Jou nal o he Ame ican Hea Associa ion
J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 1
SYSTEMATIC REVIEW AND META- ANALYSIS
Synch onous and Me ach onous Tho acic
Ao ic Aneu ysms in Pa ien s Wi h
Abdominal Ao ic Aneu ysms: A Sys ema ic
Re iew and Me a-Analysis
Ryan Gou eia e Melo , MD; Gonçalo Sil a Dua e , MD; Alice Lopes , MD; Ma iana Al es , MD;
Daniel Caldei a , MD, PhD; Ruy Fe nandes e Fe nandes , MD; Luís Mendes Ped o , MD, PhD
BACKGROUND: The p e alence o ho acic ao ic aneu ysms (TAA) in pa ien s wi h known abdominal ao ic aneu ysms (AAA)
is no well known and unde s udied. Ou aim was o conduc a sys ema ic e iew and me a-analysis o he o e all p e alence
o synch onous and me ach onous TAA (SM-TAA) in pa ien s wi h a known AAA and o unde s and he cha ac e is ics o his
sub-popula ion.
METHODS AND RESULTS: We sea ched MEDLINE, EMBASE, and CENTRAL (Coch ane Cen al Regis e o Con olled T ials)
om incep ion o No embe 2019 o all popula ion-based s udies epo ing on he p e alence o SM-TAAs in a coho o
pa ien s wi h AAA. A icle sc eening and da a ex ac ion we e pe o med by 2 au ho s and da a we e pooled using a andom-
e ec s model o p opo ions using F eeman-Tukey double a csine ans o ma ion. The main ou come was he p e alence
o SM-TAAs in pa ien s wi h AAAs. Seconda y ou comes we e he p e alence o synch onous TAAs, me ach onous TAAs,
p e alence o TAAs in pa ien s wi h AAA acco ding o he ana omic loca ion (ascending, a ch, and descending) and he di e -
ences in p e alence o hese aneu ysms acco ding o sex and isk ac o s. Six s udies we e included. The pooled-p e alence
o SM-TAA in AAA pa ien s was 19.2% (95% CI, 12.3–27.3). Resul s e ealed ha 15.2% (95% CI, 7.1–25.6) o men and 30.7%
(95% CI, 25.2–36.5) o women wi h AAA had an SM-TAA. Women wi h AAA had a 2- old inc eased isk o ha ing an SM-TAA
han men ( ela i e isk [RRs], 2.16; 95% CI, 1.32–3.55). Diabe es melli us was associa ed wi h a 43% dec eased isk o ha ing
SM-TAA (RRs, 0.57; 95% CI, 0.41–0.80).
CONCLUSIONS: Since a i h o AAA pa ien s will ha e an SM-TAA, ou ine sc eening o SM-TAA and hei clinical impac should
be mo e ho oughly s udied in pa ien s wi h known AAA.
Key Wo ds: abdominal ao ic aneu ysms ■ me a-analysis ■ me ach onous ao ic aneu ysms ■ synch onous ao ic aneu ysms
■ ho acic ao ic aneu ysms
Aneu ysmal disease is known nowadays o be a
sys emic, mul i ac o ial, and unp edic able condi-
ion wi h di e en causes, beha io s and p esen-
a ions which inc ease he complexi y o i s diagnosis,
ea men , and ou comes.1,2
Abdominal ao ic aneu ysms (AAA) a e by a he
mos common and s udied aneu ysms and sc eening
s a egies ha e shown o be e ec i e, educing he in-
cidence in aneu ysm up u e a e and imp o emen o
ca e in a cos -e ec i e ashion.3
The p esence o synch onous and me ach onous
aneu ysms has been well desc ibed in he li e a u e.4
Howe e , in con as o synch onous pe iphe al aneu-
ysms which a e equen ly sc eened and epo ed,
Co espondence o: Ryan Gou eia e Melo, MD, Hospi al de San a Ma ia – Cen o Hospi ala Uni e si á io Lisboa No e, EPE, Se iço de Angiologia e Ci u gia
Vascula . A enida P o esso Egas Moniz, 1649-028 Lisboa, Po ugal. E-mail: [email protected]
Supplemen a y Ma e ial o his a icle is a ailable a h ps://www.ahajo u nals.o g/doi/suppl/ 10.1161/JAHA.120.017468
Fo Sou ces o Funding and Disclosu es, see page 10.
© 2020 The Au ho s. Published on behal o he Ame ican Hea Associa ion, Inc., by Wiley. This is an open access a icle unde he e ms o he C ea i e
Commons A ibu ion-NonComme cial-NoDe i s License, which pe mi s use and dis ibu ion in any medium, p o ided he o iginal wo k is p ope ly ci ed, he use
is non-comme cial and no modi ica ions o adap a ions a e made.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 2
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
he incidence and beha io o synch onous/me a-
ch onous ho acic ao ic aneu ysms (SM-TAA) is
unde app ecia ed.4
In a p e ious s udy in ou cen e , we ound
ha 18.9% o pa ien s submi ed o Tho acic
Endo ascula Ao ic Repai , had a synch onous o
me ach onous AAA.5 Howe e , ho acic ao ic an-
eu ysms (TAA) in gene al, do no ha e a sc eening
p og am o da e and he incidence and p e alence
o hese aneu ysms is unde app ecia ed. Since
up u e o TAAs in pa ien s wi h a known AAA o
ollowing an AAA epai has been desc ibed,4,6,7
be e unde s anding o he p e alence o hese
synch onous/me ach onous TAAs in pa ien s wi h
a known AAA migh be c ucial o pa ien s, physi-
cians, and policy make s.
Ou aim was o es ima e he o e all p e alence o
synch onous and me ach onous TAAs in pa ien s wi h
a known AAA.
METHODS
The P e e ed Repo ing I ems o Sys ema ic
Re iews and Me a-Analyses guidelines8 we e ol-
lowed o epo ing and design o his sys ema ic
e iew. The au ho s decla e ha all suppo ing da a
a e a ailable wi hin he a icle (and i s online supple-
men a y iles).
Eligibili y C i e ia
We included all coho s udies, ei he p ospec i e
o e ospec i e, epo ing on he p e alence o ho-
acic ao ic aneu ysms in a popula ion o pa ien s wi h
known abdominal ao ic aneu ysm, i espec i e o he
diagnos ic me hod used. We accep ed he de ini ion o
AAA o TAA p o ided by he s udies. We de ined syn-
ch onous aneu ysms as occu ing concomi an ly and
me ach onous aneu ysms i he diagnosis o a new
TAA occu ed 2 yea s a e he ini ial AAA diagnosis
and no TAA was p esen ini ially.
The e we e no da e o language es ic ions. Animal
s udies we e no included.
Pape s we e excluded i hey did no speci y he
speci ic numbe o SM-TAA. I he same popula ion
was desc ibed in 2 pape s 1 o hem was excluded o
no duplica e e en s. Pape s we e also excluded i he
s udied popula ion ( he denomina o ) included pa ien s
wi hou AAA.
In o ma ion Sou ces and Sea ch Me hod
We sea ched EMBASE, MEDLINE, and CENTRAL
(Coch ane Cen al Regis e o Con olled T ials), om
incep ion o No embe 2019. We also c oss-checked
e e ences and consul ed specialis s o addi ional
po en ial s udies. The sea ch s a egy is de ailed in
TableS1.
The sea ch esul s we e c oss-checked, and dupli-
ca es we e elimina ed.
S udy Selec ion, Da a Collec ion P ocess,
and Syn hesis
Two au ho s (R.G.M. and A.L.) independen ly sc eened
he i les and abs ac s ha yielded om he sea ch.
Full- ex pape s we e also independen ly assessed
by bo h au ho s and disag eemen s we e esol ed by
consul ing wi h a hi d au ho (G.D.).
A e he inal sea ch esul , da a we e inde-
penden ly ex ac ed by 2 au ho s (R.G.M. and A.L.)
using a p e-design epo o m and uploaded on o a
able shee a e c oss-checking.
Da a e ie ed included: s udy publica ion da a
(au ho s, da e, jou nal), popula ion s udied (yea s o
he s udy and espec i e cen e s), s udy si e, numbe
o pa icipan s wi h known AAA, numbe o pa ien s
wi h SM-TAA and AAA, demog aphics (age, sex, isk
CLINICAL PERSPECTIVE
Wha Is New?
• We ound ha 19.2% o pa ien s wi h abdomi-
nal ao ic aneu ysm ha e a synch onous o me-
ach onous ho acic ao ic aneu ysm.
• Women ha e a 2- old highe isk o ha ing a
synch onous o me ach onous abdominal and
ho acic ao ic aneu ysm.
• Diabe es melli us is associa ed wi h a 43%
dec eased isk o ha ing a synch onous o
me ach onous abdominal and ho acic ao ic
aneu ysm.
Wha A e he Clinical Implica ions?
• Rou ine sc eening o synch onous/me ach o-
nous ho acic ao ic aneu ysms and hei
clinical impac should be mo e ho oughly s ud-
ied in pa ien s wi h known abdominal ao ic
aneu ysms.
• Di e ences in p e alence ound be ween men
and women migh explain, in pa , why women
ha e wo se ou comes ollowing abdominal ao -
ic aneu ysm epai .
Nons anda d Abb e ia ions and Ac onyms
CENTRAL Coch ane Cen al Regis e o
Con olled T ials
SM-TAA synch onous and me ach onous
ho acic ao ic aneu ysms
TAA ho acic ao ic aneu ysms
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 3
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
ac o s), loca ion o he TAA, diagnos ic me hods used,
and de ini ions o TAA and AAA used.
The main ou come o in e es was he o e all p e -
alence o SM-TAA in pa ien s wi h known AAA. The
p e alence was de ined as he numbe o exis ing
TAAs a he ime o he s udy in he popula ion o pa-
ien s wi h known AAA.
The seconda y ou comes o in e es included he
p e alence o synch onous TAAs; he p e alence o
me ach onous TAAs; he p e alence o SM-TAA ac-
co ding o he ana omic loca ion and he di e ence in
he p e alence o SM-TAA and AAA acco ding o sex
and o he isk ac o s (smoking, hype ension, diabe es
melli us, amily his o y o AAA/TAA, hype lipidemia,
and ch onic obs uc i e pulmona y disease).
S a is ical Analysis
We used he Open-Me a (Analys ) So wa e9 o
quan i a i e analysis and o de i e o es plo s, when
app op ia e.
The esul s yielded by he da a ex ac ion we e ex-
p essed in pe cen ages o he p e alence o SM-TAA.
The o al numbe o indi iduals wi h known AAA was
used as he denomina o and he numbe o pa ien s
wi h SM-TAA and AAA as he nume a o .
Figu e 1. P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analyses diag am.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 4
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
A andom-e ec s model was used o pool he
da a o accoun o he he e ogenei y o he included
s udies.9 The andom-e ec s model o De Simonian
and Lai d was used by de aul as his app oach is he
simples and mos commonly used me hod o i ing
he andom e ec s model and is pa icula ly use ul o
la ge samples.10 F eeman-Tukey ans o ma ion (dou-
ble a csine ans o ma ion) was used o adjus he da a
se o es ima e he equency o he e en s, limi ing he
CI among 0% o 100%.11 Fo subg oup sex analysis,
we dicho omized he p e alence da a and used male
sex as he e e ence g oup and o subg oup isk ac-
o analysis we used he g oup wi h AAA-only as he
e e ence g oup, esul s we e epo ed using isk a-
ios [RRs] and 95% CIs. S a is ical he e ogenei y was
assessed using I2, which was de ined as low (25%),
mode a e (50%), o high (75%) acco ding o Higgins
and Thompson.12
Table 1. S udy De ails Including Coho O igin and De ini ions
S udy
Yea s o he
S udy Loca ion Coho O igin
De ini ion o
AAA De ini ion o TAA
Me hods o
Diagnosing
TAA
La sson
e al, 201115
2004–2008 S ockholm, Sweden
(Ka olinska Uni e si y
Hospi al)
Pa ien s wi h AAA
diagnosis a ending he
ou pa ien clinic
Diame e
≥30mm
Women: AAD
>42mm, DAD
>33mm;
Men: AAD >47mm
and DAD >37mm
CT
Chae
e al, 20124
2000–2008 Pi sbu gh,
Pennsyl ania, USA
(Uni e si y o Pi sbu gh)
Elec onic medical
eco d
Diame e >50%
no mal diame e
o diame e
≥30mm
Diame e >30mm CT, MR, o MR
angiog am
Takigawa
e al, 201218
2001–2006 Yokosuba, Japan
(Ca dio ascula Cen e )
Unde going elec i e
g a eplacemen o
asymp oma ic in a enal
AAA
NR Diame e >40mm CT
Ag icola
e al, 201314
2013 Milan, I aly (San Ra aele
Hospi al)
Pa ien s wi h AAA who
unde wen TE be o e
su ge y
NR Women: AAD
>42mm, AA chD
>32;
Men: AAD >47mm,
AA chD >37mm
TE
Wallinde
e al, 201817
2013 Uppsala and
Väs e no land, Sweden
Swedish na ional
ascula egis y
Diame e
≥30mm
Diame e ≥42
(ascending); D ≥33
(descending)
CT
Domb owski
e al, 201916
2007–2017 Michigan, USA
(Beaumon Heal h
Sys em)
Radiology epo s o
AAA
Diame e
≥30mm
Diame e ≥40mm CT
AAA indica es abdominal ao ic aneu ysms; AAD, ascending ao ic diame e ; AA chD, ao ic a ch diame e ; CT, compu ed omog aphy; DAD, descending
ao ic diame e ; MR, magne ic esonance; NR, no epo ed; TAA, ho acic ao ic aneu ysm; and TE, ans ho acic echoca diog aphy.
Table 2. S udy Da a
S udy
No. o
Pa icipan s
Mean Age,
y (SD) Men/Women, n (%)
Pa ien s Wi h
TAA (n)
Synch onous;
Me ach onous
TAA (n)
Loca ion o he
Aneu ysm—Asc;
Desc; A ch (n)
TAAs—Men/
Women, n (%)
La sson e al,
201115
354 74 (NR) 274 (77.4)/80 (22.6) 100 100; NR 12; 94; 6 62 (62)/38 (38)
Chae e al,
20124
1082 74.6 (9) 724 (66.9)/358 (33.1) 253 117; 136 NR 143 (68.5)/105
(41.5)
Takigawa e al,
201218
157 72.7 (7.5) 128 (82)/29 (18) 13 13; NR 2; 8; 3 NR
Ag icola e al,
201314
1305 NR 1034 (79.2)/271
(20.8)
137 137; NR 52; NR; 85 66 (48)/71 (52)
Wallinde e al,
201817
217 75 (NR) 0 (0)/217 (100) 67 NR; NR 8; 53; 2 NR/67 (100)
Domb owski
e al, 201916
218 74 (NR) 136 (62.4)/82 (37.6) 40 40; NR 19; 13; 8 20 (50)/20 (50)
AAA indica es abdominal ao ic aneu ysms; A ch, ao ic a ch; Asc, ascending ho acic ao a; CT, compu ed omog aphy; Desc, descending ho acic ao a;
NR, no epo ed; and TAA, ho acic ao ic aneu ysm.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 5
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
Sensi i i y analysis was pe o med acco ding o he
diagnos ic me hod used (compu ed omog aphy [CT]
scan o magne ic esonance/magne ic esonance-an-
giog am e sus ans ho acic echoca diog aphy), o
he de ini ion o AAA used (only pa ien s admi ed
o AAA epai e sus all pa ien s wi h an abdominal
ao ic diame e ≥3cm) and ype o pa ien s included
(bo h men and women e sus only women).
Risk o Bias
We adap ed and used he C i ical App aisal Skills
P og am coho s udy checklis o assess o isk o
bias, in which we ca ego ized 9 i ems as ha ing high,
unclea , o low isk o bias.13 Two au ho s (R.G.M. and
A.L.) independen ly assessed each included pape . The
o e all isk o bias o each s udy was di ided as high-
o low- isk, wi h high- isk s udies conside ed hose in
which a leas 2 i ems we e assessed a a high isk o
bias, o whe e >3 i ems we e a ed as unclea .
RESULTS
Included S udies
The sea ch yielded 3563 pape s which esul ed in 3197
a icles a e duplica es we e emo ed. A e i le and
abs ac sc eening, 44 pape s we e included in he ull-
ex assessmen . O hese, 6 a icles we e included in
he e iew.4,14–18 The easons o exclusion o he emain-
de 38 ull- ex a icles assessed a e de ailed in Figu e1.
S udy Cha ac e is ics and Demog aphic
Da a
O e all, 3333 pa ien s wi h known AAA we e included.
O hese, 610 we e ound o ha e an SM-TAA.
De ini ions o bo h AAA and TAA a ied ac oss s ud-
ies (Table1). Fou pape s4,15–17 de ined AAA as an in-
c ease in he ao ic diame e ≥30mm and 2 pape s14,18
did no gi e p ecise de ini ion o AAA. Howe e , bo h o
hese la e s udies included pa ien s who we e unde go-
ing elec i e AAA epai , so we can assume he de ini ion
o be a diame e o , a leas 50mm.14,18,19 The diagnos-
ic me hod o TAA also a ied: CT in 4 s udies15–18; CT,
magne ic esonance, o magne ic esonance-angio-
g am in one,4 and ans ho acic echoca diog aphy in
ano he .14 Speci ic demog aphic da a, including isk
ac o s, o all pa icipan s in bo h g oups (synch o-
nous/me ach onous and only AAA pa ien s) we e only
de ailed in 2 s udies.4,16 Mean age in he o al coho
a ied be ween 72.5 and 75yea s. Mos pa ien s in he
coho we e men, excep o he pape by Wallinde e
al17 which only analyzed emale pa ien s (Table2).
Figu e 2. Fo es plo analyzing he p e alence o synch onous/me ach onous ho acic ao ic aneu ysm in pa ien s wi h
known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-TAA, synch onous/me ach onous ho acic ao ic aneu ysm.
Figu e 3. Fo es plo analyzing he p e alence o synch onous ho acic ao ic aneu ysm in pa ien s wi h known abdominal
ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and S-TAA, synch onous ho acic ao ic aneu ysm.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 6
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
Only 1 pape 4 p o ided wi h indi idualized da a o
bo h synch onous and me ach onous TAAs, 4 pa-
pe s14–16,18 only epo ed on synch onous TAAs and
ano he included bo h synch onous and me ach onous
TAAs bu did no epo he speci ic numbe o each.17
Th ee pape s p o ided he indica ions o ches
imaging: in he Ag icola e al14 s udy he eason was
o measu e he ascending ao a and ao ic a ch
diame e and in he o he 2 s udies he majo i y o
pa ien s pe o med a ches CT o non-ao ic e-
la ed p oblems, mos ly o pulmona y indica ions
(74% in Chae e al4 and 68% in Domb owski e al16).
In o ma ion on speci ic ao ic diame e o he TAAs
was only a ailable in 2 s udies.4,17 In he Wallinde
e al17 s udy, one ascending ao ic aneu ysm had
≥60mm and 14 descending ao ic aneu ysms had
≥55mm leading o 13 o he pa ien s ha ing unde -
gone epai . In he Chae e al4 s udy hey epo ed
ha 61 o 253 pa ien s unde wen epai , up u ed,
o had a TAA >55mm, and 13 pa ien s died om a
up u ed TAA. Mo ali y om TAA was no desc ibed
in any o he pape .
Risk o Bias
O e all, he isk o bias was conside ed o be high. The
main sou ce o isk o bias was he absence o adjus -
ing o key isk ac o s, which occu ed in all s udies,
such as age, smoking, and hype ension. Addi ional
sou ces o isk o bias we e: he selec i e ec ui men
o pa ien s unde going AAA epai in he s udies by
Ag icola e al14 and Takigawa e al,18 a he han in-
cluding e e y pa ien wi h AAA (ie, diame e ≥30mm);
and in he way he ou come (p e alence o TAA) was
measu ed in he s udy by Ag icola e al,14 which used
ans ho acic echoca diog aphy only (Figu eS1).
P e alence o Synch onous/
Me ach onous TAA in Pa ien s Wi h
Known AAA
O e all, we ound ha 19.2% o pa ien s wi h AAA had
an SM-TAA (95% CI, 12.3–27.3; I2=96%; 6 s udies;
3333 pa icipan s)—Figu e2.
Indi idualized P e alence o Synch onous
and Me ach onous TAA in Pa ien s Wi h
Known AAA
The p e alence o synch onous TAA in pa ien s wi h
known AAA was 14.6% (95% CI, 0.09–20.9; I2=94%;
5 s udies;, 3116 pa icipan s)—Figu e3. Only he s udy
om Chae e al4 speci ied he numbe o me ach o-
nous TAAs in pa ien s wi h known AAA and ound a
p e alence o 12.7%.
Figu e 4. Fo es plo analyzing he p e alence o synch onous/me ach onous ascending ho acic ao ic aneu ysm in
pa ien s wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-ascTAA: synch onous/me ach onous ascending ho acic ao ic aneu ysm.
Figu e 5. Fo es plo analyzing he p e alence o synch onous/me ach onous descending ho acic ao ic aneu ysm in
pa ien s wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-descTAA, synch onous/me ach onous descending ho acic ao ic aneu ysm.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 7
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
P e alence o Synch onous/
Me ach onous TAA in Pa ien s Wi h
Known AAA Acco ding o Ana omic
Loca ion
The p e alence o SM-TAA in pa ien s wi h known AAA
acco ding o he ana omic loca ion o he TAA was 4% in
he ascending ho acic ao a (95% CI, 2.4–5.7; I2=69%;
5 s udies; 2251 pa icipan s)—Figu e 4; 14.1% in he
descending ho acic ao a (95% CI, 4.7–27.3; I2=96%;
4 s udies; 946 pa icipan s)—Figu e5 and 2.8% in ol -
ing he ao ic a ch (95% CI, 0.9–5.5; I2=87%; 5 s udies;
2251 pa icipan s)—Figu e6.
P e alence and Risk o Synch onous/
Me ach onous TAA in Pa ien s Wi h
Known AAA Acco ding o Sex
We ound ha 15.2% o male pa ien s wi h AAA had
an SM-TAA (95% CI, 7.1–25.6; I2=97%; 4 s udies; 2168
pa icipan s)—Figu e7. In emale pa ien s, he p e a-
lence was highe : 30.7% o emale pa ien s wi h AAA
had an SM-TAA (95% CI; 25.2–36.5; I2=71%; 5 s udies;
1008 pa icipan s)—Figu e8.
Compa ing bo h g oups, women wi h AAA had a
2- old inc eased isk o ha ing SM-TAA compa ed wi h
men wi h AAA (RRs, 2.16; 95% CI, 1.32–3.55; I2=90%;
4 s udies; 2168 pa icipan s)—Figu e9.
Risk o Synch onous/Me ach onous TAA
in Pa ien s Wi h Known AAA Acco ding o
O he Risk Fac o s
In o ma ion on isk ac o s in bo h g oups (SM-TAA
and only AAA pa ien s) was only a ailable in 2 s ud-
ies.4,16 O e all, diabe es melli us was associa ed wi h a
43% dec eased isk o ha ing SM-TAA and AAA (RRs,
0.57; 95% CI, 0.41–0.80; I2=0%; 2 s udies; 1007 pa -
icipan s)—Figu e 10. All o he iden i ied isk ac o s:
smoking; hype ension; ch onic obs uc i e pulmona y
disease; amily his o y o ao ic aneu ysm; and hype -
lipidemia we e no associa ed wi h an inc eased o de-
c eased isk o ha ing an SM-TAA and AAA (Table3).
Sensi i i y Analysis
To analyze he impac o using di e en diagnos ic
me hods (namely ans ho acic echoca diog aphy), di -
e en de ini ions o AAA and only including emale pa-
ien s in he s udy, we pe o med a sensi i i y analysis
e alua ing hese e ec s (Table4). Excluding he pape
om Ag icola e al,14 which used ans ho acic echoca -
diog aphy as he diagnos ic me hod o sc een o TAAs
and sc eened only o ascending and a ch aneu ysms,
showed an inc ease in he p e alence (19.2% e sus
21.5%). Howe e , when analyzing acco ding o he ana-
omic loca ion he p e alence emained he same on
ascending TAAs and was lowe on a ch TAAs (2.8%
Figu e 7. Fo es plo analyzing he p e alence in men o synch onous/me ach onous ho acic ao ic aneu ysm in pa ien s
wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-TAA, synch onous/me ach onous ho acic ao ic aneu ysm.
Figu e 6. Fo es plo analyzing he p e alence o synch onous/me ach onous ho acic ao ic a ch aneu ysm in pa ien s
wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-a chTAA: synch onous/me ach onous a ch ho acic ao ic aneu ysm.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 8
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
e sus 1.9%). Also, when we only included pape s using
a de ini ion o ≥30mm4,15–17 o AAAs he p e alence o
SM-TAA also inc eased (19.2% e sus 25%).
DISCUSSION
The main indings o his e iew we e: (1) he o e all
p e alence o SM-TAA in pa ien s wi h a known AAA
was 19.2% (95% CI, 12.3–27.3) and (2) he p e alence
o SM-TAA was highe in women—30.7% (95% CI,
25.2–36.5) e sus 15.2% (95% CI, 7.1–25.6)—wi h a
2- old inc ease in isk.
These indings a e su p ising as almos a i h o
e e y pa ien wi h an AAA will ha e a TAA and ha
numbe inc eases o almos a hi d in women.
Sc eening s a egies o AAA wi h an abdominal
ul asound ha e shown o be e ec i e, educing he
incidence in aneu ysm up u e a e and imp o emen
o ca e in a cos -e ec i e ashion.3 Con a y o AAAs,
implemen ing a sc eening s a egy o TAAs is di icul ,
since o an accu a e diagnosis, a ches CT is usually
necessa y. T ans ho acic echoca diog aphy migh
ind some bu ce ainly no all TAAs, especially in he
descending ho acic ao a. We ound his in ou sen-
si i i y analysis: he p e alence inc eased (19.2% e -
sus 21.5%) when we excluded he s udy om Ag icola
e al.14 In ac , in his la e s udy,14 which used only
ans ho acic echoca diog aphy o sc een o TAAs,
he p e alence desc ibed o synch onous TAAs in pa-
ien s wi h known AAA was only 10.5%, which is p ob-
ably because o he ac ha descending TAAs we e
no sc eened (Table4).
The absence o a imely diagnosis has led o a lo
o TAAs passing undiagnosed un il a complica ion oc-
cu s, such as up u e, which is usually a al.20,21 A TAA
diagnosed be o e up u e is a po en ial li e sa ed and
his is usually made acciden ally. We ound ha 19.2%
o AAAs ha e an SM-TAA, his means ha sc eening
e e y pa ien wi h a known AAA wi h a ches CT migh
be use ul. Mo eo e , dea h a ibu able o up u e o
o he aneu ysms, such as TAAs, is al eady a p oblem
ecognized in long- e m ollow-up o AAA epai .4,6,7,22,23
Cu en ly, he e a e no clea indica ions in he cu en
Socie y o Vascula Su ge y guidelines19 abou ull ao -
ic imaging when an AAA is diagnosed. Al hough mo e
esea ch is needed o demons a e cos -e ec i eness
and he eal impac o hese SM-TAA, we belie e TAA
sc eening in pa ien s wi h a known AAA should p obably
become common p ac ice since 19.2% is no negligible.
The di e ence ound be ween male and emale
sex is s iking. I has been known ha women ha e a
lowe h eshold o aneu ysm up u e and ha e wo se
ou comes a e AAA epai , e en when ope a ed a
smalle diame e s.24,25 No one has ye clea ly unde -
s ood why his occu s. The highe p e alence o syn-
ch onous/me ach onous ho acic and abdominal ao ic
Figu e 9. Fo es plo analyzing ela i e isk o emale sex compa ing wi h male sex on he p e alence o synch onous
ho acic ao ic aneu ysm in pa ien s wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-TAA, synch onous/me ach onous ho acic ao ic aneu ysm.
Figu e 8. Fo es plo analyzing he p e alence in women o synch onous/me ach onous ho acic ao ic aneu ysm in
pa ien s wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; and SM-TAA, synch onous/me ach onous ho acic ao ic aneu ysm.
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J Am Hea Assoc. 2020;9:e017468. DOI: 10.1161/JAHA.120.017468 9
Gou eia e Melo e al Synch onous/Me ach onous Tho acic Ao ic Aneu ysms
aneu ysms in women, migh indica e ha aneu ysm
disease has a di e en pa hophysiology in he emale
sex, wi h a di e en and p obably mo e agg essi e and
sys emic beha io han in men. This migh be one o
he causes o hese wo se long- e m ou comes ound
in women. Unde s anding his ac migh lead us o in-
c ease ou diagnos ic suspicion o synch onous and
me ach onous TAAs and lead us o be e su eillance
and ul ima ely imp o ed ca e.
Because o lack o da a, we we e no able o an-
alyze in-dep h o he isk ac o s which migh be p e-
dic i e o highe p e alence o SM-TAA. We ound
diabe es melli us o be nega i ely associa ed wi h he
isk o ha ing SM-TAA and AAA, howe e , his da a
we e only a ailable in 2 s udies,4,16 which limi s ou
indings. In he pape om Chae e al4 posi i e p e-
dic o s o SM-TAA we e Black ace; amily his o y o
TAA; hype ension; and obesi y; and nega i e p edic-
o s we e diabe es melli us, in a- enal loca ion o he
AAA; and smoking.
This e iew has some limi a ions, he di e ence in
s udy designs on diagnos ic me hod and de ini ions o
bo h AAA and TAAs b ings some clinical and possibly
s a is ical he e ogenei y o ou esul s in gene al. The
ac ha he da a e ie ed was no age-s anda dized
also limi s ou indings, and explains, a leas , pa -
ially, he s a is ical he e ogenei y. The lack o da a
abou isk ac o s in bo h g oups (synch onous and
AAA-only pa ien s), such as smoking o hype en-
sion, limi ed ou analysis on possible con ounding o
p edic i e ac o s o he p esence o SM-TAA. O he
impo an da a ha we e no a ailable ac oss all s ud-
ies was he size o he TAAs ound, he numbe o
TAAs ha up u ed, and hei mo ali y be o e epai ,
which limi s ou analysis abou isk and he p ognosis
o hese aneu ysms.
Fu he s udies a e needed o unde s and he clini-
cal beha io o synch onous and me ach onous TAAs
in AAA pa ien s (including hei mo bidi y and mo al-
i y), wha is he ue impac o sc eening pa ien s wi h
an AAA wi h a ches CT, o assess he cos -e ec i e-
ness o such a sc eening p og am and o unde s and
hei ela ionship wi h he emale sex.
A easible obse a ional s udy would be o compa e
2 ime pe iods: p e- and pos -SM-TAA sc eening wi h
a ches CT in all pa ien s wi h a known AAA o add ess
he impac o sc eening in he numbe o ea able/nea
ea able TAAs and he numbe o p e en able up u ed
TAAs and dea hs. Also, using la ge egis y da a would
be use ul o iden i y o he clinical cha ac e is ics ha
migh be mo e common in pa ien s wi h synch onous
o me ach onous ao ic aneu ysms.
CONCLUSIONS
This me a-analysis inc eases he e idence abou he
p esence o synch onous/me ach onous TAA in pa-
ien s wi h known AAA. The highe p e alence o hese
aneu ysms in women is s iking and migh explain one
o he aspec s why wo se ou comes on ollow-up o
AAA a e obse ed in women and shows he impo -
ance o ao ic sc eening in women.
To imp o e sho - and long- e m ou comes a e
AAA epai , he au ho s ecommend ha ou ine
sc eening o synch onous and me ach onous TAAs
and hei clinical impac should be mo e ho oughly
s udied, since 19.2% o AAAs wi h an SM-TAA is no a
negligible numbe .
Table 3. Rela i e Risk o Ha ing a Synch onous TAA and
AAA Compa ed Wi h Pa ien s Wi h AAA Only Ac oss he
Di e en Risk Fac o s
Risk Fac o Rela i e Risk
Diabe es melli us 0.57 (95% CI, 0.41–0.80; I2=0%;
2 s udies; 1007 pa icipan s)
Smoking 0.97 (95% CI, 0.85–1.10; I2=62%;
2 s udies; 1007 pa icipan s)
Hype ension 1.01 (95% CI, 0.94–1.01; I2=70%;
2 s udies; 1007 pa icipan s)
Hype lipidemia 1.10 (95% CI, 0.89–1.3; I2=58%;
2 s udies; 1007 pa icipan s)
COPD 1.09 (95% CI, 0.93–1.28; I2=0%;
2 s udies; 1007 pa icipan s)
Family his o y o AAA/TAA 2.37 (95% CI, 0.97–5.77; I2=35%;
2 s udies; 1007 pa icipan s)
AAA indica es abdominal ao ic aneu ysm; COPD, ch onic obs uc i e
pulmona y disease; and TAAs, ho acic ao ic aneu ysms.
Figu e 10. Fo es plo analyzing ela i e isk o diabe es melli us on he p e alence o synch onous ho acic ao ic
aneu ysm in pa ien s wi h known abdominal ao ic aneu ysm.
AAA indica es abdominal ao ic aneu ysm; DM, diabe es melli us; RR, ela i e isk; and SM-TAA, synch onous/me ach onous ho acic
ao ic aneu ysm.
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