Archives of Academic Emergency Medicine. 2020; 8(1): e4 OR I G I N A L RE S E A RC H Characteristics and Outcome of Abdominal Aortic Aneurysm in Emregncy Department; a 10-year Cross- sectional Study Mohammad Mehdi Forouzanfar1, Fatemeh Barazesh1, Behrooz Hashemi1, Saeed Safari2,1∗ 1. Emergency Department, Shohadye Tajrish Hospital, Shahid Behehsti University of Medical Sciences, Tehran, Iran. 2. Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: October 2019; Accepted: December 2019; Published online: 25 January 2020 Abstract: Introduction: Abdominal aortic aneurysm (AAA, triple A) is one of the less common but important causes of abdominal pain. This study aimed to evaluate the characteristics and outcome of patients presenting to emer- gency department with triple A. Methods: In this retrospective cross-sectional study, all cases with confirmed triple A, who were presented to the emergency department of Shohadaye Tajrish Hospital, Tehran, Iran from 2006 to 2017 (10 years) were enrolled using census sampling method. Results: 500 cases with the mean age of 68.11 ± 11.98 (25 - 94) years were studied (84% male). The mean duration of symptoms was 2.32 ± 9.58 months and mean aneurysmal size was 63.91 ± 20.08 mm. In 4 (0.8%) cases, atrial fibrillation (AF) was found during cardiac monitoring. Patients stayed in the hospital for an average of 7.06 ± 6.32 days. Aneurysmal leak was seen in 130 (26%) cases based on abdominal computed tomography (CT) scan findings. 369 (73.8%) cases underwent aneurysmorrhaphy, 126 (25.2%) were treated with non-surgical approaches, and 5 (1%) underwent grafting. 104 (20.8%) died and 396 (79.2%) were treated successfully. Older age (p = 0.017), shock state at the time of presenta- tion (p < 0.0001), leakage of aneurysm (p < 0.001), larger size of aneurysm (p = 0.024), and aneurysmorrhaphy (p < 0.001) were among the factors significantly associated with mortality. Conclusion: Based on the findings, the most frequent presenting symptom of patients was abdominal pain. The mortality rate of this series was 21% and older age, shock state, leakage of aneurysm, larger size of aneurysm, and performing aneurysmorrhaphy were among the factors significantly associated with mortality. Keywords: Aortic aneurysm, abdominal; abdominal pain; iliac aneurysm; outcome assessment Cite this article as: Forouzanfar M M, Barazesh F, Hashemi B, Safari S. Characteristics and Outcome of Abdominal Aortic Aneurysm in Em- regncy Department; a 10-year Cross-sectional Study. Arch Acad Emerg Med. 2020; 8(1): e4. 1. Introduction Abdominal aortic aneurysm is a progressive abnormal local dilatation due to gradual aorta wall weakness (1). It is de- fined as increase in the mean diameter of abdominal aorta by twice the standard error of mean, and has a prevalence rate of 0.5 to 7.2 percent in men and 1 to 1.3 percent in women (2, 3). Abdominal aortic aneurysm is usually asymptomatic un- til rupture (2). The risk of spontaneous rupture in these pa- tients depends on the aortic diameter with rates of less than 0.5%, 1%, 11%, and 26% in cases with diameter less than 4 cm, 4-5 cm, 5-6 cm, and 6-7 cm, respectively (4). Nearly 50 ∗Corresponding Author: Saeed Safari; Emergency Department, Shohadye Tajrish Hospital, Shahrdari Avenue, Tajrish Square, Tehran, Iran. Tel: 00989128251535, Email: safari266@gmail.com | s.safari@sbmu.ac.ir to 90 percent of patients with aneurysmal rupture die before surgery, especially elderly men (5). Also, the postoperative mortality rate is more than forty percent (6). Prompt diagno- sis and elective surgery would decrease the mortality rate to less than six percent (7). Postoperative 30-day mortality rate in elective cases is 5 to 8 percent (8). Considering the high mortality and morbidity rates in cases with abdominal aortic aneurysm and importance of early diagnosis to decrease the burden of the problem and noting the increase in frequency of aneurysm due to increased life longevity and higher rate of atherosclerotic diseases (9-14), this study aimed to evaluate the characteristics and outcome of patients with abdominal aortic aneurysm presenting to emergency department. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M M. Forouzanfar et al. 2 2. Methods 2.1. Study design and setting In this retrospective cross-sectional study, patients with ab- dominal aortic aneurysm presenting to emergency depart- ment of Shohadaye Tajrish Hospital, Tehran, Iran, from 2006 to 2017 (10 years) were studied. The study protocol was ap- proved by ethics committee of Shahid Beheshti University of Medical Sciences (Ethics code: IR.SBMU.MSP.REC.1396.189). Researchers adhered to principles of Helsinki decleration re- garding the ethical issues in biomedical studies. 2.2. Participants All patients with confirmed abdominal aortic aneurysm, who had presented to the emergency department during the study period, were enrolled using census sampling method. Patients with an incomplete medical profile and those dis- charged against medical advice were excluded. There was not any age or sex limitation. 2.3. Data gathering Data were extracted from patients’ medical profiles using predesigned checklists containing demographic data (age, gender), presenting chief complaint, medical history, fam- ily history of aneurysm, characteristics of aneurysm (loca- tion, size), presence or absence of leakage based on com- puted tomography (CT) scan findings, and treatment ap- proach, as well as outcome (mortality). A third year emer- gency medicine resident was responsible for data gathering. 2.4. Statistical Analysis Data analysis was done using SPSS version 21.0 statisti- cal software. Findings were presented as mean ± standard deviation or frequency (%) for numerical and categorical variables, respectively. The utilized tests were chi-square, independent-sample-t test, and Fisher’s exact test. P values less than 0.05 were considered statistically significant. 3. Results 3.1. Baseline characteristics of patients 500 cases with the mean age of 68.11 ± 11.98 (25 - 94) years were studied (84% male). Table 1 shows the base- line characteristics of studied patients. Anatomical loca- tion of aneurysm was abdominal aorta in 468 (93.6%) cases, abdomino-thoracic aorta in 28 (5.6%) cases, and iliac artery in 4 (0.8%) cases. The most frequent chief complaint of pa- tients at the time of presenting to ED was abdominal pain (73.8%). The mean duration of symptoms was 2.32 ± 9.58 months and mean aneurysmal size was 63.91 ± 20.08 mm. In 4 (0.8%) cases, atrial fibrillation (AF) was found during car- diac monitoring. Table 1: Baseline characteristics of studied patients Variables Frequency (%) Gender Male 412 (82.4) Female 88 (17.6) Presenting cheif complaint Abdominal pain 369 (73.8) Shock state 30 (6.0) Limb ischemia 40 (8.0) Chest pain 22 (4.4) Others 39 (7.8) Medical history Cerebrovascular accident 44 (8.8) Hypertension 258 (51.6) Smoking 169 (33.8) Dyslipidemia 57 (11.4) Diabetes mellitus 50 (10.0) Ischemic heart disease 173 (34.6) Chronic kidney disease 23 (4.6) Abdominal surgery 28 (5.6) Family history of aneurysm No 497 (99.4) Yes 3 (0.06) Location of aneurysm Abdominal aorta 468 (93.6) Iliac artery 4 (0.8) Thoracic aorta 28 (5.6) Leakage of aneurysm No 368 (79.2) Yes 130 (20.8) 3.2. Outcomes Patients stayed in the hospital for an average of 7.06 ± 6.32 days. Aneurysmal leak was seen in 130 (26%) cases based on abdominal CT scan findings. 369 (73.8%) cases under- went aneurysmorrhaphy, 126 (25.2%) were treated with non- surgical approaches, and 5 (1%) underwent grafting. 104 (20.8%) died and 396 (79.2%) were treated successfully. Older age (p = 0.017), shock state at the time of presentation (p < 0.0001), leakage of aneurysm (p < 0.001), larger size of aneurysm (p = 0.024), and aneurysmorrhaphy (p < 0.001) were among the factors significantly associated with mortal- ity (table 2). 4. Discussion Based on the findings, the most frequent presenting symp- tom of patients was abdominal pain. The mortality rate of this series was 21% and older age, shock state, leakage of aneurysm, larger size of aneurysm, and performing aneurys- morrhaphy were among the factors significantly associated with mortality. Mirsharifi et al. (9) assessed 240 elderly patients using abdominal ultrasonography and incidentally found aorta aneurysm in 10% with mean diameter of 3.9 cm. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2020; 8(1): e4 Table 2: Correlation between baseline characteristics of patients and mortality Variables Survived (n = 396) Died (n = 104) P value Gender Male 329 (79.9) 83 (20.1) 0.435 Female 67 (76.1) 21 (23.9) Age (year) Mean ± SD 67.4 ± 11.8 70.7 ±12.3 0.017 Shock state* No 380 (80.9) 90 (19.1) < 0.0001 Yes 16 (53.3) 14 (46.4) Type of surgery Not surgical 119 (94.4) 7 (5.6) Aneurysmorrhaphy 272 (73.2) 97 (26.3) < 0.001 Grafting 5 (100.0) 0 (0.0) Leakage of aeurysm No 334 (90.8) 34 (9.2) < 0.001 Yes 60 (46.2) 70 (53.8) Location of aneurysm Abdominal aorta 370 (79.1) 98 (20.9) Iliac artery 3 (75.0) 1 (25.0) 0.907 Thoracic aorta 23 (82.1) 5 (17.9) Medical history No 78 (80.4) 19 (19.6) 0.743 Yes 318 (78.9) 85 (21.1) Duration of symptom (month) Mean ± SD 1.9 ± 3.7 2.04 ± 5.4 0.881 Aneurysm size (mm) Mean ± SD 62.4 ±18.4 71.6 ± 21.9 0.024 Duration of hospital stay Mean ± SD 7.4 ± 5.8 5.7 ± 7.6 0.014 Data are presented as frequency (%) or mean ± standard deviation (SD). *: At the time of presenting to emergency department. Kuivaniem et al. (10) reported that smoking and family his- tory are the most important risk factors for abdominal aor- tic aneurysm. They also reported that mortality rate ranged from 50 to 80 percent, whereas it was only 20 percent in our study. Chabok et al. (11) assessed 50,000 female subjects from the general population and reported that 82 subjects had abdominal aortic aneurysm and also stated that smok- ing, hypertension, older age, ischemic heart disease (IHD), and stroke were its main risk factors. Tang et al. (12) assessed 15729 patients and reported that 5.5% had abdominal aor- tic aneurysm, which was more common among men, smok- ers, and those with dyslipidemia as shown in our study, es- pecially about the effects of gender and smoking. Yuan et al. (13) assessed 465 patients and reported hypertension, smok- ing, and dyslipidemia as the main risk factors for abdominal aortic aneurysm, which is similar to our results, especially re- garding the first two factors. Giribono and colleagues (14) assessed nine cases with ab- dominal aortic aneurysm, 4 of which required endovascu- lar surgery and all were successful. But in our study, twenty percent of the patients died, especially cases under aneurys- morrhaphy. Assessment of factors affecting the outcome is important for being able to predict the prognosis in patients with abdominal aortic aneurysm. In the current study, about 80% of the cases were discharged with good outome. Considering the factors significantly associated with mortal- ity in this study (older age, shock state, leakage of aneurysm, larger size of aneurysm, and performing aneurysmorrha- phy), it seems that performing prophylactic abdominal ul- trasonography in high risk subjects such as smokers and hy- pertensive patients could be helpful in detection of cases in younger age and with stable situation. Controlling the risk factors and planning for management before patients show symptoms and face a critical situation seems to be a logical strategy to reduce mortality. 5. Limitations Retrospective study design, missing data, not following the patients, and being a single center study were among the most important limitations of this study. 6. Conclusion Based on the findings, the most frequent presenting symp- tom of patients was abdominal pain. The mortality rate of This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M M. Forouzanfar et al. 4 this series was 21% and older age, shock state, leakage of aneurysm, larger size of aneurysm, and performing aneurys- morrhaphy were among the factors significantly associated with mortality. 7. Declarations 7.1. Acknowledgements All efforts of emergency department and documentary unit staff of Shohadaye Tajrish Hospital are appritiated. 7.2. Author contribution All the authors met the criteria of authorship based on the recommendations of the international committee of medical journal editors. Authors ORCIDs Mohammad Mehdi Forouzanfar: 0000-0003-0626-8545 Behrooz Hashemi: 0000-0002-5077-8545 Saeed Safari: 0000-0002-7407-1739 7.3. Funding/Support There was no funding and support. 7.4. Conflict of interest We had no conflict of interest. References 1. Lo RC, Schermerhorn ML. Abdominal aortic aneurysms in women. Journal of vascular surgery. 2016;63(3):839-44. 2. Kontopodis N, Lioudaki S, Pantidis D, Papadopoulos G, Georgakarakos E, Ioannou CV. Advances in determining abdominal aortic aneurysm size and growth. World jour- nal of radiology. 2016;8(2):148-58. 3. Gianfagna F, Veronesi G, Bertu L, Tozzi M, Tarallo A, Ferrario M, et al. 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Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations Conclusion Declarations References