Identification of the main determinants of abdominal aorta size: a screening by Pocket Size Imaging Device
Esposito et al. Cardiovascular Ultrasound
Identification of the main determinants of abdominal aorta size: a screening by Pocket Size Imaging Device
Roberta Esposito 1
Federica Ilardi 1
Vincenzo Schiano Lomoriello 1
Regina Sorrentino 1
Vincenzo Sellitto 1
Giuseppe Giugliano 1
Giovanni Esposito 1
Bruno Trimarco 1
Maurizio Galderisi 0 1
0 Interdepartimental Laboratory of Cardiac Imaging, Federico II University Hospital , Via S. Pansini 5,bld 1, 80131 Naples , Italy
1 Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital , Naples , Italy
Background: Ultrasound exam as a screening test for abdominal aorta (AA) can visualize the aorta in 99% of patients and has a sensitivity and specificity approaching 100% in screening settings for aortic aneurysm. Pocket Size Imaging Device (PSID) has a potential value as a screening tool, because of its possible use in several clinical settings. Our aim was to assess the impact of demographics and cardiovascular (CV) risk factors on AA size by using PSID in an outpatient screening. Methods: Consecutive patients, referring for a CV assessment in a 6 months period, were screened. AA was visualized by subcostal view in longitudinal and transverse plans in order to determine the greatest anterior-posterior diameter. After excluding 5 patients with AA aneurysm, 508 outpatients were enrolled. All patients underwent a sequential assessment including clinical history with collection of CV risk factors, physical examination, PSID exam and standard Doppler echoc exam using a 2.5 transducer with harmonic capability, both by expert ultrasound operators, during the same morning. Standard echocardiography operators were blinded on PSID exam and viceversa. Results: Diagnostic accuracy of AA size by PSID was tested successfully with standard echo machine in a subgroup (n = 102) (rho = 0.966, p < 0.0001). AA diameter was larger in men than in women and in ≥50 -years old subjects than in those <50 -years old (both p < 0.0001). AA was larger in patients with coronary artery disease (CAD) (p < 0.0001). By a multivariate model, male sex (p < 0.0001), age and body mass index (both p < 0.0001), CAD (p < 0.01) and heart rate (p = 0.018) were independent predictors of AA size (cumulative R2 = 0.184, p < 0.0001). Conclusion: PSID is a reliable tool for the screening of determinants of AA size. AA diameter is greater in men and strongly influenced by aging and overweight. CAD may be also associated to increased AA diameter.
Abdominal aorta; Pocket size imaging device; Ultrasound; Aging; Cardiovascular risk factors; Coronary artery disease
Abdominal aortic aneurysm (AAA) is a localized
abnormal dilatation of the aorta defined as a diameter ≥30 mm
or a >50% increase of the aortic diameter at the diaphragm
. Incidence of AAA is increasing  due mainly to life
prolongation in the current era. The incidence of AAAs in
the general population is about 1.0 to 1.5% . This
incidence is particularly high in presence of male gender,
advanced age, arterial systemic hypertension, family
history of AAA, peripheral artery disease or coronary artery
disease (CAD), and/or cerebrovascular disease [4–6]. The
most feared complication is rupture, which relates directly
to size and is especially frequent in patients with AAA
>5.5 cm . AAA rupture entails 85–90% overall
mortality, 60% pre-hospital and from 40 to 70% in-hospital
(following emergency interventions) . AAAs usually do not
produce symptoms and ruptured aneurysms often occur
without warning. This comprehensive information
highlights the need for an early detection of abdominal aorta
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(AA) dilatation, together with identification of high-risk
patients that could benefit from a screening program.
Ultrasound exam as a screening test for AAA is able to
visualize the aorta in 99% of patients and has a sensitivity
and specificity approaching 100% in screening settings for
AAA [9, 10]. In addition, ultrasound test is non invasive,
fast, relatively inexpensive, and without biological risk of
radiation. The feasibility of population-based ultrasound
screening of AAA has been established through large
randomized screening trials [11, 12]. Pocket Size Imaging
Device (PSID) is an ultrasound machine not classifiable as
a standard echocardiographic machine because of
impossibility of calculating chamber volumes and quantifying
valvular flow by pulsed or continuous Doppler. It has a
potential value as a screening tool [13, 14], because of its
possible use in several clinical settings.
The present study was designed to identify the
influence of demographic variables and cardiovascular (CV)
risk factors on AA size in a screening of outpatient
population using PSID and to validate it in comparison
to standard transthoracic echo-Doppler exam.
Five hundred thirteen consecutive patients, referring to
Echo-lab of Federico II University hospital for a CV
assessment in a 6 months period, were screened. All
subjects gave written informed consent and the study was
approved by the Institutional Ethical Committee. During
the screening, 5 patients with AAA (diameter ≥ 3.0 cm
in maximum antero-posterior or latero-lateral
dimensions) were identified and excluded from subsequent
analysis. The final study population included 508
outpatients (M/F = 305/203). All the patients underwent a
sequential assessment including: 1. clinical history with
collection of CV risk factors; 2. physical examination; 3.
PSID exam (Vscan, GE, Horten, Norway) and 4.
standard Doppler echocardiographic exam (Vivid E9
ultrasound scanner, GE, Horten, Norway) using a 2.5
transducer with harmonic capability, both by expert
ultrasound operators, during the same morning.
Standard echocardiography operators were blinded on PSID
exam and viceversa.
Arterial systemic hypertension was diagnosed if
systolic blood pressure (BP) exceeded 140 mmHg and/or
diastolic BP exceeded 90 mmHg, or if the patient was
taking antihypertensive drugs . Hypercholesterolemia
was defined as plasma total cholesterol >200 mg/dL,
plasma low-density lipoprotein cholesterol >130 mg/dL,
or when the patient used lipid-lowering medications
. Diabetes mellitus was diagnosed if plasma fasting
glucose exceeded 126 mg/dL or if the patient used
hypoglycaemic drugs . A history of CAD was
documented by hospital records, it including acute
coronary syndromes, angina pectoris, previous coronary
revascularization procedures and positive inducible
AA ultrasound exam was performed using a PSID
(unit + probe = 390 g) which provides 2-D, black and
white and colour flow images (fixed pulse-repetition
frequency and colour-box size), and is connected to a
broad-bandwith, phased array probe (1.7–3.8 MHz). The
flow sector represents blood flow within an angle of 30°.
Videos (automatic autocycle without ECG need) and
images can be produced and stored in separate folders,
recalled via a gallery function and transferred to
hardware by an intermediate docking station. In the present
study we utilized an abdominal setting whereas the
alternative cardiac/thoracic setting was not applied. AA was
visualized using subcostal and abdominal views, with the
patient lying supine. No abdominal preparation was
required. The entire AA was first visualized in longitudinal
and transverse plans from the diaphragm to the aorta
bifurcation in order to determine the greatest aortic
diameter, which was considered for statistical analyses.
Antero-posterior and latero-lateral outer diameters were
measured in the transverse plane, at the largest portion
of infrarenal aorta [18, 19] (Fig. 1). In a subgroup of 102
patients the diagnostic accuracy of AA size
measurements obtained by PSID was tested in comparison with
the same measurements taken by a standard
Statistical analyses were performed by SPSS package,
release 12 (SPSS Inc, Chicago, Illinois, USA). Data are
presented as mean value ± SD. Descriptive statistics were
done by one-factor ANOVA (Bonferroni post-hoc test).
Intra-class correlation analysis was used to assess
agreement of AA size between PSID and standard echo. The
null hypothesis was rejected at p ≤ 0.05.
The feasibility of AA measurements by both PSID and
standard echo machine was 100%.
Figure 2 shows the univariate relation between AA
size measured by PSID and that taken by standard
echocardiography. The agreement between the two
instrumentations was also excellent (rho = 0.966, 95%
CI = 0.956–0.974, p < 0.0001).
Demographic characteristics and CV risk factors of the
study population are listed in Table 1. Of note,
hypertensive patients were 64.9% of the study population, the
majority being under anti-hypertensive therapy.
AA diameter was larger in men (1.84 ± 0.35 cm) than
in women (1.65 ± 0.29 cm) (p < 0.0001) and in
patients with > 50 years (1.80 ± 0.36 cm), compared with
patients >50 years old (1.64 ± 0.25 cm) (p < 0.0001). Of
note, smokers had larger AA diameter in comparison with
Fig. 1 AA visualized in longitudinal and transverse plans from the diaphragm to the bifurcation of the aorta. Antero-posterior and latero-lateral
outer diameters were measured in the transverse plane, at the largest portion of infrarenal aorta. The figure shows the good concordance of the
two measured diameters between standard echocardiography (panel a) and PSID (panel b): 17.89 mm versus 1.77 cm and 17.11 mm versus 1.71 cm
non smokers (p = 0.007) as well as hypercholesterolemic
(p < 0.01) versus non hypercholesterolemic. Conversely,
the presence of both arterial hypertension and diabetes
mellitus did not differentiate larger AA diameters. AA
was larger also in patients with CAD (1.93 ± 0.43 cm)
than in those without (1.72 ± 0.31 cm) (p < 0.0001).
In the pooled population, AA diameter was
positively related to age (p < 0.0001) (Fig. 3), systolic BP
(p < 0.005) (Fig. 4), mean BP and pulse pressure (both
r = 0.11, p < 0.01), weight, height and body mass
index (BMI) (all p < 0.0001) (Fig. 5). Diastolic BP and
heart rate were not significantly related with AA size.
In a multiple linear regression analysis performed in the
pooled population, after adjusting for several confounders,
male sex, age and BMI (all p < 0.0001), and, with a lesser
extent, CAD (p < 0.01) and heart rate (p = 0.018) were
independent predictors of AA size whereas cigarette
Fig. 2 Univariate relation of PSID and standard echocardiographic
machine measurements of abdominal aorta (AA) in a subgroup of
smoking and hypercholesterolemia did not enter the model
(cumulative R2 = 0.184, SEE = 0.31 cm, p < 0.0001)
The present study demonstrates (1) PSID's excellent
feasibility and accuracy in assessing AA size in comparison to
standard echocardiography and that (2) by using this tool,
male sex, age, body mass index are major independent
determinants of AA size, whereas the presence of CAD and
increased heart rate should not be underestimated.
PSID is a latest generation, portable device that allows
to acquire real-time 2D and colour Doppler images,
giving the chance to obtain linear and area measurements
of cardiac and vascular structures. Its additional
diagnostic value to the simple physical examination has been
shown [20–22], particularly in conditions such as
evaluation of left ventricular size and function [21–23], right
ventricular heart failure [21, 24], mitral valve prolapse
 and pleural or pericardial effusions . Being a
very small unit it offers the potential possibility of an
easy and practical use and effectiveness for population
screening . The screening for AAA using PSID by
experienced physicians has been already proposed as a
valuable extension of routine physical examination in
Table 1 Characteristics of Study Population
Arterial Hypertension, n (%)
Hypercholesterolemia, n (%)
Type II diabetes mellitus, n (%)
Cigarette smoking, n (%)
Coronary artery disease, n (%)
Anti-hypertensive therapy, n (%)
vascular patients. It appeared to have a 100% of agreement
with a standard ultrasound machine in diagnosing
aneurysms in 204 patients hospitalized in a cardiology institute
. Another study showed a good diagnostic accuracy in
measuring AA size in comparison with standard
ultrasound exam in patients referring for acute myocardial
infarction in coronary care unit . The present study is in
agreement with these findings since we found an excellent
concordance between measurements of AA taken by PSID
and those obtained by a standard ultrasound machine.
Accordingly, PSID can be judged as a valuable tool for
detecting AA dilation.
AAA represents still nowadays an important cause of
mortality in the western countries . To date, in expert
hands, ultrasound exam represents a consolidated tool for
AA assessment . Therefore, an effective screening plan
Fig. 4 Positive univariate relation between systolic blood pressure
(BP) and abdominal aorta (AA) diameter
could be valuable to prevent extreme AA dilation and
rupture and appropriately address high risk patients
towards surgery. The importance of an early detection of
AA dilatation has been indirectly proven by the
observation that AAA and AA rupture can be reasonably
excluded in old patients with abdominal pain admitted in
emergency department if they had a normal AA size on a
previously performed computed tomography or
ultrasound exam . A recent study has also shown that a
systematic and targeted approach based on CV risk
assessment could be very useful to identify undiagnosed
cases . The cost-effectiveness of AAA screening
programs has been demonstrated in men with >65 years .
Even women should be involved in these programs,
because, in spite of the lower prevalence, AAA in woman
has a higher risk of rupture .
By using standard ultrasound machines, determinants of
AAA have been more extensively investigated than factors
influencing AA size itself. In an unselected population of
742 patients, Bekkers et al. observed that AAA prevalence
increased with age, especially in men . In the very
large sample size of Tromso study, the prevalence of AAA
increased with age, additional factors being represented by
smoke, low serum high density lipoprotein cholesterol
and antihypertensive therapy . In a meta-analysis of 15
cross-sectional studies, male sex was strongly associated
with AAA (OR 5.69), while cigarette smoking (OR 2.41),
history of myocardial infarction (OR 2.28) or peripheral
vascular disease (OR 2.50) showed moderate associations
and arterial hypertension was only weakly associated with
AAA (OR 1.33) . The association of obesity with AAA
is controversial. Body mass index was not associated with
AAA presence and growth in the experiences of Tagaki et
al. [38, 39]. However, in a large cohort of 12.203 men who
had an ultrasound examination of their AA and filled out
a questionnaire including demographic, behavioural and
medical variables, AAA was significantly associated with a
waist/hip ratio greater than 0.9 .
In our study population, we extended the screening
to outpatients without overt AAA. By this assessment.
male sex, age and BMI were all major independent
determinants of AA size, whereas the association of
higher heart rate and AA was marginal but
significant. Although this latter finding is in disagreement
with a cross sectional study showing a negative
correlation between heart rate and AA diameter , it
is conceivable that tachycardia could exert a
detrimental effect on AA size . Systolic BP showed a
positive univariate relation with AA diameter in our
study population but this association disappeared in
the multivariate model. Conversely, in a recent study
diastolic BP was a risk factor of AAA expansion .
The undergoing anti-hypertensive therapy of the
majority of our patients (57%, see Table 1) could have
Fig. 5 Positive relation of weight (panel a), height (panel b) and body mass index (BMI) (panel c) with abdominal aorta (AA) diameter
blunted the association between increased afterload
due to hypertension and AA size of the present study.
The independent association of CAD with AA size is
consistent with the data of Bekkers et al., who found
a significant association of AAA with established
coronary and peripheral arterial disease  and also
with a meta-analysis of 15 cross-sectional studies .
Cigarette smoking and hypercholesterolemia were not
independently associated with increased AA size,
findings which are in disagreement with some previous
studies assessing determinants of AAA [36, 37]. It has
however to be taken into account that the rate of
smoking in our population sample was relatively low
and that the present study investigated determinants
of AA diameter in earlier stages than that explored in
these previous observations on AAA.
Cumulative R2 = 0.184, SEE = 0.31 cm, p < 0.0001
AA abdominal aorta, BP blood pressure, BMI body mass index, HR heart rate
The main limitation of the present study is
represented by the fact that we demonstrated the
diagnostic capability of PSID in measuring AA and not AAA.
However, looking at our correlation between AA data
assessed by PSID and standard echo we can suppose
that PSID-derived measurements of AAA could be
also consistent with those taken by standard echo
machine. Another limitation could be considered our
lack of correlation data between AA and ascending
aorta, an association previously reported by Agricola
et al. in patients with known AAA . Finally, PSID
derived AA size in the present study was measured by
experts in cardiac ultrasound whereas it could be even
more important to collect measurements taken by non
The physical examination does not always allow
diagnosis of AAA in patients without a very large AA
diameter . The findings of the present study
demonstrate that the use of a miniaturized and portable
device such as PSID could allow to widen the
spectrum of patients susceptible of screening, allowing
AA visualization also during a routine medical
examination. Thus, the physician has the opportunity to
complete the evaluation of patients, especially those
at higher CV risk, to precociously detect patients with
abnormalities of AA size and possibly treat
cardiovascular risk factors more aggressively.
RE and FI designed the study and drafted the manuscript, VSL, RS and VS
participated in the design of the study and performed the statistical analyses,
GG participated in the study design and coordination and helped to draft
the manuscript, GE, BT and MG conceived the study and its designed and
revised critically the final manuscript All authors read and approved the final
Ethics approval and consent to participate
Ethics approval from Federico II University Hospital Naples (2014). Informed
consent obtained from each patient.
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