Aortic Aneurysm Disease Research Articles

Next-Generation Sequencing in the Assessment of the Transcriptomic Landscape of DNA Damage Repair Genes in Abdominal Aortic Aneurysm, Chronic Venous Disease and Lower Extremity Artery Disease.

Vascular diseases are one of the most common causes of death and morbidity. Lower extremity artery disease (LEAD), abdominal aortic aneurysm (AAA) and chronic venous disease (CVD) belong to this group of conditions and exhibit various presentations and courses; thus, there is an urgent need for revealing new biomarkers for monitoring and potential treatment. Next-generation sequencing of mRNA allows rapid and detailed transcriptome analysis, allowing us to pinpoint the most pronounced differences between the mRNA expression profiles of vascular disease patients. Comparison of expression data of 519 DNA-repair-related genes obtained from mRNA next-generation sequencing revealed significant transcriptomic marks characterizing AAA, CVD and LEAD. Statistical, gene set enrichment analysis (GSEA), gene ontology (GO) and literature analyses were applied and highlighted many DNA repair and accompanying processes, such as cohesin functions, oxidative stress, homologous recombination, ubiquitin turnover, chromatin remodelling and DNA double-strand break repair. Surprisingly, obtained data suggest the contribution of genes engaged in the regulatory function of DNA repair as a key component that could be used to distinguish between analyzed conditions. DNA repair-related genes depicted in the presented study as dysregulated in AAA, CVD and LEAD could be utilized in the design of new biomarkers or therapies associated with these diseases.

Abstract 15742: Thoracic Aortic Aneurysmal Disease Prevalence and Outcomes in Women With Connective Tissue Diseases

Introduction: Connective tissue disease patients are at risk for thoracic aortic aneurysm (TAA) and its complications. We sought to clarify risk factors for TAA specific to women. Methods: Using Yale Aortic Institute database, we identified 266 female patients with diagnosis of Marfan’s, Ehlers-Danlos, or Loeys-Dietz Syndromes. We included imaging, clinical and surgical information collected using retrospective chart review. Results: Amongst women with CTD, the prevalence of TAA in our population was 25%. MFS patients constituted 23% of the study population but accounted for 70% of aneurysm patients. EDS patients comprised 74% of the study population and 24% aneurysm patients. LDS comprised a small percentage of both populations. Non-Caucasian ethnicities seemed to have much higher likelihood of developing an aneurysm. CTD patients with aortic aneurysms were more likely to have valvular heart disease (VHD: MVP, AI), HTN, DLP, and DM. Aneurysm rates were slightly higher in ever-pregnant patients, with highest rates in MFS. TAA patients had higher rates of all-cause mortality (15% vs 2%). CV/aortic-related complications and death occurred only in TAA patients. Aortic dissection occurred in 24%; 30/67 required aortic surgery, with 13/67 requiring multiple surgeries. MFS manifested higher rates of aortic dissection (40%), surgery (40%), and mortality (both all cause and CV/Ao). Conclusions: TAA is common amongst women with CTD, with Marfan’s patients being at highest risk for TAA and its complications (aortic dissection, need for surgery, and death). Risk factors for TAA were VHD, HTN, DLP, and DM. Pregnancy appears to be a risk factor for TAA in select CTD subgroups.

The impact of neighborhood social disadvantage on abdominal aortic aneurysm severity and management

ObjectiveRecent studies have highlighted socioeconomic disparities in the severity and management of abdominal aortic aneurysm (AAA) disease. However, these studies focus on individual measures of social disadvantage such as income and insurance status. The area deprivation index (ADI), a validated measure of neighborhood deprivation, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on AAA severity and its management. MethodsWe identified all patients who underwent endovascular or open repair of an AAA in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing deprivation. Patients were categorized by ADI quintiles. Outcomes of interest included rates of ruptured AAA (rAAA) repair versus an intact AAA repair and rates of endovascular repair (EVAR) versus the open approach. Logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes. ResultsAmong 55,931 patients who underwent AAA repair, 6649 (12%) were in the lowest ADI quintile, 11,692 (21%) in the second, 15,958 (29%) in the third, 15,035 (27%) in the fourth, and 6597 (12%) in the highest ADI quintile. Patients in the two highest ADI quintiles had a higher proportion of rAAA repair (vs intact repair) compared with those in the lowest ADI quintile (8.8% and 9.1% vs 6.2%; P < .001). They were also less likely to undergo EVAR (vs open approach) when compared with the lowest ADI quintile (81% and 81% vs 88%; P < .001). There was an overall trend toward increasing rAAA and decreasing EVAR rates with increasing ADI quintiles (P < .001). In adjusted analyses, when compared with patients in the lowest ADI quintile, patients in the highest ADI quintile had higher odds of rAAA repair (odds ratio, 1.4; 95% confidence interval, 1.2-1.8; P < .001) and lower odds of undergoing EVAR (odds ratio, 0.54; 95% confidence interval, 0.45-0.65; P < .001). ConclusionsAmong patients who underwent AAA repair in the Vascular Quality Initiative, those with higher neighborhood deprivation had significantly higher rates of rAAA repair (vs intact repair) and lower rates of EVAR (vs open approach). Further work is needed to better understand neighborhood factors that are contributing to these disparities to identify community-level targets for improvement.

Pathophysiological Role of Chymase-Activated Matrix Metalloproteinase-9.

Chymase present in mast cells can directly form matrix metalloproteinase (MMP)-9 from proMMP-9. Chymase-activated MMP-9 has been reportedly closely related to the pathogenesis of various diseases, and inflammation-related diseases in particular. Upregulated chymase and MMP-9 have been observed in tissues from patients and animal models of aortic aneurysm, inflammatory gastrointestinal and hepatic diseases, acute pancreatic failure, atopic dermatitis and rheumatoid arthritis. Chymase at these regions is only derived from mast cells, while MMP-9 is derived from macrophages and neutrophils in addition to mast cells. Chymase inhibitors attenuate MMP-9 formation from pro-MMP-9, and ameliorate the development and progression of these disorders, along with reduction in inflammatory cell numbers. MMP-9 activated by chymase might also be involved in angiogenesis in the tumor environment. Development of angiogenesis around several cancers is closely related to the expression of chymase and MMP-9, and postoperative survival curves have revealed that patients with a higher number of chymase positive cells have lower survival rates. In this review, we wanted to clarify the role of chymase-activated MMP-9, which might become an important therapeutic target for various inflammatory disorders.

Fulminant Herpes Pneumonia Postaortic Surgery with Known Ankylosing Spondylitis.

Herpes simplex virus (HSV) pneumonitis is rare after cardiac surgery. A 36-year-old gentleman with ankylosing spondylitis underwent emergency surgery for a complex aortic aneurysmal disease. Preoperative treatment of aortitis with antitumor necrosis factor and steroid medication and surgical stress including cardiopulmonary bypass potentially created an immunosuppressive state and reactivation of undiagnosed HSV. Rapid HSV pneumonia ensued, culminating in fulminant organ failure and mortality. HSV pneumonia should be considered postoperatively in patients with severe respiratory distress, especially if immunocompromised.

NLRP3 inflammasome: The rising star in cardiovascular diseases.

Cardiovascular diseases (CVDs) are the prevalent cause of mortality around the world. Activation of inflammasome contributes to the pathological progression of cardiovascular diseases, including atherosclerosis, abdominal aortic aneurysm, myocardial infarction, dilated cardiomyopathy, diabetic cardiomyopathy, heart failure, and calcific aortic valve disease. The nucleotide oligomerization domain-, leucine-rich repeat-, and pyrin domain-containing protein 3 (NLRP3) inflammasome plays a critical role in the innate immune response, requiring priming and activation signals to provoke the inflammation. Evidence shows that NLRP3 inflammasome not only boosts the cleavage and release of IL-1 family cytokines, but also leads to a distinct cell programmed death: pyroptosis. The significance of NLRP3 inflammasome in the CVDs-related inflammation has been extensively explored. In this review, we summarized current understandings of the function of NLRP3 inflammasome in CVDs and discussed possible therapeutic options targeting the NLRP3 inflammasome.

Early outcomes of valve preservation in patients with ascending aortic aneurysm and bicuspid valve disease

Background: Bicuspid aortic valve (BAV) is the most frequent congenital heart disease affecting 1% to 2% of the population, with thoracic aortic aneurysm (TAA) formation being its second most frequent complication after aortic valve dysfunction (stenosis or insufficiency). Aortic valve replacement (AVR) with mechanical or biologic prostheses has long been the procedure of choice. Although prosthetic AVR is effective in correcting the hemodynamic problem, there are important long-term drawbacks. These are particularly present in a younger patient population, such as the majority of individuals with a BAV. Patient and methods: 40 patients underwent aortic valve repair for bicuspid aortic valve disease with ascending aortic aneurysm in the period between June 2020 and February 2022 in Kasr Alainy hospitals. Results: All our patients showed significant improvement regarding left ventricular dimensions and contractility. Two patients had mild to moderate regurge and thirty eight patients had non-significant regurge in the six month follow up echo. One patient complicated by complete heart block required permanent pacemaker implantation, another two patients had postoperative high drainage required revision for bleeding. One patient died from ventilator associated pneumonia after prolonged mechanical ventilation due to disturbed conscious level.

Temporal trends in medical cardioprotective treatment in patients with abdominal aortic aneurysms: A population-based national cohort study

Background and Aims : Patients with abdominal aortic aneurysmal (AAA) disease suffer high morbidity and mortality, driven mainly by cardiovascular comorbidity, and not the aneurysmatic disease itself. Initiation of cardioprotective therapy with statin and antiplatelets is recommended at AAA diagnosis. However, the implementation of recommendations over time is not well described. We aimed to provide up-to-date insights on temporal trends in the use of cardioprotective therapy in patients diagnosed with AAA.

The new educational project Televascular Games during the Coronavirus Disease 2019 pandemic.

ObjectiveTo report methodology and first-year results of a new educational project called “Televascular Games”, which took place during COVID-19 pandemic.MethodsComplex aneurysmal aortic disease was discussed during a 2-hour competition webinar, according to three modalities. 1) Planning case competition (PCC): 2-4 pre-operative Computed Tomography Angiography (CTA) scans of an already performed selected case were submitted for the competition. CTA-scans were anonymously uploaded, without any reference to the center or the surgeon who performed the case. The competitor had to prepare a presentation of how he/she would have diagnosed, sized, planned, treated and followed up the case, of the medical therapy and of the bail-out maneuvers. 2) Challenging case competition (CCC): the competitor elaborates a presentation of an already treated case concerning an aortic topic and discusses sizing, planning, treatment, possible bail-out maneuvers and obtained results. For the CCC and PCC, the competitors with the best score were pre-selected to present and discuss their plan during the webinars. 3) Quiz competition (QZ): 2-6 angio-CTA scans of already performed selected aortic cases were submitted for the competition. A quiz with multiple-choice questions was answered by the competitors. The top four competitors were selected for the webinars and then they discussed the cases during the webinar. Finally, at the end of the case-discussion, the effective case resolution and follow-up were shown. A final winner was voted via televoting, based on six pre-established criteria. The project was endorsed by different National and International Societies.ResultsBetween October-2020 and December-2021, there were 12 Italian and 1 international webinars with overall 1695 participants (mean 130, range:86-177). Competitors were 54 (mean age 27, range 22-38 years). Two editions were CCCs, two QZs, and nine PCCs. The reliability of the inter-observer sizing of competitors was k=.43 and k=.62 for the proximal and distal sealing measurements respectively and very good (k =.88-.95) in the evaluation of orientation of the vessels, presence of angulations, calcifications and thrombus. The sizing discrepancy resulted in a significant variability of the planning (k=.45). The project ranked 9.6 in a “10-point” rating scale by all the participants and competitorsConclusionsThe formula of gaming and collegial discussion of aortic cases herein reported has proved valid and attractive during COVID-19 pandemic period. The variability of the results on sizing and planning suggested to confer with a second opinion especially for less experienced surgeons.

National Adherence to Medical Management of Aortic Aneurysms

ObjectivesThe purpose of this study was to describe levels of adherence to guideline-based medical management in patients with aortic aneurysms, using an analogous population with coronary artery disease as a comparator. Adherence among those with aortic aneurysms has never been studied. MethodsAdult patients with an aortic aneurysm or coronary artery disease diagnosed between 2004 and 2018 in the Optum Clinformatics deidentified Datamart were queried. Aneurysms were subclassified as thoracic, abdominal, or both. Receipt of an antihypertensive or antihyperlipidemic was determined through pharmacy claims. Adherence was determined as receipt of the indicated pharmacologic(s) after a diagnosis of aneurysm or coronary artery disease. Adherence was compared between those with aneurysms and coronary disease using univariable logistic regression. ResultsAfter exclusions, 194,144 patients with an aortic aneurysm and 3,946,782 with coronary artery disease were identified. Overall adherence was low (45.0%) and differed significantly by aneurysm subtype: highest in isolated thoracic (45.9%) and lowest in isolated abdominal aneurysms (42.6%). Adherence levels declined significantly after 1 year by about 15% in each aneurysm subtype. All subtypes of aneurysm had a significantly lower odds of adherence compared to those with coronary disease with odds ranging from 0.61 in those with isolated abdominal aneurysms to 0.80 with isolated thoracic aneurysms. ConclusionsAdherence among those with aortic aneurysms is very low, differs by subtype, and declines with time. Levels of adherence in those with aortic aneurysms is significantly lower compared to those with coronary artery disease. This should prove a reasonable target for implementation initiatives.

Gender based differences in histopathology of abdominal aorta in patients with abdominal aortic aneurysm and aortoiliac occlusive disease

Relevance. Evidence exists that infrarenal aortic aneurisms and aortoiliac occlusive disease in women are different than in men in terms of anatomical features and more severe clinical course. Gender differences in histopathology of abdominal aorta are not fully studied.The objective was to study gender based differences in histopathology of abdominal aorta in patients with aortic aneurisms and aortoiliac occlusive disease.Methods and materials. The study included 96 biopsy specimens from 71 patients with aorto-iliac lesions (23 women and 48 men). A number of morphological characteristics and expression of matrix metalloproteinase 9 (MMP-9) were analyzed. The data obtained were processed statistically.Results. Adventitial infiltrate and medial sclerosis are more intense in the aneurysm than in occlusive-stenotic lesions, differences in the grade of fibrosis were proven only in men. Regardless of the patients’ gender, adventitial infiltration is denser in the aneurysmal body than in the neck; other changes in the anatomic parts of the aneurysm are similar. MMP-9 expression in the adventitia in the aneurysmal neck is higher in women, than in men. MMP-9 expression in the media and adventitia is higher in men with aneurysm, then with occlusive or stenotic lesion. Almost all indices of the aortic wall remodeling and MMP-9 expression correlate with each other in men with the aneurysm, in contrast to women.Conclusion. Gender based features in histopathology of abdominal aorta and the degree of their correlation may determine differences in the anatomy and course of abdominal aortic aneurysm and aortoiliac occlusive disease in women and men.

Proximal Aortic Surgery in Women—We Need to Do Better

Sex-Related Differences After Proximal Aortic Surgery: Outcome Analysis of 1773 Consecutive PatientsThe Annals of Thoracic SurgeryPreviewGuidelines on the management of aortic aneurysm disease do not account for sex differences regarding surgical procedures on the proximal aorta, although faster aneurysm growth, increased rupture risk, and higher postoperative mortality have been found in women. We therefore analyzed outcome differences between men and women receiving operations on the proximal aorta. Full-Text PDF

A real-world analysis of anti-atherosclerotic medical treatment and risk factor control in a cohort of vascular surgery patients.

The aim of this study was to assess the pattern of anti-atherosclerosis medicines in patients admitted to a vascular surgery department, the effective control of the target values and its subsequent modification by the vascular surgery team. A retrospective single-center cohort study of prospectively collected data was performed between May 2017 and May 2018 in a tertiary center. The STROBE guidelines were followed. All patients undergoing a primary elective surgery for carotid disease, aortic aneurysm and peripheral arterial disease were included. 'Best medical treatment' was defined as treatment with both anti-thrombotic and lipid-lowering treatment and, when appropriate, antihypertensive and anti-diabetic drugs. Both baseline and post-discharge best medical treatment were recorded. Blood work-up was performed at admission and 'adequately controlled patient' was defined if all blood test values were in agreement with the guidelines. A total of 279 patients (78% male; mean age 69 years-old) were included. Optimal medical therapy was registered in 58.8% upon admission but improved to 73.8% (95% CI, 2.197 - 7.781; p < 0.001) after discharge. At baseline, a total of 65.4% of patients were on lipid-lowering agents and of these, only 37% had LDL-C values within the targets. Likewise, only 34.6% of the 78 patients with diabetes had glycated hemoglobin within the normal range. Additionally, 8.5% of the remaining cohort had undiagnosed diabetes. In our current practice, only 75% of the patients receive best medical treatment. Although the admission in a Vascular Surgery department was an opportunity to optimize medical therapy, treatment remains suboptimal in one-quarter of patients. Further efforts should be carried out to alert vascular surgeons to this problem and to find future multidisciplinary solutions that can improve the cardiovascular risk profiles of these patients.

Mortality trend of heart diseases in China, 2013–2020

Background and purpose: Heart diseases are the leading cause of death in China. Understanding of the secular trend of different subcategories of heart disease is important for policy making. The purpose of this study is to analyze the mortality trend of heart diseases in China from 2013 to 2020. Methods: A population-based longitudinal analysis was conducted using the China National Mortality Surveillance System to examine heart disease mortality change during a period from 2013 to 2020. The causes of death were coded using the International Classification of Diseases-10th Revision. The number of deaths and mortality rate were calculated based on sex, subcategories of heart disease, urban versus rural setting, and across different geographic locations. Data from the sixth census in China in 2010 was used as the standard population, and the mortality rates were adjusted based on the under-reporting rate. Results: Ischemic heart disease (IHD), hypertensive heart disease (HHD), and rheumatic heart disease (RHD) are the three leading causes of heart disease deaths during 2013–2020. There was a trend for increased age-standardized mortality rate (ASMR) of cardiac arrest, aortic aneurysm (AA), and nonrheumatic valvular heart diseases (NRVHDs) during the study period. In comparison to men, women had higher ASMR of RHD, and lower ASMR of IHD, HHD, cardiac arrest, AA, and NRVHDs. In comparison to rural areas, urban areas had lower ASMR of IHD, HHD, and RHD, and higher ASMR of cardiac arrest, AA, and NRVHDs. The spectrum of heart diseases differed significantly across age groups. In 2020, the percentages of IHD and HHD in the ≥65-year age group were higher than in other age groups. Significant differences in ASMR were noted across different geographic locations, with the highest in Xinjiang (198.14/100,000) and the lowest in Shanghai (62.19/100,000) in 2020. Conclusions: The mortality rate decreased for IHD, HHD, and RHD during the study period, but remained the leading causes of heart disease death in China. There was a trend for increasing mortality of cardiac arrest, AA, and NRVHDs, and significant difference across different geographic locations.

One Year on: Test Your Knowledge From July 2021

1. A retrospective analysis of three studies (the Multi-centre Aneurysm Screening Study (MASS), the 2013/14 cohort of the English NHS AAA Screening Programme (NAAASP) and the Framingham Heart Study (FHS) offspring cohort) of male participants screened for aortic aneurysm disease investigated the association between infra-renal aortic diameter and cardiovascular risk. According to the results of these studies, which of the following is correct? 1A)A small aortic diameter was a uniform risk factor for cardiovascular events across the three studies.B)Cardiovascular mortality in all studies was higher in patients with an abdominal aortic aneurysm (AAA) compared to those without.C)Aortic diameter was risk factor for cardiovascular events, but this association was not confirmed on multivariable analysis.D)Aortic diameter was risk factor for stroke.E)None of the above.

Between the Devil and the Deep Blue Sea: New Insights into the Effects of Cancer Therapy on Abdominal Aortic Aneurysm Growth

In the setting of increasing prevalence of co-existing malignancy and abdominal aortic aneurysmal (AAA) disease, Becker von Rose et al. address a clinically relevant topic.1 To date, patients presenting with concomitant cancer and AAA should not undergo prophylactic aneurysm repair for different indications from patients without cancer.2 A few limited series have reported the effect of cytotoxic chemotherapy on AAA growth, and the follow up in this subset of patients remains non-standardised. The present study, which includes the largest number of aneurysms in oncological patients, might fill this gap and help in stratifying the AAA growth rate estimate in such settings.

Sex-Related Differences After Proximal Aortic Surgery: Outcome Analysis of 1773 Consecutive Patients

BackgroundGuidelines on the management of aortic aneurysm disease do not account for sex differences regarding surgical procedures on the proximal aorta, although faster aneurysm growth, increased rupture risk, and higher postoperative mortality have been found in women. We therefore analyzed outcome differences between men and women receiving operations on the proximal aorta. MethodsA total of 1773 patients underwent nonemergency surgical procedures on the aortic valve (AV) and proximal aorta at our institution between 2000 and 2018. Of these, 772 patients (21.8% women) received a Bentall procedure, 349 (20.3% women) had AV-sparing root replacement, and 652 (31.1% women) underwent AV and supracommissural ascending aorta replacement. Primary outcomes were in-hospital mortality and midterm survival. ResultsWhen assessing sex-related differences within the entire group of patients that received an operation on the proximal aorta, women were found to be older, had a lower body mass index, and were smokers less often. Despite shorter procedural times, median ventilation times and intensive care unit length of stay were longer in women. In-house mortality was also higher in women (3.6% vs 0.9%, P < .001). Multivariable logistic regression revealed age (odds ratio [OR], 1.8; 95% CI, 1.4-2.3 per 5 years added; P < .001), female sex (OR, 2.6; 95% CI, 1.2-5.8; P = .02), and urgent surgery (OR, 3.1; 95% CI, 1.2-7.3; P = .01) as independent risk factors for in-house death. Midterm survival was lower for women in the entire cohort (P = .02) and particularly within the Bentall subgroup (P = .004). ConclusionsFemale sex is an independent risk factor for operative mortality in patients undergoing proximal aortic surgery but is currently not addressed in guidelines. More research should focus on etiology and prevention of these worse outcomes in female patients.

Temporal trends in abdominal aortic aneurysmal disease: a nationwide cohort study on cardiovascular morbidity and medical cardioprotective therapy.

Abdominal aortic aneurysmal disease is associated with increased risk of cardiovascular morbidity and death, which potentially can be reduced with cardioprotective medical therapy. The aim of this study was to observe temporal trends in prevalence and incidence of cardiovascular comorbidity as well as use of medical cardioprotective treatment in patients diagnosed with abdominal aortic aneurysmal disease. This was a population-based cohort study based on data from national health registries, including all patients diagnosed with abdominal aortic aneurysms between 1998 and 2018. Data were stratified into four time periods (1999-2003, 2004-2008, 2009-2013, and 2014-2018) to illustrate trends over time. Outcome measures were (i) cardiovascular comorbidity and medical cardioprotective therapy at time of diagnosis, (ii) new admissions for atherosclerotic cardiovascular disease, and (iii) all-cause mortality after 2-year follow-up. The study cohort included 33 296 individuals. Mean age was 74 years. Prevalence of atherosclerotic cardiovascular comorbidity at diagnosis decreased from 41.5 to 32.6%. Use of statins increased from 17.9 to 66.9%, antiplatelets from 45.6 to 63.3%, and combined therapy with both antiplatelets and statins from 11.3 to 44.8%, and from 12.1 to 50.7% when anticoagulant therapy was included. Developments in medication use plateaued after 2013. Prevalence and incidence of atherosclerotic cardiovascular disease decreased through all four time periods. The same applied to all-cause mortality, which decreased from 24.3 to 12.4 deaths (per 100 person-years). In patients diagnosed with abdominal aortic aneurysm, cardiovascular comorbidity at diagnosis, risk of future cardiovascular events, and all-cause mortality is decreasing. Nevertheless, cardiovascular burden and mortality rates remain substantial, and medical cardioprotective therapy can be further improved.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Preliminary experience with the new off-the-shelf 4 inner branches E-nside for the treatment of complex aortic disease

Abstract Objective In case of complex aortic aneurysmal disease, fenestrated or branched EVAR (b/f-EVAR) is considered as a valid and safe alternative to open surgery. However, one the main limitation is the time required for manufacture, limiting its use in emergent situations. The new off-the-shelf 4 inner branches E-nside (Jotec, Hechingen, Germany) has been developed to offer a solution in such circumstances. The aim of this study was to report our preliminary monocentric experience with this new device. Methods Retrospective analysis of prospective data retrieved from 1 center between November 2020 and January 2022 was done. Endpoints were technical success, postoperative morbidity, rate of endoleak and any aneurysm-related re-interventions during follow-up. Results In this study, 15 patients (mean age 73 years, range 59–90) were identified. There was a majority of male (9/15) and all of them but 3 were asymptomatic. The mean aneurysmal diameter was 60 mm (range 50–100). There were 3 cases of juxtarenal aortic aneurysms (20%), 1 Crawford type I (7%), 4 type II (27%), 4 type III (27%) and 3 type IV (20%) aneurysms. In 7 cases, a 2-steps procedure was done with a TEVAR first followed by Enside implantation. There was a technical success in 93% with 1 open conversion for a mesenterical bypass. There was no death in the post-operative period. During the post-operative period, 33% of patients (5/15) presented complications with 3 complications related to the femoral or iliac access and 2 cases of spinal cord ischemia (13%). One case occurred in an emergent setting of a type III aneurysm rupture. The other case was the open conversion and the patient also developed a colic ischemia and finally died 4 months alter. The mean length of stay was 9 days. During the follow-up, 2 reinterventions were necessary, 1 for a type Ic endoleak with distal prolongation of the stent and 1 renal stent occlusion treated by relining. The overall target vessel patency was 98%. Conclusion The use of the off-the-shelf 4 inner branches E-nside appears to be safe with good technical success for the treatment of complex aortic aneurysmal disease. It is associated with an acceptable rate of complications and allows for treatment of a wide variety of diseases in an emergent setting. Further patients and longer follow-up are required to better evaluate the exact role of this new device.