Asymptomatic Aneurysms Research Articles

Surgery for small asymptomatic abdominal aortic aneurysms.

Surgery for small asymptomatic abdominal aortic aneurysms.

Frailty Remains Highly Correlated With Mortality After Endovascular Aneurysm Repair in Octogenarians

The elective treatment of asymptomatic abdominal aortic aneurysm must be balanced with individual life expectancy, which can be difficult to estimate. Frailty can help estimate perioperative risk, but most scales are heavily weighted by patient age. The objective of this study was to assess how frailty affects the outcomes of those with advanced age (≥80 years) undergoing endovascular aneurysm repair (EVAR). The Vascular Quality Initiative EVAR module was queried for all patients ≥80 years who underwent elective EVAR. A previously validated frailty model, the modified frailty index (mFI), was used to calculate a score for each patient. The mFI scores were calculated both with and without age as a variable. Low-, moderate-, and high-risk groups were created on the basis of the 0 to 25th, 26th to 75th, and 76th to 99th percentile distributions of the score across the study cohort. Logistic and Cox proportional hazards models were built using mFI score as a continuous variable. Of 9780 patients older than 80 years undergoing elective EVAR, 8462 (87%) had sufficient data to calculate the mFI. The mFI scores ranged from 26 to 56 with a median of 31. Low frailty corresponded to mFI score of <30; moderate frailty, 30 to 34; and high frailty, ≥35. There was no difference between groups in intraoperative complications or early reoperation. Among the low, moderate, and high frailty groups, the rates of early postoperative complications (7%, 7.1%, and 10%; P = .003) and 30-day mortality (0.8%, 1.1%, and 2.7%; P < .001) were higher in the highest frailty group. One-year mortality increased across the low (4%), moderate (6.8%), and high (13.6%) frailty groups (P < .001). An unadjusted Cox proportional hazards model yielded a hazard ratio of 1.09 (95% confidence interval, 1.08-1.1), representing a 9% increase in mortality hazard for every 1-point increase in mFI score. Kaplan-Meier survival curves by frailty group are shown in Fig 1. When frailty scores were calculated independently of age, postoperative complications and mortality were unchanged between groups as shown in Fig 2. A validated, easily calculable frailty index is strongly associated with perioperative and 1-year mortality among patients ≥80 years undergoing EVAR. In low-frailty octogenarians, EVAR is safe with low postoperative morbidity and mortality. Despite being the most heavily weighted component of the mFI, age adds little or no prognostic value past 80 years old.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The selection of patients for ambulatory endovascular aneurysm repair of elective asymptomatic abdominal aortic aneurysm

ObjectivesTo identify candidates undergoing elective endovascular aneurysm repair (EVAR) of asymptomatic infrarenal abdominal aortic aneurysm who are eligible for early (≤6 hours) hospital discharge or to have EVAR performed in free-standing ambulatory surgery centers. MethodsA retrospective medical record review of all elective EVAR performed at a university medical center over 5 years was undertaken. Potential candidates for early discharge or to have EVAR performed in a free-standing ambulatory surgery setting were defined as those who used routine monitoring services only or had self-limited minor adverse events (AE) that were identified, treated, and resolved within 6 hours of surgery. Risk factors for ineligibility were determined by logistic regression. Sensitivity, specificity, negative and positive predictive values were measured to determine the veracity of the risk factor profile. ResultsThere were 272 elective EVARs; the mean patient age was 74 years (range, 52-94 years), and 75% were male. Twenty-five operative major AEs (MAE) occurred in 21 patients (7.7%): bleeding (5.9%), thrombosis (1.8%), and arterial injury (1.8%). Percutaneous EVAR (PEVAR) attempted in 260 patients (96%) was successful in 238 (88%). Failed PEVAR was associated with operative MAE (P < .001). Combined operative/postoperative MAE occurred in 43 patients (15.8%); 17 (6%) required intensive care admission; 88% directly from the operating room/postanesthesia care unit. Only two MAE (0.7%) occurred beyond 6 hours; (congestive heart failure at 24 hours, thrombosis/reoperation at 15 hours). Other AE included nausea (17%), blood pressure alteration (15%), and urinary retention (13%). Need for nonroutine services or treatment of other AE occurred in 131 (48%) patients with 79 (29%) developing or requiring treatment ≥6 hours postoperatively. However, 22 (8%) were treated/resolved in <6 hours; 30 (11%) patients required monitoring only and 36% had no complications, so, overall eligibility for same-day discharge/free-standing ambulatory surgery center was 55%. Failed PEVAR (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.25-4.49; P = .008), PEVAR performed outside of instructions for use (IFU) criteria (OR, 2.84; 95% CI, 1.07-7.56; P = .037), Endologix AFX graft (OR, 1.66; 95% CI, 1.19-2.33; P = .003) were independent predictors of MAE or AE occurring/requiring treatment >6 hours postoperatively; EVAR, which did not require an additional aortic cuff, was associated with a lower incidence (OR, 0.17; 95% CI, 0.04-0.65; P = .01). Neither aortic nor limb IFU were independent predictors. Profiles using PEVAR IFU, PEVAR failure, and graft type demonstrated only moderate sensitivity (63%), specificity (71%), positive predictive value (70%), and negative predictive value (63%). ConclusionsMore than one-half of all patients who undergo EVAR are ready for discharge within 6 hours postoperatively. Failed PEVAR, aortic cuffs, and Endologix AFX graft were independent predictors of MAE or AE occurring/requiring treatment for ≥6 hours. However, sensitivity parameters of this profile were insufficient to advocate EVAR in free-standing ambulatory surgical units at this time, but hospital-based ambulatory admission with same-day discharge would be a viable option because of easy inpatient transition for those requiring continued care.

LO54: Emergency department prevalence of intracranial aneurysm on computed tomography angiography (EPIC-ACT)

Introduction: Evidence is accumulating that a CT plus a CT angiogram (CTA) of the head and neck may be adequate to rule out subarachnoid haemorrhage (SAH) in patients with a thunderclap headache, thus potentially negating the need for lumbar puncture. One of the most widely cited objections to this strategy is the fear of detecting “incidental asymptomatic aneurysms,” lesions seen on angiography that are not in fact the cause of the patient's symptoms. Currently existing data on the background rate of aneurysms are based on cadaveric studies, invasive angiography, or MRI, and thus does not reflect the true rate of incidental aneurysms that would be detected using a CT plus CTA strategy. This study characterizes the rate of incidental aneurysms identified on CTA in an emergency department population. Methods: In this multicentre retrospective cohort study we analyzed the electronic medical records of all emergency department patients ≥ 18 years of age who underwent CTA of the head and neck over a two month period across four urban tertiary care emergency departments. Two independent reviewers evaluated the final radiology reports and extracted relevant data. The primary outcome of interest was the presence of incidental intracranial aneurysm, defined as a newly diagnosed aneurysm not associated with evidence of acute hemorrhage. Secondary outcomes included aneurysm location and size. Results: Of 739 charts meeting inclusion criteria, incidental intracranial aneurysms were detected in 21 cases or 2.85% (95% confidence interval, 1.77 - 4.32). An additional 20 aneurysms were identified but excluded from the analysis as they were previously known (n = 9) or were associated with evidence of acute hemorrhage (n = 11) and thus were not considered incidental. Of 21 patients with identified incidental aneurysms, 7 had multiple aneurysms. The most common aneurysm sites were internal carotid artery (n = 13), middle cerebral artery (n = 6) and anterior cerebral artery (n = 4). The average size of incidental aneurysm was 4.1 mm. Conclusion: The rate of incidental intracranial aneurysm among emergency department patients undergoing CTA of the head and neck is lower than many previously described estimates obtained through invasive angiography and MRI studies. To our knowledge, this is the first study on the prevalence of incidental intracranial aneurysms in an emergency department specific population and may therefore help guide clinicians when considering using a CT plus CTA rule out strategy for patients presenting with acute headache suspicious for SAH.

Increased Serum KLF4 in Severe Atheromatosis and Extensive Aneurysmal Disease

Krüppel-like factor 4 (KLF4) is known to preserve vascular homeostasis. In the present study, we sought to correlate serum KLF4 levels with arterial aneurysm size and their clinical presentation. We also explored the association between serum KLF4 levels and the severity of extracranial carotid and peripheral arterial disease. Patients undergoing surgery for various forms of atheromatosis (ATH group) or for arterial aneurysm repair (AA group) were eligible for inclusion. KLF4 levels were measured via enzyme-linked immunosorbent assay. Patients in the atheromatic and aneurysmal groups had significantly higher serum KLF4 levels compared with controls. Patients with permanent end-organ damage (ATH3) had higher serum KLF4 (6.96±0.75 pg/mL) compared with patients with asymptomatic internal carotid stenosis >70% or claudication (ATH1) (2.76±0.68 pg/mL; mean difference [MD], -4.20; 95% confidence interval [95% CI], -5.35 to -3.04; P<0.01) and those with transient ischemic attack or rest pain (ATH2) (4.47±1.08 pg/mL; MD, -2.48; 95% CI, -3.76 to -1.21). Furthermore, patients with an asymptomatic aneurysm of a diameter 250-300% of that of the normal artery (AA1, 5.01±1.08 pg/mL) had considerably lower serum KLF4 compared with those suffering from either a symptomatic aneurysm or an asymptomatic aneurysm of a diameter >350% of that of normal artery (AA3, 6.63±1.92 pg/mL; MD, -2.61; 95% CI, -5.04 to -0.18; P<0.01). Serum KLF4 levels are significantly increased in patients with end-organ damage related to atheromatosis as well as those with extensive aneurysmal disease.

"King size" asymptomatic aortic aneurysm after bicuspid aortic valve surgery.

"King size" asymptomatic aortic aneurysm after bicuspid aortic valve surgery.

Exceptional case of rapid growth and ruptured of a very small asymptomatic unruptured intracranial aneurysm which was stable over years in a 72 years old active smoker (2487)

Exceptional case of rapid growth and ruptured of a very small asymptomatic unruptured intracranial aneurysm which was stable over years in a 72 years old active smoker (2487)

Variation in Surgical Treatment of Abdominal Aortic Aneurysms With Small Aortic Diameters in the Netherlands.

To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of <55 mm for men and <50 mm for women were considered guideline deviations. National deviation and hospital variation in deviation were evaluated over time. Questionnaires were distributed among all Dutch VSUs, inquiring for acceptable reasons for guideline deviation. VSUs were asked to estimate the guideline deviation percentage in their hospital which was then compared with their DSAA percentage. In all, 9039 patients were included. In 15%, we found guideline deviation, varying from 2% to 40% between VSUs. Over time, 21 VSUs were identified with a lower percentage of deviation than the national mean each year and 8 VSUs with a higher percentage. 44/60 VSUs completed the questionnaire. Most commonly reported reasons to deviate were concomitant large iliac diameter (91%) and saccular aneurysm (82%). The majority of the VSUs (77%) estimated their guideline deviation to be <5%. Eleven VSUs (25%) estimated their deviation concordant with their DSAA percentage, but 75% of VSUs underestimated their deviation. Dutch VSUs regularly deviate from the guidelines regarding aneurysm diameter, with variation between VSUs. Consensus exists amongst VSUs on acceptable reasons for guideline deviations; however, the majority underestimates their actual deviation percentage.

Influence of genetics in intracranial aneurysms

The prevalence of unruptured intracranial aneurysms is approximately 3-5%. Subarachnoid hemorrhage caused by rupture of an aneurysm often affects middle-aged people and harbors high morbidity and mortality. The increasing availability of noninvasive imaging techniques over time is accompanied by an increase in the incidental detection of aneurysms. The etiology in aneurysm development is heterogeneous. Besides polygenic multifactorial diseases, often triggered by well-established vascular risk factors, monogenic diseases should also be considered. Advances in genetics has helped to identify genes that contribute to the risk of intracranial aneurysm development. The genetic basis of intracranial aneurysms shows abroad heterogeneity and complexity. Currently, besides imaging there is no reliable diagnostic test to identify patients who are at higher risk for asymptomatic intracranial aneurysms.

Greater aortic inflammation and calcification in abdominal aortic aneurysmal disease than atherosclerosis: a prospective matched cohort study

ObjectiveUsing combined positron emission tomography and CT (PET-CT), we measured aortic inflammation and calcification in patients with abdominal aortic aneurysms (AAA), and compared them with matched controls with atherosclerosis.MethodsWe prospectively...

Gadolinium Enhancement of the Aneurysm Wall in Extracranial Carotid Artery Aneurysms.

The natural history and optimal treatment of extracranial carotid artery aneurysms are unknown. Gadolinium enhancement of the aneurysm wall may reflect aneurysm wall inflammation and instability. In this study, we investigated the feasibility of extracranial carotid artery aneurysm wall imaging and explored a potential relationship of aneurysm wall enhancement with aneurysm growth and the presence of (silent) brain infarcts and white matter lesions. Fourteen conservatively treated patients with 15 asymptomatic extracranial carotid artery aneurysms underwent gadolinium-enhanced 3T MR imaging at 2 time points with a 12-month interval. Primary outcome was growth of the aneurysm sac (≥2.0 mm); secondary outcomes were the presence of (silent) brain infarcts and white matter lesions at baseline and follow-up. MR images were reviewed by 2 independent observers, and inter- and intraobserver reproducibility was assessed. Seven (50%) patients were men; the median age was 55 years (range, 40-69 years). Eleven extracranial carotid artery aneurysms (73%) were saccular (median size, 11 mm; range, 5.0-38.5 mm), and 4 were fusiform (median size, 21.5 mm; range, 10.0-40.0 mm). Eleven of 15 aneurysms (73%) exhibited gadolinium enhancement at baseline. Four aneurysms (27%) showed growth at follow-up imaging, 2 gadolinium-positive (+) and 2 gadolinium-negative (-) (P = .245). Three patients (21%) had ipsilateral brain infarcts at baseline; 1 of them showed a new silent brain infarct at follow-up imaging (gadolinium+). Nine patients (64%) showed bilateral white matter lesions at baseline. In 3 patients, increased white matter lesion severity was observed at follow-up (2 gadolinium+). All observations showed excellent inter- and intraobserver reproducibility. In this explorative study, we demonstrated that extracranial carotid artery aneurysm wall imaging was feasible. Future well-powered studies are needed to investigate whether extracranial carotid artery aneurysm gadolinium enhancement predicts aneurysm growth and thromboembolic complications.

Magnetic resonance imaging assessment of proteolytic enzyme concentrations and biologic properties of intraluminal thrombus in abdominal aortic aneurysms

ObjectiveThe aim of the study was to determine whether magnetic resonance imaging (MRI) can be used in assessment of biologic activity of intraluminal thrombus (ILT) and proteolytic processes of the abdominal aortic aneurysm wall. MethodsUsing MRI, 50 patients with asymptomatic infrarenal abdominal aortic aneurysm were analyzed at the maximum aneurysm diameter on T1-weighted images in the arterial phase after administration of contrast material. Relative ILT signal intensity (SI) was determined as the ratio between ILT SI and psoas muscle SI. During surgery, the full thickness of the ILT and the adjacent part of the aneurysm wall were harvested at the maximal diameter for biochemical analysis. The concentrations of matrix metalloproteinase 9 and neutrophil elastase (NE/ELA) were analyzed in harvested thrombi, and the concentrations of collagen type III, elastin, and proteoglycans were analyzed in harvested aneurysm walls. ResultsA significant positive correlation was found between the NE/ELA concentration of the ILT and the relative SI (ρ = 0.309; P = .029). Furthermore, a negative correlation was observed between the elastin content of the aneurysm wall and the relative SI (ρ = −0.300; P = .034). No correlations were found between relative SI and concentration of matrix metalloproteinase 9, NE/ELA, collagen type III, or proteoglycan 4 in the aneurysm wall. ConclusionsThese findings indicate a potential novel use of MRI in prediction of thrombus proteolytic enzyme concentrations and the extracellular matrix content of the aneurysm wall, thus providing additional information for the risk of potential aneurysm rupture.

Asymptomatic unruptured aneurysm of the left sinus of Valsalva: a case history report

.

Tissue-specific relaxin-2 is differentially associated with the presence/size of an arterial aneurysm and the severity of atherosclerotic disease in humans.

Circulating or tissue-related biomarkers are of clinical value for risk stratification in patients with abdominal aortic aneurysms. Relaxin-2 (RL2) has been linked to the presence and size of arterial aneurysms, and to the extent of atherosclerosis in human subjects. Here, we assessed the expression levels of RL2 in aneurysmal (AA, n = 16) and atherosclerotic (ATH, n = 22) arteries, and established the correlation between RL2 levels and the presence/size of AA and the clinical severity of atherosclerosis. The expression levels of metalloproteinases (MMPs) and endothelial nitric oxide synthetase (eNOS) were also detected for correlations with different phenotypes of atherosclerosis and AA. Temporal artery biopsy specimens (n = 6) and abdominal aortic tissues harvested from accident victims during autopsy (n = 10) were used as controls. Quantitative tissue biomarker analysis revealed that tissue-specific RL2 was increased in patients with larger or symptomatic AA compared to subjects with atherosclerotic disease and healthy controls. In situ RL2 levels were proportional to the size and the severity of aneurysmatic disease, and were substantially elevated in patients with symptomatic aneurysm of any diameter or asymptomatic aneurysm of a diameter >350% of that of the normal artery. In contrast, tissue RL2 was inversely associated with the clinical severity of atherosclerotic lesions. Correlation between RL2 and MMP2 was different between ATH1 and ATH2, depending on atherosclerosis grade. Overall, tissue RL2 is differentially associated with discrete phenotypes of arterial disease and might exert multipotent biological effects on vascular wall integrity and remodeling in human subjects.

Multimodality imaging of an asymptomatic giant right atrial appendage aneurysm.

Right atrial appendage (RAA) aneurysm is a rare congenital cardiac abnormality thought to be caused by dysplasia of the muscular wall of the RA and RAA. Structural, contractile, or electrical atrial changes are associated with the onset and progression of atrial fibrillation. The RAA aneurysm can have various symptoms, such as thromboembolic complications. Diagnosis of RAA aneurysm greatly depends on imaging modalities, among which echocardiography is the most widely used one. Echocardiography is very effective in discovering the aneurysm, distinguishing it from other abnormalities such as pericardial cysts, Ebstein's anomaly and cor triatriatum, and detecting intracardiac thrombosis or blood flow limitations. Cardiac magnetic resonance imaging and computed tomography are important complementary examinations. They may provide more details on the neighboring structures of the aneurysm, especially when echocardiographic images are suboptimal.

Asymptomatic intracranial aneurysms in beta-thalassemia: a three-year follow-up report

BackgroundNo information is currently available regarding the natural history of asymptomatic intracranial aneurysms in beta-thalassemia, raising several concerns about their proper management.MethodsWe performed a prospective longitudinal three-year-long MR-angiography study on nine beta-thalassemia patients (mean-age 40.3 ± 7.5, six females, 8 transfusion dependent) harboring ten asymptomatic intracranial aneurysms. In addition, we analyzed the clinical files of all adult beta-thalassemia patients (160 patients including those followed with MR-angiography, 121 transfusion dependent) referring to our Centers between 2014 and 2019 searching for history of subarachnoid hemorrhage or history of symptomatic intracranial aneurysms.ResultsAt the end of the three-year-long follow-up, no patient showed any change in the size and shape of the aneurysms, none presented new intracranial aneurysms or artery stenoses, none showed new brain vascular-like parenchymal lesions or enlargement of the preexisting ones. Besides, in our database of all adult beta-thalassemia patients, no one had history of subarachnoid hemorrhage or history of symptomatic intracranial aneurysms.ConclusionsIncidental asymptomatic intracranial aneurysms do not seem to be associated, in beta-thalassemia, with an increased risk of complications (enlargement or rupture) at least in the short term period, helping to optimize human and economic resources and patient compliance during their complex long-lasting management.

Risk Factors for Asymptomatic Intracranial Small Aneurysm Rupture Determined by Electrocardiographic-Gated 4D Computed Tomographic (CT) Angiography.

BackgroundTo study the risk predictors of intracranial asymptomatic small aneurysm rupture by electrocardiographic (ECG)-gated 4D-CT angiography (4D-CTA).Material/MethodsA total of 168 patients with intracranial aneurysms <7 mm who underwent 4D-CTA examinations were retrospectively analyzed and divided into a ruptured group and an unruptured group. The original scanning data of all cases were reconstructed to obtain 20 groups of data in 5% time intervals in the cardiac cycle. After processing with 3D workstation software, 20 sets of images and dynamic images were achieved. The morphological characteristics and clinical features of the 2 groups of aneurysms were analyzed through univariate analysis, then logistic regression analysis was performed for the meaningful indicators. Finally, the optimum diagnostic cut-off point was calculated by ROC curve analysis.ResultsUnivariate analysis showed that sex, smoking history, vascular bifurcation point, pulsation point appearance, aneurysm height, aspect ratio (AR), and size ratio (SR) were significantly different (P<0.05) between the ruptured group and unruptured group. Multivariate regression analysis indicated that the pulsation points (OR=8.188, 95% CI: 3.984–17.198) and high SR values (OR=5.325, 95% CI: 1.503–18.867) were independent predictors of asymptomatic small aneurysm rupture. When the SR value was higher than 1.65, the area below the ROC curve was 0.723, the diagnostic sensitivity was 75%, and the specificity was 80%.ConclusionsThe occurrence of pulsation points and SR values >1.65 were independent predictors for the rupture of asymptomatic small intracranial aneurysms <7 mm in diameter.

The Treatment of Aneurysms of the Extremities Arteries - a Systematic Overview - New Therapies for Isolated Iliac Artery Aneurysm Employing a New Classification

Aneurysms of arteries in the extremities have a low incidence and are often manifest through complications. The most serious complications are rupture and extremity-threatening ischemia. Both usually lead to the diagnosis. Absolute indications for therapy are symptomatic aneurysms and asymptomatic aneurysms of 2 cm diameter or more. The extrailiacal gold standard is interponat or bypass with venous graft material. Endovascular methods are reserved for inoperable patients and clinical decisions on special cases. In contrast, complex endovascular techniques have been established in isolated iliac aneurysms and have significantly improved treatment options. Their implementation is bound to the existence of a suitable landing zone. This is the basis for a new classification of isolated iliac artery aneurysm. With the help of morphological subtypes, this classification permits standardised procedure planning for perfusion preservation of the internal iliac artery. The present article gives an overview of the current treatment strategy for aneurysms of extremities arteries. Similarities and regional differences in therapy are discussed.

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.

Spontaneous coronary dissection and asymptomatic splenic artery aneurysms in a young woman

Spontaneous coronary dissection and asymptomatic splenic artery aneurysms in a young woman