 15(8.7%) Nolong-termdata. 4
Diabetes:172 83(4.7%)
Nodiabetes:1,764 OR1.92;95%
CI1.08e3.41;
p¼.023
OR1.94;95%
CI1.07e3.51);
p¼0.029a
Continuedonnextpage
2
5
1
Table3-continued 2
5
Study AAA 30-dmortality Comment 1-yearsurvival 3-yearsurvival Otheroutcomes 2
Markovic etal.,201060 12,451electiveEVAR In-hospital Nosignofin-hospitalmortality indiabetics.
Diabetes:1,506 OR0.43;95% Nolong-termdata.
Nodiabetes:10,945 CI0.58e3.32;
p¼0.42a
Schlösser,etal.201061,a 3,457electiveAAArepair 28d Nosignofmortalityat 1-y: 5-y:
Diabetes:104 HR1.2295% 28dor1y.Higher5-y HR:1.40;95%CI: HR:1.35; 95%
Nodiabetes:3,353 CI0.68e2.17a mortalityin 0.94e2.09a CI:1.01e1.80a
diabetics.
DeRangoetal.,201262,a 360smallAAAsurveillance Nodata No30-dmortality. 3-y: LowerAAA
(CAESAR) Diabetes:49 Higher3-ymortalityin 88.0% growthin
Nodiabetes:311 diabetic; lowergrowth. 96.1% diabetics
HR:7.39; 95%
CI1.55e35.13;
p¼.012a
Melletal.,201263,a 634AAAsmall Nosurgerynatural No30-daydata.Higher 1-y: 3-y:83.0%
(SCCOR) Diabetes:162 history 1e3ymortalityin 96.8% HR:2.34; 95%
Nodiabetes:472 diabetics. CI:1.19e4.60
HR:2.24; 95%
CI:1.12e4.47a
Hughesetal.,201364,a 2,110electiveopen 30-d Nosignof30-dmortality indiabetics. SSIhigherin
Diabetes:245 13(5.3%) SSIhigherindiabetics. diabetics.
Nodiabetes:1,865 66(3.5%);p¼.171 Nolong-termdata.
OR1.4;95%CI
0.68e2.71a
Note.EUROSTAR¼EuropeanCollaboratorsOnStent-graftTechniquesforAbdominalAorticAneurysmRepair;SCCOR:StanfordAbdominalAorticAneurysmSpecializedCenterofClinically
Oriented Research; CARP ¼ Coronary Artery Revascularization Prophylaxis; SMART ¼ Secondary Manifestations of ARTerial disease; CAESAR: Comparison of surveillance vs. Aortic
Endografting for Small Aneurysm Repair; EVAR ¼ endovascular repair; NCEP ¼ National Cholesterol Education Program; NCEP-R ¼ National Cholesterol Education Program revised;
MetS ¼ metabolic syndrome status; NS ¼ not significant; RR ¼ relative risk; CI ¼ confidence interval; HR ¼ hazard ratio; SSI ¼ superficial surgical site infections; MI ¼ myocardial
infarction; PAOD¼peripheralobstructivearterial disease.
a Adjusteddata available.
P
.
D
e
R
a
n
g
o
e
t
a
l.