Imperial College London

ProfessorJanetPowell

Faculty of MedicineDepartment of Surgery & Cancer

Visiting Professor
 
 
 
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Contact

 

+44 (0)20 8846 7312j.powell

 
 
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Location

 

4N17Charing Cross HospitalCharing Cross Campus

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Summary

 

Publications

Publication Type
Year
to

433 results found

von Allmen RS, Gahl B, Powell JT, 2016, Editor's choice - Incidence of stroke following thoracic endovascular aortic repair for descending aortic aneurysm: a systematic review of the literature with meta-analysis., European Journal of Vascular and Endovascular Surgery, Vol: 53, Pages: 176-184, ISSN: 1532-2165

OBJECTIVE: Stroke is an increasingly recognised complication following thoracic endovascular aortic repair (TEVAR). The aim of this study was to systematically synthesise the published data on perioperative stroke incidence during TEVAR for patients with descending thoracic aneurysmal disease and to assess the impact of left subclavian artery (LSA) coverage on stroke incidence. METHODS: A systematic review of English and German articles on perioperative (in-hospital or 30 day) stroke incidence following TEVAR for descending aortic aneurysm was performed, including studies with ≥50 cases, using MEDLINE and EMBASE (2005-2015). The pooled prevalence of perioperative stroke with 95% CI was estimated using random effect analysis. Heterogeneity was examined using I(2) statistic. RESULTS: Of 215 studies identified, 10 were considered suitable for inclusion. The included studies enrolled a total of 2594 persons (61% male) between 1997 and 2014 with a mean weighted age of 71.8 (95% CI 71.1-73.6) years. The pooled prevalence for stroke was 4.1% (95% CI 2.9-5.5) with moderate heterogeneity between studies (I(2) = 49.8%, p = .04). Five studies reported stroke incidences stratified by the management of the LSA, that is uncovered versus covered and revascularised versus covered and not-revascularised. In cases where the LSA remained uncovered, the pooled stroke incidence was 3.2% (95% CI 1.0-6.5). There was, however, an indication that stroke incidence increased following LSA coverage, to 5.3% (95% CI 2.6-8.6) in those with a revascularisation and 8.0% (95% CI 4.1-12.9) in those without revascularisation. CONCLUSION: Stroke incidence is an important morbidity after TEVAR, and probably increases if the LSA is covered during the procedure, particularly in those without revascularisation.

Journal article

Powell JT, 2016, Commentary on: "The DanCavas pilot study of multifaceted screening for subclinical cardiovascular disease in men and women aged 65-74 years", European Journal of Vascular and Endovascular Surgery, Vol: 53, Pages: 132-132, ISSN: 1532-2165

Journal article

Powell JT, 2016, Prophylactic abdominal aortic aneurysm repair? Open repair brings early pain but later gain., European Journal of Vascular and Endovascular Surgery, Vol: 52, Pages: 719-720, ISSN: 1532-2165

Journal article

Jones GT, Tromp G, Kuivaniemi H, Gretarsdottir S, Baas AF, Giusti B, Strauss E, van 't Hof FN, Webb T, Erdman R, Ritchie MD, Elmore JR, Verma A, Pendergrass S, Kullo IJ, Ye Z, Peissig PL, Gottesman O, Verma SS, Malinowski J, Rasmussen-Torvik LJ, Borthwick K, Smelser DT, Crosslin DR, de Andrade M, Ryer EJ, McCarty CA, Bottinger EP, Pacheco JA, Crawford DC, Carrell DS, Gerhard GS, Franklin DP, Carey DJ, Phillips VL, Williams MJ, Wei W, Blair R, Hill AA, Vasudevan TM, Lewis DR, Thomson IA, Krysa J, Hill GB, Roake J, Merriman TR, Oszkinis G, Galora S, Saracini C, Abbate R, Pulli R, Pratesi C, Saratzis A, Verissimo A, Bumpstead SJ, Badger SA, Clough RE, Cockerill GW, Hafez H, Scott DJ, Futers TS, Romaine SP, Bridge K, Griffin KJ, Bailey MA, Smith A, Thompson MM, van Bockxmeer F, Matthiasson SE, Thorleifsson G, Thorsteinsdottir U, Blankensteijn JD, Teijink JA, Wijmenga C, de Graaf J, Kiemeney LA, Lindholt JS, Hughes AE, Bradley DT, Stirrups K, Golledge J, Norman PE, Powell JT, Humphries SE, Hamby SE, Goodall AH, Nelson CP, Sakalihasan N, Courtois A, Ferrell RE, Eriksson P, Folkersen L, Franco-Cereceda A, Eicher JD, Johnson AD, Betsholtz C, Ruusalepp A, Franzén O, Schadt E, Björkegren JL, Lipovich L, Drolet AM, Verhoeven E, Zeebregts CJ, Geelkerken RH, van Sambeek MR, van Sterkenburg SM, de Vries JP, Stefansson K, Thompson JR, de Bakker PI, Deloukas P, Sayers RD, Harrison S, van Rij AM, Samani NJ, Bown MJet al., 2016, Meta-analysis of genome-wide association studies for abdominal aortic aneurysm identifies four new disease-specific risk loci., Circulation Research, Vol: 120, Pages: 341-353, ISSN: 1524-4571

RATIONALE: Abdominal aortic aneurysm (AAA) is a complex disease with both genetic and environmental risk factors. Together, 6 previously identified risk loci only explain a small proportion of the heritability of AAA. OBJECTIVE: To identify additional AAA risk loci using data from all available genome-wide association studies (GWAS). METHODS AND RESULTS: Through a meta-analysis of 6 GWAS datasets and a validation study totalling 10,204 cases and 107,766 controls we identified 4 new AAA risk loci: 1q32.3 (SMYD2), 13q12.11 (LINC00540), 20q13.12 (near PCIF1/MMP9/ZNF335), and 21q22.2 (ERG). In various database searches we observed no new associations between the lead AAA SNPs and coronary artery disease, blood pressure, lipids or diabetes. Network analyses identified ERG, IL6R and LDLR as modifiers of MMP9, with a direct interaction between ERG and MMP9. CONCLUSIONS: The 4 new risk loci for AAA appear to be specific for AAA compared with other cardiovascular diseases and related traits suggesting that traditional cardiovascular risk factor management may only have limited value in preventing the progression of aneurysmal disease.

Journal article

Powell JT, 2016, Diverse requirements for efficient population screening for abdominal aortic aneurysm, Circulation, Vol: 134, Pages: 1149-1151, ISSN: 0009-7322

Journal article

Patel R, Sweeting MJ, Powell JT, Greenhalgh RMet al., 2016, Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial, Lancet, Vol: 388, Pages: 2366-2374, ISSN: 1474-547X

BackgroundShort-term survival benefits of endovascular aneurysm repair (EVAR) versus open repair of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is lost after a few years. We investigated whether EVAR had a long-term survival benefit compared with open repair.MethodsWe used data from the EVAR randomised controlled trial (EVAR trial 1), which enrolled 1252 patients from 37 centres in the UK between Sept 1, 1999, and Aug 31, 2004. Patients had to be aged 60 years or older, have aneurysms of at least 5·5 cm in diameter, and deemed suitable and fit for either EVAR or open repair. Eligible patients were randomly assigned (1:1) using computer-generated sequences of randomly permuted blocks stratified by centre to receive either EVAR (n=626) or open repair (n=626). Patients and treating clinicians were aware of group assignments, no masking was used. The primary analysis compared total and aneurysm-related deaths in groups until mid-2015 in the intention-to-treat population. This trial is registered at ISRCTN (ISRCTN55703451).FindingsWe recruited 1252 patients between Sept 1, 1999, and Aug 31, 2004. 25 patients (four for mortality outcome) were lost to follow-up by June 30, 2015. Over a mean of 12·7 years (SD 1·5; maximum 15·8 years) of follow-up, we recorded 9·3 deaths per 100 person-years in the EVAR group and 8·9 deaths per 100 person-years in the open-repair group (adjusted hazard ratio [HR] 1·11, 95% CI 0·97–1·27, p=0·14). At 0–6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0·61, 95% CI 0·37–1·02 for total mortality; and 0·47, 0·23–0·93 for aneurysm-related mortality, p=0·031), but beyond 8 years of follow-up open-repair had a significantly lower mortality (adjusted HR 1·25, 95% CI 1·00–1·56, p=0&mi

Journal article

Kelsey LJ, Miller K, Norman PE, Powell JT, Doyle BJet al., 2016, The influence of downstream branching arteries on upstream haemodynamics, JOURNAL OF BIOMECHANICS, Vol: 49, Pages: 3090-3096, ISSN: 0021-9290

Journal article

Kiru G, Bicknell C, Falaschetti E, Powell J, Poulter Net al., 2016, An evaluation of the effect of an angiotensin-converting enzyme inhibitor on the growth rate of small abdominal aortic aneurysms: a randomised placebo-controlled trial (AARDVARK), Health Technology Assessment, Vol: 20, ISSN: 1366-5278

BACKGROUND: Although data are inconsistent, angiotensin-converting enzyme inhibitors (ACE-Is) have been associated with a reduced incidence of abdominal aortic aneurysm (AAA) rupture in analysis of administrative databases. OBJECTIVES: (1) To investigate whether or not the ACE-I perindopril (Coversyl arginine, Servier) reduces small AAA growth rate and (2) to evaluate blood pressure (BP)-independent effects of perindopril on small AAA growth and to compare the repeatability of measurement of internal and external aneurysm diameters. DESIGN: A three-arm, multicentre, single-blind, randomised placebo-controlled trial. SETTING: Fourteen hospitals in England. PARTICIPANTS: Men or women aged ≥ 55 years with an AAA of 3.0-5.4 cm in diameter by internal or external measurement according to ultrasonography and who met the trial eligibility criteria. INTERVENTIONS: Patients were randomised to receive 10 mg of perindopril arginine daily, 5 mg of the calcium channel blocker amlodipine daily or placebo daily. MAIN OUTCOME MEASURES: The primary outcome was AAA diameter growth using external measurements in the longitudinal plane, which in-trial studies suggested was the preferred measure. Secondary outcome measures included AAA rupture, AAA repair, modelling of the time taken for the AAA to reach the threshold for intervention (5.5 cm) or referral for surgery, tolerance of study medication (measured by compliance, adverse events and quality of life) and a comparison of the repeatability of measures of internal and external AAA diameter. Patients were followed up every 3-6 months over 2 years. RESULTS: In total, 227 patients were recruited and randomised into the three groups, which were generally well matched at baseline. Multilevel modelling was used to determine the maximum likelihood estimates for AAA diameter growth. No significant differences in the estimates of annual growth were apparent [1.68 (standard error 0.02) mm, 1.77 (0.

Journal article

Kelsey LJ, Powell JT, Norman PE, Miller K, Doyle BJet al., 2016, A comparison of hemodynamic metrics and intraluminal thrombus burden in a common iliac artery aneurysm, International Journal for Numerical Methods in Biomedical Engineering, Vol: 33, ISSN: 2040-7947

Aneurysms of the common iliac artery (CIAA) are typically found in association with an abdominal aortic aneurysm (AAA). Isolated CIAAs, in the absence of an AAA, are uncommon. Similar to AAAs, CIAA may develop intraluminal thrombus (ILT). As isolated CIAAs have a contralateral common iliac artery for comparison, they provide an opportunity to study the hemodynamic mechanisms behind ILT formation. In this study, we compared a large isolated CIAA and the contralateral iliac artery using computational fluid dynamics to determine if hemodynamic metrics correlate with the location of ILT. We performed a comprehensive computational fluid dynamics study and investigated the residence time of platelets and monocytes, velocity fields, time-averaged wall shear stress, oscillatory shear index, and endothelial cell activation potential. We then correlated these data to ILT burden determined with computed tomography. We found that high cell residence times, low time-averaged wall shear stress, high oscillatory shear index, and high endothelial cell activation potential all correlate with regions of ILT development. Our results show agreement with previous hypotheses of thrombus formation in AAA and provide insights into the computational hemodynamics of iliac artery aneurysms.

Journal article

van 't Hof FNG, Ruigrok YM, Lee CH, Ripke S, Anderson G, de Andrade M, Baas AF, Blankensteijn JD, Böttinger EP, Bown MJ, Broderick J, Bijlenga P, Carrell DS, Crawford DC, Crosslin DR, Ebeling C, Eriksson JG, Fornage M, Foroud T, von Und Zu Fraunberg M, Friedrich CM, Gaál EI, Gottesman O, Guo D-C, Harrison SC, Hernesniemi J, Hofman A, Inoue I, Jääskeläinen JE, Jones GT, Kiemeney LALM, Kivisaari R, Ko N, Koskinen S, Kubo M, Kullo IJ, Kuivaniemi H, Kurki MI, Laakso A, Lai D, Leal SM, Lehto H, LeMaire SA, Low S-K, Malinowski J, McCarty CA, Milewicz DM, Mosley TH, Nakamura Y, Nakaoka H, Niemelä M, Pacheco J, Peissig PL, Pera J, Rasmussen-Torvik L, Ritchie MD, Rivadeneira F, van Rij AM, Santos-Cortez RLP, Saratzis A, Slowik A, Takahashi A, Tromp G, Uitterlinden AG, Verma SS, Vermeulen SH, Wang GT, Aneurysm Consortium; Vascular Research Consortium of New Zealand, Han B, Rinkel GJE, de Bakker PIWet al., 2016, Shared Genetic Risk Factors of Intracranial, Abdominal, and Thoracic Aneurysms., Journal of the American Heart Association, Vol: 5, ISSN: 2047-9980

BACKGROUND: Intracranial aneurysms (IAs), abdominal aortic aneurysms (AAAs), and thoracic aortic aneurysms (TAAs) all have a familial predisposition. Given that aneurysm types are known to co-occur, we hypothesized that there may be shared genetic risk factors for IAs, AAAs, and TAAs. METHODS AND RESULTS: We performed a mega-analysis of 1000 Genomes Project-imputed genome-wide association study (GWAS) data of 4 previously published aneurysm cohorts: 2 IA cohorts (in total 1516 cases, 4305 controls), 1 AAA cohort (818 cases, 3004 controls), and 1 TAA cohort (760 cases, 2212 controls), and observed associations of 4 known IA, AAA, and/or TAA risk loci (9p21, 18q11, 15q21, and 2q33) with consistent effect directions in all 4 cohorts. We calculated polygenic scores based on IA-, AAA-, and TAA-associated SNPs and tested these scores for association to case-control status in the other aneurysm cohorts; this revealed no shared polygenic effects. Similarly, linkage disequilibrium-score regression analyses did not show significant correlations between any pair of aneurysm subtypes. Last, we evaluated the evidence for 14 previously published aneurysm risk single-nucleotide polymorphisms through collaboration in extended aneurysm cohorts, with a total of 6548 cases and 16 843 controls (IA) and 4391 cases and 37 904 controls (AAA), and found nominally significant associations for IA risk locus 18q11 near RBBP8 to AAA (odds ratio [OR]=1.11; P=4.1×10(-5)) and for TAA risk locus 15q21 near FBN1 to AAA (OR=1.07; P=1.1×10(-3)). CONCLUSIONS: Although there was no evidence for polygenic overlap between IAs, AAAs, and TAAs, we found nominally significant effects of two established risk loci for IAs and TAAs in AAAs. These two loci will require further replication.

Journal article

Bicknell CD, Kiru G, Falaschetti E, Powell J, Poulter Net al., 2016, An evaluation of the effect of an angiotensin-converting enzyme inhibitor on the growth rate of small abdominal aortic aneurysms: A randomised placebo controlled trial (AARDVARK), European Heart Journal, Vol: 37, Pages: 3213-3221, ISSN: 1522-9645

Aims The AARDVARK (Aortic Aneurysmal Regression of Dilation: Value of ACE-Inhibition on RisK) trial investigated whether ACE-inhibition reduces small abdominal aortic aneurysms (AAA) growth rate, independent of blood pressure (BP) lowering.Methods and results A three-arm, multi-centre, single-blind, and randomized controlled trial (ISRCTN51383267) was conducted in 14 hospitals in England. Subjects aged ≥55 years with AAA diameter 3.0–5.4 cm were randomized 1:1:1 to receive perindopril arginine 10 mg, or amlodipine 5 mg, or placebo and followed 3–6 monthly over 2 years. The primary outcome was aneurysm growth rate (based on external antero-posterior ultrasound measurements in the longitudinal plane), determined by multi-level modelling to provide maximum likelihood estimates. Two hundred and twenty-four subjects were randomized (2011–2013) to placebo (n = 79), perindopril (n = 73), or amlodipine (n = 72). Mean (SD) changes in mid-trial systolic BP (12 months) were 0.5 (14.3) mmHg, P = 0.78 compared with baseline, −9.5 (13.1) mmHg (P < 0.001), and −6.7 (12.0) mmHg (P < 0.001), respectively. No significant differences in the modelled annual growth rates were apparent [1.68 mm (SE 0.2), 1.77 mm (0.2), and 1.81 mm (0.2), respectively]. The estimated difference in annual growth between the perindopril and placebo groups was 0.08 mm (CI −0.50, 0.65). Similar numbers of AAAs in each group reached 5.5 cm diameter and/or underwent elective surgery: 11 receiving placebo, 10 perindopril, and 11 amlodipine.Conclusion Small AAA growth rates were lower than anticipated, but there was no significant impact of perindopril compared with placebo or placebo and amlodipine, combined despite more effective BP lowering.

Journal article

Ulug P, Powell J, Sweeting MJ, Bown MJ, Thompson SGet al., 2016, Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women, British Journal of Surgery, Vol: 103, Pages: 1097-1104, ISSN: 1365-2168

BackgroundAlthough women represent an increasing proportion of those presenting with abdominal aortic aneurysm (AAA) rupture, the current prevalence of AAA in women is unknown. The contemporary population prevalence of screen-detected AAA in women was investigated by both age and smoking status.MethodsA systematic review was undertaken of studies screening for AAA, including over 1000 women, aged at least 60 years, done since the year 2000. Studies were identified by searching MEDLINE, Embase and CENTRAL databases until 13 January 2016. Study quality was assessed using the Newcastle–Ottawa scoring system.ResultsEight studies were identified, including only three based on population registers. The largest studies were based on self-purchase of screening. Altogether 1 537 633 women were screened. Overall AAA prevalence rates were very heterogeneous, ranging from 0·37 to 1·53 per cent: pooled prevalence 0·74 (95 per cent c.i. 0·53 to 1·03) per cent. The pooled prevalence increased with both age (more than 1 per cent for women aged over 70 years) and smoking (more than 1 per cent for ever smokers and over 2 per cent in current smokers).ConclusionThe current population prevalence of screen-detected AAA in older women is subject to wide demographic variation. However, in ever smokers and those over 70 years of age, the prevalence is over 1 per cent.

Journal article

Powell JT, Sweeting MJ, 2015, Retrospective Studies, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 50, Pages: 675-678, ISSN: 1078-5884

Journal article

Powell JT, Hinchliffe RJ, 2015, Emerging strategies to treat ruptured abdominal aortic aneurysms, Expert Review of Cardiovascular Therapy, Vol: 13, Pages: 1411-1418, ISSN: 1477-9072

Population screening programmes and a falling population prevalence of smoking have led to a declining incidence of ruptured abdominal aortic aneurysms in men. However, ruptured abdominal aortic aneurysms remain a common vascular surgical emergency, with an increasing proportion of ruptures being in women. About one quarter of the ruptures have a juxta-renal aneurysm and are more challenging to repair using endovascular technologies. Endovascular technologies may not reduce the overall mortality, compared with open surgical repair, but appear to offer early benefits with respect to patient quality of life at acceptable cost. Challenges over the next 5 years include widening the access to repair, developing an accurate bedside risk scoring tool, as well as optimising strategies for pre-operative resuscitation, standardising peri-operative care and the management of post-operative complications.

Journal article

Powell JT, Ulug P, 2015, PATIENTS AND TRIAL ENROLMENT DECISIONS Flexibility in trial enrolment decisions, BMJ, Vol: 351, ISSN: 1756-1833

Journal article

Powell JT, 2015, Questionnaires for Surgical Research: Not Always a Simple Option, European Journal of Vascular and Endovascular Surgery, Vol: 50, Pages: 534-534, ISSN: 1532-2165

Journal article

Sweeting MJ, Balm R, Desgranges P, Ulug P, Powell JT, Ruptured Aneurysm Trialistset al., 2015, Individual-patient meta-analysis of three randomized trials comparing endovascular versus open repair for ruptured abdominal aortic aneurysm, British Journal of Surgery, Vol: 102, Pages: 1229-1239, ISSN: 1365-2168

BACKGROUND: The benefits of endovascular repair of ruptured abdominal aortic aneurysm remain controversial, without any strong evidence about advantages in specific subgroups. METHODS: An individual-patient data meta-analysis of three recent randomized trials of endovascular versus open repair of abdominal aortic aneurysm was conducted according to a prespecified analysis plan, reporting on results to 90 days after the index event. RESULTS: The trials included a total of 836 patients. The mortality rate across the three trials was 31·3 per cent for patients randomized to endovascular repair/strategy and 34·0 per cent for those randomized to open repair at 30 days (pooled odds ratio 0·88, 95 per cent c.i. 0·66 to 1·18), and 34·3 and 38·0 per cent respectively at 90 days (pooled odds ratio 0·85, 0·64 to 1·13). There was no evidence of significant heterogeneity in the odds ratios between trials. Mean(s.d.) aneurysm diameter was 8·2(1·9) cm and the overall in-hospital mortality rate was 34·8 per cent. There was no significant effect modification with age or Hardman index, but there was indication of an early benefit from an endovascular strategy for women. Discharge from the primary hospital was faster after endovascular repair (hazard ratio 1·24, 95 per cent c.i. 1·04 to 1·47). For open repair, 30-day mortality diminished with increasing aneurysm neck length (adjusted odds ratio 0·69 (95 per cent c.i. 0·53 to 0·89) per 15 mm), but aortic diameter was not associated with mortality for either type of repair. CONCLUSION: Survival to 90 days following an endovascular or open repair strategy is similar for all patients and for the restricted population anatomically suitable for endovascular repair. Women may benefit more from an endovascular strategy than men and patients are, on average, discharged sooner after endovascular repair.

Journal article

Sweeting MJ, Ulug P, Powell JT, Desgranges P, Balm R, Ruptured Aneurysm Trialistset al., 2015, Ruptured aneurysm trials: The importance of longer-term outcomes and meta-analysis for 1-year mortality., European Journal of Vascular and Endovascular Surgery, Vol: 50, Pages: 297-302, ISSN: 1532-2165

OBJECTIVE: To assess current knowledge for the management of ruptured abdominal aortic aneurysm (AAA), based on the 1-year outcomes of 3 recent randomised trials. METHODS: An individual patient data meta-analysis of three recent randomised trials of endovascular versus open repair, including 817 patients, was conducted according to a pre-specified analysis plan, report all-cause mortality and re-interventions at 1 year after the index event. RESULTS: Mortality across the 3 trials at 1-year was 38.6% for the EVAR or endovascular strategy patient groups and 42.8% for the open repair groups, pooled odds ratio 0.84 (95% CI 0.63-1.11), p = .209. There was no evidence of heterogeneity in the odds ratios between trials. When the patients in the endovascular strategy group of the IMPROVE trial were restricted to those with proven rupture who were anatomically suitable for endovascular repair, the pooled odds ratio reduced slightly to 0.80 (95% CI 0.56-1.16), p = .240. CONCLUSIONS: After 1 year there is a consistent but non-significant trend for lower mortality for EVAR or an endovascular strategy. Taken together with the recent gains in health economic outcomes demonstrated at 1 year in the IMPROVE trial, the evidence suggests that endovascular repair should be used more widely for ruptured aneurysms.

Journal article

Bicknell C, Powell JT, 2015, Aortic disease: thoracic endovascular aortic repair, HEART, Vol: 101, Pages: 586-591, ISSN: 1355-6037

Journal article

Grieve R, Gomes M, Sweeting MJ, Ulug P, Hinchliffe RJ, Thompson MM, Thompson SG, Ashleigh R, Greenhalgh RM, Powell JT, IMPROVE trial investigatorset al., 2015, Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial., European Heart Journal, Vol: 36, Pages: 2061-2069, ISSN: 1522-9645

AIMS: To report the longer term outcomes following either a strategy of endovascular repair first or open repair of ruptured abdominal aortic aneurysm, which are necessary for both patient and clinical decision-making. METHODS AND RESULTS: This pragmatic multicentre (29 UK and 1 Canada) trial randomized 613 patients with a clinical diagnosis of ruptured aneurysm; 316 to an endovascular first strategy (if aortic morphology is suitable, open repair if not) and 297 to open repair. The principal 1-year outcome was mortality; secondary outcomes were re-interventions, hospital discharge, health-related quality-of-life (QoL) (EQ-5D), costs, Quality-Adjusted-Life-Years (QALYs), and cost-effectiveness [incremental net benefit (INB)]. At 1 year, all-cause mortality was 41.1% for the endovascular strategy group and 45.1% for the open repair group, odds ratio 0.85 [95% confidence interval (CI) 0.62, 1.17], P = 0.325, with similar re-intervention rates in each group. The endovascular strategy group and open repair groups had average total hospital stays of 17 and 26 days, respectively, P < 0.001. Patients surviving rupture had higher average EQ-5D utility scores in the endovascular strategy vs. open repair groups, mean differences 0.087 (95% CI 0.017, 0.158), 0.068 (95% CI -0.004, 0.140) at 3 and 12 months, respectively. There were indications that QALYs were higher and costs lower for the endovascular first strategy, combining to give an INB of £3877 (95% CI £253, £7408) or €4356 (95% CI €284, €8323). CONCLUSION: An endovascular first strategy for management of ruptured aneurysms does not offer a survival benefit over 1 year but offers patients faster discharge with better QoL and is cost-effective. CLINICAL TRIAL REGISTRATION: ISRCTN 48334791.

Journal article

Hinchliffe RJ, Powell JT, 2015, Improving the outcomes from ruptured abdominal aortic aneurysm: interdisciplinary best practice guidelines, Annals of the Royal College of Surgeons of England, Vol: 95, Pages: 96-97, ISSN: 1478-7083

Journal article

Bjorck M, Bown MJ, Choke E, Earnshaw J, Florenes T, Glover M, Kay M, Laukontaus S, Lees T, Lindholt J, Powell JT, van Rij A, Svensjo S, Wanhainen Aet al., 2015, International Update on Screening for Abdominal Aortic Aneurysms: Issues and Opportunities, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 49, Pages: 113-115, ISSN: 1078-5884

Journal article

Powell JT, Sweeting MJ, Thompson MM, Hinchliffe RJ, Ashleigh R, Bell R, Greenhalgh RM, Thompson SG, Ulug Pet al., 2015, The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm, European Heart Journal, Vol: 36, Pages: 1328-U137, ISSN: 1522-9645

The influence of six morphological parameters (maximum aortic diameter, aneurysm neck diameter, length and conicality,proximal neck angle, and maximum common iliac diameter) on mortality and reinterventions within 30 days was investigatedin rAAA patients randomized before morphological assessment in the Immediate Management of the Patient withRupture: Open Versus Endovascular strategies (IMPROVE) trial. Patients with a proven diagnosis of rAAA, who underwentrepair and had their admission computerized tomography scan submitted to the core laboratory, were included.Among 458 patients (364 men, mean age 76 years), who had either EVAR (n ¼ 177) or open repair (n ¼ 281) started,there were 155 deaths and 88 re-interventions within 30 days of randomization analysed according to a pre-specifiedplan. The mean maximum aortic diameter was 8.6 cm. There were no substantial correlations between the six morphologicalvariables. Aneurysm neck length was shorter in those undergoing open repair (vs. EVAR). Aneurysm neck length(mean 23.3, SD 16.1 mm) was inversely associated with mortality for open repair and overall: adjusted OR 0.72 (95% CI0.57, 0.92) for each 16 mm (SD) increase in length. There were no convincing associations of morphological parameterswith reinterventions.

Journal article

von Allmen RS, Anjum A, Powell JT, Earnshaw JJet al., 2015, Hospital trends of admissions and procedures for acute leg ischaemia in England, 2000-2011, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 97, Pages: 59-62, ISSN: 0035-8843

Journal article

Filardo G, Powell JT, Martinez MA-M, Ballard DJet al., 2015, Surgery for small asymptomatic abdominal aortic aneurysms, COCHRANE DATABASE OF SYSTEMATIC REVIEWS, ISSN: 1469-493X

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Hinchliffe RJ, Powell JT, 2014, The Value of Registries for Rare Diseases Bacterial or Mycotic Aortic Aneurysm, CIRCULATION, Vol: 130, Pages: 2129-2130, ISSN: 0009-7322

Journal article

von Allmen RS, Anjum A, Powell JT, 2014, Outcomes After Endovascular or Open Repair for Degenerative Descending Thoracic Aortic Aneurysm Using Linked Hospital Data, JOURNAL OF VASCULAR SURGERY, Vol: 60, Pages: 1709-1709, ISSN: 0741-5214

Journal article

Vavra AK, Kibbe MR, Bown MJ, Powell JTet al., 2014, Debate: Whether evidence supports reducing the threshold diameter to 5 cm for elective interventions in women with abdominal aortic aneurysms, JOURNAL OF VASCULAR SURGERY, Vol: 60, Pages: 1695-1698, ISSN: 0741-5214

Journal article

Bown MJ, Powell JT, 2014, Part Two: Against the Motion. Evidence Does Not Support Reducing the Threshold Diameter to 5 cm for Elective Interventions in Women with Abdominal Aortic Aneurysms, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 48, Pages: 614-618, ISSN: 1078-5884

Journal article

Filardo G, Lederle FA, Ballard DJ, Hamilton C, da Graca B, Herrin J, Sass DM, Johnson GR, Powell JTet al., 2014, Effect of Age on Survival Between Open Repair and Surveillance for Small Abdominal Aortic Aneurysms, AMERICAN JOURNAL OF CARDIOLOGY, Vol: 114, Pages: 1281-1286, ISSN: 0002-9149

Journal article

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