Aneurysm Expansion Research Articles

Mid-term Outcomes and Predictors of Transarterial Embolization for Type II Endoleak After Endovascular Abdominal Aortic Aneurysm Repair.

To evaluate the mid-term outcomes of transarterial embolization (TAE) for type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR) and investigate the predictors of sac enlargement after embolization. We conducted a retrospective analysis of 55 patients [48 men and 7 women, median age 79.0 (interquartile ranges 74-82)years] who underwent TAE for type II endoleak from 2010 to 2018. The aneurysmal sac enlargement, endoleaks, aneurysm-related adverse event rate, and reintervention rate were evaluated. Patients' characteristics and clinical factors were evaluated for their association with sac enlargement. Fifty-five patients underwent TAE with technical success and were subsequently followed for a median of 636 (interquartile ranges 446-1292)days. The freedom from sac enlargement rates at 1, 3, and 5years was 73.2%, 32.0%, and 26.7%, respectively. After initial TAE, the recurrent type II, delayed type I, and occult type III endoleak were identified in 39 (71%), 5 (9%), and 3 (5%) patients, respectively. Although a patient had aorto-duodenal fistula, there was no aneurysm-related death. The freedom from reintervention rates was 84.6%, 35.7%, and 17.0%, respectively. In the multivariate analysis, sac diameter > 55mm at initial TAE (hazard ratios, 3.23; 95% confidence intervals, 1.22-8.58; P < 0.05) was a significant predictor of sac enlargement. TAE for type II endoleak was not effective in preventing sac enlargement, and reinterventions were required among the mid-term follow-up. The sac diameter > 55mm at initial TAE was a significant predictor of sac enlargement.

Endovascular treatment of the persistent false lumen of post-dissection aneurysms with "candy-plug" technique

A 79-year-old male patient was operated with Bentall procedure, thoracic aorta-aortic interposition and stent graft implantation for aortic dissection type A. Because of the persistent false lumen a chronic, 60 mm thoraco-abdominal post-dissection aortic aneurysm developed, which we managed with a new endovascular treatment, the so-called "candy-plug" technique. Thoracic endovascular aortic repair (TEVAR) can induce the thrombosis of the false lumen and the aortic remodelling via the covering of the proximal intimal tear. However, the thrombosis of the false lumen is often - in 60% of the cases - incomplete. In these cases we have to prepare for the persistent expansion of the aorta, which can be managed only with high-risk open or endovascular repair. Hence a new solution with lower risk was investigated, which combines TEVAR and the false lumen closure devices. Such a new treatment is the "candy-plug" technique, which was performed in our case. This minimally invasive technique, which excludes the circulation of the false lumen and stops the progression of the aneurysm expansion, can be an effective and safe solution for the treatment of the chronic post-dissection aortic aneurysms. Orv Hetil. 2020; 161(11): 437-439.

Rapidly expanding saphenous vein graft myoctic aneurysm causing ST-elevation myocardial infarction: a case report.

Background Mycotic aneurysms of coronary vein grafts are rare and associated with high mortality. They are most commonly a result of surgical or percutaneous intervention, and present with complications including myocardial infarction (MI), infective endocarditis. A recent literature review identified 97 cases of mycotic coronary aneurysms in total.Case summaryA 49-year-old man with a history of coronary artery bypass grafting and septic arthrithis presented with chest pain and fevers and ST elevation on electrocardiogram. Urgent angiogram showed an aneurysmal saphenous vein graft from the PL branch to PDA—no acute intervention was performed due to concern about bacteraemia. Methicillin-sensitive Staphylococcus aureus was grown in urine and blood but no focus of infection was identified. Despite treatment with antibiotics and antiplatelets, the patient returned with evidence of expansion of the SVG aneurysm requiring surgical resection.Discussion This case highlights the difficulty in treating acute coronary syndromes involving mycotic aneurysms. Multimodal imaging approaches are useful to identify suspected infection, but false negatives occur. Due to high risk of rupture or haemorrhage, there are limited options for urgent reperfusion in cases of MI with mycotic aneurysm, demonstrating the need for an individualized approach and close follow-up.

Abstract WMP27: PAT Model Accurately Predicts Aneurysm Enlargement in 16 Growing Aneurysm Cases

Objective: Imaging technology for unruptured intracranial aneurysms (UIA) has improved detection of such aneurysms. However, there is limited information on UIA change over time, and how to predict the rate of enlargement. The objective of this study was to quantify the accuracy of the Predicted Aneurysm Trajectory (PAT) model recently developed by Chien et al. (J Neurosurgery. 2019; Mar 1:1-11). Methods: Patients diagnosed with UIA were prospectively enrolled at the UCLA Medical Center, and followed through serial imaging. 16 UIA cases exhibiting growth across multiple follow-ups were included in this study. Prior images and medical records were collected. Characteristics relevant to the PAT model (mean ± stdev), including initial UIA size (7.26 ± 6.38), patient age (67.4 ± 9.48 yrs.), sex (4 male), history of smoking (n=5), hypothyroidism (n=4), and follow-up duration (36.5 ± 50.0 mos.) were used to predict UIA size at each follow-up. Predicted and actual UIA sizes at follow-up were compared using symmetric mean absolute percentage error (SMAPE) with percentage error ranging from 0-100%. Results: The 16 UIA cases were split by initial UIA size. For UIA smaller than 7 mm (10 cases, 23 follow-up), SMAPE = 11.13%. For UIA greater than 7 mm (6 cases, 15 follow-up), SMAPE = 8.07%. For all UIA cases (16 cases, 38 follow-up), SMAPE = 9.92%. Conclusions: The PAT model predicts the rate of enlargement for UIA, as opposed to whether or not UIA will grow. With this new sample of data, we found the predicted UIA size at follow-up to be quite accurate, deviating in the range of 10% from the actual, measured size. Patient characteristics such as the demographics and behavior included in the model influence the growth of UIA, which allows prediction of growth to optimize treatment and management in future cases.

Ulinastatin Inhibits the Formation and Progression of Experimental Abdominal Aortic Aneurysms

Aims: Aortic mural inflammatory damage takes a vital part in abdominal aortic aneurysm (AAA). Recently, ulinastatin (UTI) has attracted attention for its anti-inflammatory function. Our study aimed to evaluate potential influences of UTI on experimental AAA. Methods: A mouse model of AAA was induced by infusion of porcine pancreatic elastase (PPE) into the abdominal aorta. Mice were treated with UTI (50,000 U/kg/day i.p.) beginning either immediately or on the 4th day after PPE infusion, with treatment being continued until the 14th day. UTI effects were assessed by aortic diameter measurements and aortic histopathological analysis. Results: Significant and time-dependent aortic diameter enlargement persisted in the control mice from day 0. In the UTI group, aortic diameter increased, and depletion of aortic mural smooth muscle cells and elastin was significantly ­attenuated. Simultaneously, mural CD68+ macrophages, CD8+ T-cell and B220+ B-cell density, as well as neoangiogenesis were suppressed by UTI. In addition, delayed UTI treatment could still effectively limit aneurysm expansion. Conclusions: UTI treatment limits the formation and growth of experimental AAA, and UTI may be a potential treatment for early AAA disease.

Effects of size and elasticity on the relation between flow velocity and wall shear stress in side-wall aneurysms: A lattice Boltzmann-based computer simulation study.

Blood flow in an artery is a fluid-structure interaction problem. It is widely accepted that aneurysm formation, enlargement and failure are associated with wall shear stress (WSS) which is exerted by flowing blood on the aneurysmal wall. To date, the combined effect of aneurysm size and wall elasticity on intra-aneurysm (IA) flow characteristics, particularly in the case of side-wall aneurysms, is poorly understood. Here we propose a model of three-dimensional viscous flow in a compliant artery containing an aneurysm by employing the immersed boundary-lattice Boltzmann-finite element method. This model allows to adequately account for the elastic deformation of both the blood vessel and aneurysm walls. Using this model, we perform a detailed investigation of the flow through aneurysm under different conditions with a focus on the parameters which may influence the wall shear stress. Most importantly, it is shown in this work that the use of flow velocity as a proxy for wall shear stress is well justified only in those sections of the vessel which are close to the ideal cylindrical geometry. Within the aneurysm domain, however, the correlation between wall shear stress and flow velocity is largely lost due to the complexity of the geometry and the resulting flow pattern. Moreover, the correlations weaken further with the phase shift between flow velocity and transmural pressure. These findings have important implications for medical applications since wall shear stress is believed to play a crucial role in aneurysm rupture.

Comparison of Computed Tomography Angiography (CTA) Findings in Post-Endovascular Aortic Aneurysm Repair CTA between Persistent and Transient Type II Endoleak

Objective: To compare first post-endovascular aortic aneurysm repair (EVAR) computed tomography angiography (CTA) imaging characteristics between transient and persistent type II endoleaks. Methods: This retrospective study enrolled patients who underwent EVAR and were diagnosed with type II endoleak from first post-operative CTA during January 2005 to October 2017 at the Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Aneurysmal sac size, aneurysmal sac growth, and endoleak were recorded among patients whose endoleak disappeared within 6 months (transient group), and among patients whose endoleak persisted for more than 6 months (persistent group). Results: Eighty-eight patients with a mean age of 75.3±7.3 years were included. Of those, 12 and 76 patients were in the transient group and persistent group, respectively. There were 71 males and 17 females. Univariate analysis showed number of feeding arteries (odds ratio [OR]: 9.9, p =0.012) and presence of inferior mesenteric artery (IMA) as an endoleak source (OR: 4.3, p =0.026) to be found more frequently in the persistent group than in the transient group; however, neither factor survived multivariate analysis. No significant difference between two groups was seen for endoleak diameter, endoleak complexity, or aneurysmal sac enlargement. Conclusion: The number of feeder arteries and presence of IMA as an endoleak source on first postoperative CTA to be more likely found in patients with persistent type II endoleak. Further prospective study in a larger study population is necessary to identify any existing statistically significant differences and/or associations.

A Systematic Overview Of Abdominal Aortic Aneurysm (AAA)

An abdominal aortic aneurysm (AAA) is defined as an abnormal dilatation of the abdominal aorta more than 50% of its diameter. The aortic wall continues to weaken and become unable to hold the forces of the luminal blood pressure, resulting in progressive dilatation and rupture. The rupture of the aneurysm wall is influenced by several factors, such as the aneurysm size, expansion rate, continued smoking, and persistent hypertension. The AAA is a common degenerative condition with high mortality in older people. The AAA increases these last two decades. It is occurring in 7-8% of men at the age of over 65 years old. The disease prevalence is six times higher in men than in women. It is also increasing dramatically by the presence of the following factors: age older than 60 years old, smoking, hypertension, and ethnicity. Repair of large or symptomatic AAA by open surgery or endovascular is recommended, but not significant in the small aneurysm.

Machine Learning to Predict the Rapid Growth of Small Abdominal Aortic Aneurysm.

The purpose of this study was to determine whether computed tomography (CT) angiography with machine learning (ML) can be used to predict the rapid growth of abdominal aortic aneurysm (AAA). This retrospective study was approved by our institutional review board. Fifty consecutive patients (45 men, 5 women, 73.5 years) with small AAA (38.5 ± 6.2 mm) had undergone CT angiography. To be included, patients required at least 2 CT scans a minimum of 6 months apart. Abdominal aortic aneurysm growth, estimated by change per year, was compared between patients with baseline infrarenal aortic minor axis. For each axial image, major axis of AAA, minor axis of AAA, major axis of lumen without intraluminal thrombi (ILT), minor axis of lumen without ILT, AAA area, lumen area without ILT, ILT area, maximum ILT area, and maximum ILT thickness were measured. We developed a prediction model using an ML method (to predict expansion >4 mm/y) and calculated the area under the receiver operating characteristic curve of this model via 10-fold cross-validation. The median aneurysm expansion was 3.0 mm/y. Major axis of AAA and AAA area correlated significantly with future AAA expansion (r = 0.472, 0.416 all P < 0.01). Machine learning and major axis of AAA were a strong predictor of significant AAA expansion (>4 mm/y) (area under the receiver operating characteristic curve were 0.86 and 0.78). Machine learning is an effective method for the prediction of expansion risk of AAA. Abdominal aortic aneurysm area and major axis of AAA are the important factors to reflect AAA expansion.

GSK2593074A blocks progression of existing abdominal aortic dilation

ObjectiveReceptor interacting proteins kinase 1 and 3 (RIPK1 and RIPK3) have been shown to play essential roles in the pathogenesis of abdominal aortic aneurysms (AAAs) by mediating necroptosis and inflammation. We previously discovered a small molecular inhibitor GSK2593074A (GSK’074) that binds to both RIPK1 and RIPK3 with high affinity and prevents AAA formation in mice. In this study, we evaluated whether GSK’074 can attenuate progression of existing AAA in the calcium phosphate model. MethodsC57BL6/J mice were subjected to the calcium phosphate model of aortic aneurysm generation. Mice were treated with either GSK’074 (4.65 mg/kg/day) or dimethylsulfoxide (DMSO) controls starting 7 days after aneurysm induction. Aneurysm growth was monitored via ultrasound imaging every 7 days until harvest on day 28. Harvested aortas were examined via immunohistochemistry. The impact of GSK’074 on vascular smooth muscle cells and macrophages were evaluated via flow cytometry and transwell migration assay. ResultsAt the onset of treatment, mice in both the control (DMSO) and GSK’074 groups showed similar degree of aneurysmal expansion. The weekly ultrasound imaging showed a steady aneurysm growth in DMSO-treated mice. The aneurysm growth was attenuated by GSK’074 treatment. At humane killing, GSK’074-treated mice had significantly reduced progression in aortic diameter from baseline as compared with the DMSO-treated mice (83.2% ± 13.1% [standard error of the mean] vs 157.2% ± 32.0% [standard error of the mean]; P < .01). In addition, the GSK’074-treated group demonstrated reduced macrophages (F4/80, CD206, MHCII), less gelatinase activity, a higher level of smooth muscle cell-specific myosin heavy chain, and better organized elastin fibers within the aortic walls compared with DMSO controls. In vitro, GSK’074 inhibited necroptosis in mouse aortic smooth muscle cells; whereas, it was able to prevent macrophage migration without affecting Il1b and Tnf expression. ConclusionsGSK’074 is able to attenuate aneurysm progression in the calcium phosphate model. The ability to inhibit both vascular smooth muscle cell necroptosis and macrophage migration makes GSK’074 an attractive drug candidate for pharmaceutical treatment of aortic aneurysms.

Effectiveness and safety of structured exercise vs. no exercise for asymptomatic aortic aneurysm: systematic review and meta-analysis.

We conducted a systematic review to compare the effectiveness and safety of exercise versus no exercise for patients with asymptomatic aortic aneurysm. We followed the guidelines set out in the Cochrane systematic review handbook. We searched Medline, Embase, CENTRAL, LILACS, PeDRO, CINAHL, clinicaltrials.gov, ICTRP, and OpenGrey using the MeSH terms “aortic aneurysm” and “exercise”. 1189 references were identified. Five clinical trials were included. No exercise-related deaths or aortic ruptures occurred in these trials. Exercise did not reduce the aneurysm expansion rate at 12 weeks to 12 months (mean difference [MD], −0.05; 95% confidence interval [CI], −0.13 to 0.03). Six weeks of preoperative exercise reduced severe renal and cardiac complications (risk ratio, 0.54; 95% CI, 0.31–0.93) and the length of intensive care unit stay (MD, −1.00; 95% CI, −1.26 to −0.74). Preoperative and postoperative forward walking reduced the length of hospital stay (MD, −0.69; 95% CI, −1.24 to −0.14). The evidence was graded as ‘very low’ level.

Aneurysm Sac Thrombus Volume Predicts Aneurysm Expansion with Type II Endoleak After Endovascular Aneurysm Repair

Several studies have analyzed risk factors that may influence the incidence of type II endoleak with sac expansion after endovascular aneurysm repair (EVAR). However, the impact of intraluminal thrombus volume on the incidence of sac expansion with type II endoleak requires further analysis. This study examined the correlation between preoperative intraluminal thrombus and the incidence of type II endoleak and late sac expansion by measuring the thrombus volume. Between June 2007 and March 2014, 423 patients underwent EVAR at our institution. Two hundred and eighty patients with preoperative and postoperative computed tomography angiography (CTA) were included in this study. Data were collected prospectively and supplemented with a retrospective review of the medical records and radiologic images, and demographic and clinical characteristic profiles were collected. Logistic regression and Cox regression analyses were used to assess each variable's association with the incidences of persistent or new endoleak and sac expansion. Of the 280 patients, 46.7% (131 patients) had persistent type II endoleak, and 19.6% (55 patients) had persistent type II endoleak with significant sac expansion (≥5mm). The mean follow-up duration was 60months (interquartile range, 24-72months). Cox regression analysis showed that older age (P=0.001), intraluminal thrombus volume ratio (thrombus volume [T vol]/aortic aneurysm volume [A vol]) (P=0.042) and IMA diameter (P=0.004) were significant predictors of the incidence of sac expansion with persistent or new type II endoleak. The receiver operating characteristic curve analysis revealed a cutoff of 51% T vol/A vol (area under the curve [AUC]: 0.59) and 2.9mm (area under the curve [AUC]: 0.60). The rate of freedom from sac expansion (≥5mm) during followup was significantly higher in patients with ≥51% T vol/A vol than in those with a lower T vol/A vol (P=0.010). Preoperative sac thrombus volume, IMA diameter, and older age predict the incidence of aneurysm expansion with type II endoleak after EVAR.

Fenestrated and Branched Endografting After Previous Open Infra-renal Aortic Aneurysm Repair

Introduction - Proximal para-anastomotic aneurysms, or aneurysmal degenerations of the native aorta above a previous infra-renal aortic open repair (P-AAAs), are not rare challenging scenarios. The aim of this study was to report the early and mid-term outcomes following endovascular repair of P-AAAs with fenestrated and branched endografts (FB-EVAR) Methods - From 2006 to 2017, we prospectively collected and retrospectively analyzed pre, intra and postoperative data of patients undergoing FB-EVAR for P-AAAs at two European vascular surgery units. Early outcomes were: technical success (target visceral vessels cannulation and stenting, absence of Type I-III endoleak, iliac limb occlusion and 24-h mortality), spinal cord ischemia (SCI), and 30-day mortality. Mid-term outcomes were: survival, target visceral vessels (TVV) patency, and freedom from re-interventions. Fisher’s exact test, Kaplan Mayer and Log rank were used for the statistical analysis Results - During the study period, 108 patients (M:94%; age:71±4years; ASA 3-4:74%>26%) were enrolled. The previous aortic OR was a tubular aorto-aortic 63(58%), a bifurcated aorto bi-iliac 37(34%) or an aorto bi-femoral 8(8%) bypass. The OR was performed 10±2years prior to the FB-EVAR. A previous TEVAR had also been performed in 7 patients (6%). The aortic lesions at the time of FB-EVAR was a type I-III 69(64%) or type IV 39(36%) thoracoabdominal aneurysm according to the Crawford’s classification. The mean aneurysm diameter was 64±6mm. Overall, 390 TVVs (3.6±1 TVV/case) were perfused by endograft fenestrations (63;58%), branches (26;24%) or both fenestrations and branches (19;18%). Tubular, tri-modular or aorto-monoiliac implants were planned in 68 (63%), 38 (35%) and 2 (2%) patients, respectively. Proximal TEVAR, carotid-subclavian bypass and iliac branch devices were planned adjunctive procedures in 41 (38%), 5 (5%) and 3 (3%) cases, respectively. Technical success was 93%. Technical failures included 5 TVV-loss (celiac trunk:1; renal arteries:4) and 3 deaths within 24 hours (cardiac aetiology). Post-operative SCI was diagnosed in 7 patients (7%), including 4 (4%) permanent. Type I-III TAAAs (p .04) and endograft incorporating both fenestrations and branches (p .04) were associated with SCI. Cardiac and pulmonary morbidity was 9% and 10%, respectively. Post-operative renal failure (GFR reduction >30% of baseline) was diagnosed in 22 patients (20%). Bowel ischemia was depicted in 3 (3%) patients. The 30-day mortality was 4%. Preoperative chronic renal failure (p .03), post-operative cardiac morbidity (p .04), and bowel ischemia (p .003) were associated with 30-day mortality. The mean follow-up was 38±18 months. Survival at 1, 3 and 5 years was 82%, 64% and 54%, respectively. There was no late aneurysm-related mortality. Survival during follow-up was significantly impacted by pre-operative chronic renal failure (p .005), post-operative cardiac morbidity (p .04), and SCI (p .04). Target visceral patency at 1, 3 and 5 years was 93%, 91% and 91%, respectively. New onset of hemodialysis was required in 4 patients (4%). Aneurysm enlargement (>5mm) was detected in 6 (5.5%) cases. Freedom from re-interventions at 1, 3 and 5 years was 89%, 77% and 74%, respectively Conclusion - Endovascular treatment of aortic aneurysmal evolution above a prior open AAA repair with FB-EVAR is safe and effective. If those promising results are confirmed during late follow-up, FB-EVAR should be considered as a therapeutic option, especially in high-risk patients

One-year Results of a Prospective, Multicenter, Observational Study of Thoracic Aortic Pathologies Treated with a Bare and Non-bare Stent Endograft and Dual-sheath Delivery System

Introduction: To report the results of RelayPlus (Terumo Aortic, Sunrise, FL, USA) which is CE-marked for the endovascular treatment of aneurysms of the descending thoracic aorta (DTA), aortic dissection (AD), aortic transection (AT) and penetrating aortic ulcers (PAU). This study was a postmarket surveillance requirement. The device is available in bare-stent (BS) and non-bare stent (NBS) configurations and a dual-sheath delivery system includes a flexible inner catheter. Methods: A prospective, non-randomized, observational study using a standard treatment and follow-up protocol enrolled consecutive patients treated with the device in 10 sites between January 2015 and December 2018. Standard endpoints (mortality, neurological deficits, endoleaks, all complications, migration, device integrity) are assessed at 30 days and through five years; one-year results are reported here. Results: The study enrolled 170 patients. Data from 148 patients with a mean follow-up of 379 days are reported here; mean age was 67.4 years (25−93), mostly male (n=104, 70%), 78 (52.7%) ASA ≥3. Patients were treated in 59 cases (40%) for DTA, 61 (41%) Type B AD, 16 (11%) AT, and 12 (8%) PAU. Average aneurysm diameter was 57 (28−106) mm. An average of 1.4 units was used per patent. BS or NBS was physician preference: NBS was more typical in AD (n=39, 64%) and AT (n=9, 56%). Landing was in Z0 (6%), Z1 (5%), Z2 (18%), Z3 (43%), and Z4 (28%). Revascularization of the innominate (n=1) and left subclavian (n=16) arteries were associated. There was no surgical conversion. At 30 days, mortality was 2.7%, there were no stroke, 0.6% paraplegia (n=2), no retrograde dissection and 6% type I endoleaks (7 Ia, 4 Ib). At one year, there were 2 non-TEVAR-related deaths (6 in total, all-cause mortality 4%), one type I endoleak, four type II and no conversion to open repair, migration or endograft collapse. There were 15 (10%) secondary interventions for endoleak (n=9, 6%), aneurysm expansion (n=5, 3%), and rupture (n=1, 0.6%). Average aneurysm diameter at one year was 46 (26−74) mm. Conclusion: Real world, standard clinical practice in the treatment of thoracic aortic pathologies with RelayPlus is highly predictable with a low number of units per patients and acceptable rates of mortality and reintervention in a challenging patient population. Disclosure: Nothing to disclose

Fabric Tears of Stent Graft Often Exist Among Aneurysm Sac Expansion After Endovascular Abdominal Aortic Aneurysm Repair

Introduction: Although type IIIb endoleaks caused by fabric tears are rare in endovascular abdominal aneurysm repair (EVAR) -related complications, they can lead to serious complications, including aneurysm expansion and eventual aneurysm rupture. Under the direct inspection in late open surgery for aneurysm sac expansion by persistent type II endoleak, we observed not only type II endoleak from patent lumber arteries but also type IIIb endoleak by fabric tears of an endovascular stent graft in several cases. There may be other types of endoleak, especially type IIIb, not diagnosed in pre-operation. There may be more type IIIb endoleak than we consider among aneurysm expansion by type II endoleak. Methods: Between January 2009 and December 2017, 182 patients underwent EVAR in our institution. Secondary intervention for sac diameter expansion by persistent type II endoleak was performed in 17 patients (9.3%). We examined peri-operative characteristics of the 17 patients. Results: For 16 out of 17 patients with type II endoleak at pre-secondary intervention, open surgery method was performed. Definitive diagnoses of endoleak type with intraoperative findings were type II only in 10 patients, type II and type IIIb in 6 patients (38%). The devices used for the 6 patients who diagnosed type II and type IIIb were Zenith 2, Excluder 2, Endurant 1 and AFX 1. Operative procedures for 10 type II only patients were, bifurcated graft repair in 2 patients, and open ligation of lumber arteries in 8 patients. For type II and type IIIb patients, open ligation of lumber arteries was performed for type II endoleak, then for type IIIb procedure, a suture hemostasis was selected in 4 patients, and an additional leg insertion in 2 patients. All patients' postoperative course was uneventful, and in-hospital death was 0 patient. Conclusion: Our experience demonstrated that there is a possibility of complex condition with not only type II endoleak but also type IIIb endoleak in patients with type II endoleak in pre-operative diagnosis. Although type IIIb endoleak is often difficult to detect, there were much more type IIIb endoleak than we consider. We should note that type IIIb endoleak caused by fabric tears of stent graft is present among sac expansion after EVAR. Disclosure: Nothing to disclose

Surgical Fenestration of the Abdominal Aorta in Patients with Acute and Chronic Aortic Dissection

Introduction - Surgical aortic fenestration for acute and chronic aortic dissection has been used at our institution since 1986. The aim of the study is to define the indications for its use and to evaluate its success at relieving organ or limb malperfusion. Methods - The records of all patients (n=57) who underwent surgical fenestration of abdominal aorta at our department during the past decade (from 2007 to 2017) were identified. Emergency aortic fenestration for treatment of acute aortic dissection underwent 2 patients with type B dissection. Clinical presentation was malperfusion syndrome: 1 patient had bilateral lower limb and renal ischemia and 1 patient had acute renal and mesenteric ischemia. In both cases malperfusion syndrome occurred despite prior proximal descending throracic aortic replacement. The mean interval between malperfusion onset and fenestration was 7 hours (range, 6 - 8 hours). 55 patients underwent elective aortic fenestration for treatment of chronic aortic dissection. 2 patient had type A dissection, and 53 patients had type B dissection. The primary clinical presentation was chronic malperfusion syndrome in all 55 patients and infrarenal aortic aneurysmal disease in 5 patients. Among them 9 patients had lower limb claudication, 41 patients had renal ischemia, and 17 patients had severe refractory renovascular hypertension caused by the compressed true lumen. 7 patients had symptoms related to chronic mesenteric ischemia. 2 patients had prior ascending aortic Bentall procedure and 5 patients - prior proximal descending thoracic aortic replacement. The main condition and indication for surgical aortic fenestration was the absence of aneurysmal enlargement of the abdominal aorta at the para and suprarenal level (aortic diameter less then 5 cm). Abdominal aortic fenestration was performed through longitudinal aortotomy at the para- and suprarenal level by resection of the septum between the false and true lumen. The aortotomy then was sutured and reinforced with strips of Teflon, which resulted in a slightly redused aortic diameter. Concomitant graft replacement for the infrarenal abdominal aorta was done in 14 patients. Results - The malperfusion syndrome was relieved for 55 patients with organ or limb ischemia. Early operative survival from fenestration was 96.5 % (55 /57). In the acute dissection group the operative mortality was 50 % (1/2) and cause of death - anuria and bowel ischemia. In one patient, acute renal and lower limb malperfusion syndrome was successfully relieved. In the chronic dissection group, operative mortality was 1.8 % (1/55), with the cause of death being multi-systemic organ failure. The 54 patients with evidence of chronic malperfusion syndrome had complete relief. None of the patients were seen with complications that called for reoperation. The mean follow-up for 54 survivors was 3 years (range, 3 months to 5 years). All patients remained free from symptomatic recurrence of malperfusion syndrome and had postoperative imaging studies done. Among all patients there was no evidence of aneurysmal formation at the site of aortic fenestration. Conclusion - Surgical fenestration of the abdominal aorta is a safe and effective method for the treatment of ischemic complications associated with the aortic dissection and malperfusion.

Abdominal Aortic Aneurysm Expansion Abrogation in a Preclinical Hypercholesterolemic LDLR-/- Pig Model by Anti-miR-29b Coated Balloon Angioplasty

Abdominal Aortic Aneurysm Expansion Abrogation in a Preclinical Hypercholesterolemic LDLR-/- Pig Model by Anti-miR-29b Coated Balloon Angioplasty

Therapeutic strategy and effect of different approaches for microsurgical treatment of basilar artery bifurcation aneurysms

Objective To investigate the strategy and effect of microsurgical treatment of basilar artery bifurcation aneurysms with different surgical approaches. Methods We retrospectively reviewed the clinical data of 43 patients with basilar artery bifurcation aneurysms who underwent microsurgical clipping at Department of Neurosurgery, the Second Xiangya Hospital, Central South University from April 2011 to April 2018. Of all 43 cases, 32 cases had ruptured basilar aneurysms and 11 cases had unruptured basilar aneurysms. According to the different morphological and anatomical locations of aneurysms, 17 cases underwent infraorbital approach, 26 cases underwent transsyvian approach (including the transorbirozygomatic approach, the 'half-half’ approach which combined the subtemporal approach with pterion approach and the simple pterion approach) to conduct microsurgical clipping. Intraoperative monitoring was performed using the combination of multiple technologies. Clinical and imaging follow-up was conducted over 6 months post surgery. Results Of all 43 cases with basilar artery bifurcation aneurysms, 38 cases were completely clipped, 4 cases were partially clipped, and 1 case was wrapped. There were 2 cases (4.7%) of hemiplegia after operation, 1 case (2.3%) of coma, 14 cases (32.6%) of oculomotor nerve palsy and no death during perioperative period. Thirty-seven patients (86.4%) were followed up for 25.0±10.1 months (range: 6 months to 4 years). Among them, 35 patients underwent radiographic review without aneurysm residual and 1 patient with partial clipping was treated with second-stage interventional embolization. In 1 case with wrapped aneurysm, the significantly enlargement of aneurysm was not observed in the follow-up image. Of 14 cases with oculomotor nerve palsy after operations, 11 were followed up and 8 of them improved significantly afterwards. Glasgow′s outcome scale(GOS) showed that grade V was reported in 34, grade IV in 1 case, grade III in 1 case, grade II in 0 and grade I in 1 case who died from severe pulmonary infection at 42 days post operation. Conclusions The superior treatment of the basilar artery bifurcation aneurysm could be achieved through subtemporal and transsyvian approach. Preoperative evaluation of anatomical and morphological characteristics of aneurysm seems important for the choice of surgical approach. The application of various assistive techniques during surgery is an important part of ensuring the safety of surgery. Key words: Intracranial aneurysm; Basilar artery; Microsurgery; Treatment outcome

Neuroimaging characteristics and long-term prognosis of myxoma-related intracranial diseases.

Myxoma-related intracranial diseases were rarely documented in history. The main purpose of our study is to provide a more comprehensive and detailed understanding of the pathogenesis, imaging features, surgical procedures and pathology of such patients through long-term follow-up. From March 2012 to July 2018, baseline information that included neuroimaging and neuropathology data from 12 cardiac myxoma patients with neurological symptoms were retrospectively analysed, and the treatment options were discussed. Nine patients underwent long-term postoperative follow-up. Twelve cardiac myxoma patients with neurological symptoms were identified, and among them, 10 patients were postoperative patients who had undergone excision of cardiac myxoma, 5 patients had received craniotomy, and the others had received conservative treatment. Positive neuroimaging findings were found in all patients, including cerebral infarction (12/12, 100%), multiple intracranial aneurysms (8/12, 67%), and extravascular metastasis (6/12, 50%). After a long-term average follow-up of 27 months, an increased number of metastatic lesions or an enlargement of the intracranial aneurysms was found in 4 patients. Neuroimaging findings of myxoma-related intracranial lesions were diversed and usually presented as multiple cerebral infarction, aneurysm formation, focal intracranial haemorrhage and space-occupying lesions. Progress is over a long period of time after primary tumour resection. It is necessary for patients to be regularly examined within 2 years after cardiac myxoma resection using MRI+CTA/MRA/DSA in order to be ruled out. Stable and effective chemotherapy drugs are urgently needed.

Feasibility of Assessing Inflammation in Asymptomatic Abdominal Aortic Aneurysms With Integrated 18F-Fluorodeoxyglucose Positron Emission Tomography/Magnetic Resonance Imaging

This study aimed to evaluate the feasibility of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) combined with contrast enhanced magnetic resonance imaging (MRI) to identify inflammation in asymptomatic abdominal aortic aneurysms (AAA). FDG PET/MRI was performed on 15 patients with asymptomatic infrarenal AAAs >45mm diameter. Prevalence of FDG uptake and MRI findings of inflammatory changes (oedema, wall thickening, and late gadolinium enhancement [LGE]) in the aortic wall were investigated at three levels: suprarenal aorta; non-aneurysmal aortic neck; and AAA. The median diameter of the AAAs was 54mm (range 47-65mm) and the median expansion rate in the last 12 months was 3mm (range 1-13mm). The standard uptake value (SUV) of FDG in the aneurysmal wall (SUVmax 2.5) was higher than the blood pool (SUVmax 1.0; p<.001). The maximum target to background ratio was higher in the suprarenal aorta (mean±SD; 3.1±0.6) and aortic neck (2.7±0.5) than in the aneurysmal aorta (2.5±0.5; p<.001). Thirty-six FDG hotspots were observed in the aneurysmal wall of 13 patients. Wall thickening and LGE were identified in eight patients. The number of FDG hotspots correlated with recent AAA growth (r=0.62, p=.01). The recent aneurysm expansion rate was higher in aneurysms with LGE than in those without (7mm vs. 2mm; p=.03). MRI inflammatory changes were observed in nine of 36 hot spots (25%) and in three of 13 patients with focal FDG uptake. Fully integrated FDG PET/MRI can be used to study inflammation in asymptomatic AAAs. Heterogenous uptake of FDG in the aneurysmal wall indicates increased glucose metabolism, suggesting an ongoing inflammation. However, these FDG hotspots rarely correspond to MRI findings of inflammation, raising the question of which type of cellular activity is present in these areas. The presence of LGE and FDG hotspots both correlated to recent aneurysm growth, and their usefulness as clinical markers of aneurysm growth warrant additional investigation.