Aneurysm Diameter Research Articles

Comparison of bridging stent grafts in branched endovascular aortic repair

BackgroundEndovascular treatment of thoracoabdominal aortic aneurysms has become common, with satisfactory results. Nevertheless, long-term durability remains an issue mainly because of target visceral vessel (TVV) instability. Currently, no covered stent has been approved as a bridging stent graft (BSG), demanding continuous research on this topic. MethodsThis was a multicenter observational retrospective cohort study comparing the midterm results of the Bard Covera Plus and Gore VBX as BSGs during branched endovascular aneurysm repair. The primary outcome was the comparison of the target vessel instability between the two groups. Primary patency, freedom from branch-related type I and III endoleaks and reintervention, and technical and clinical success were considered secondary outcomes. Logistic regression analysis was used to assess the association between selected baseline factors and TVV instability. TVV instability during follow-up was then evaluated using the Kaplan-Meier cumulative function. ResultsThree hundred forty-five TVVs in 106 patients were considered suitable for the analysis. Two hundred twenty vessels were stented with the Covera stent graft (64%) and 125 with VBX (36%). Two hundred ninety-nine TVVs received a single BSG, 45 two BSGs, and only 1 three BSGs. Bare metal stent relining was required in 36% of TVVs, mostly in the Covera group (89 [41%] vs 36 [29%]) (P = .030). The primary technical success rate was 96% (331/345), and the assisted primary technical success rate was 99% (342/345). The TVV instability rate within 30 days was 2% (one Covera and five VBX; P = .015). Three BSG occlusions (one Covera and two VBX) and three type Ic endoleaks (three VBX) were detected. The median follow-up was 13.9 months (range, 5.8-25.5 months). Sixteen TVV instabilities were detected during the follow-up. Twelve BSG occlusions (six Covera and six VBX), three type Ic endoleaks (one Covera and two VBX), and one type IIIc endoleak (VBX). The overall target vessel instability rate was 5% (16/342). TVV instability was associated with the use of Gore VBX in the univariable logistic regression (odds ratio, 3.0; 95% confidence interval, 1.1-8.0; P = .027). Aneurysm rupture and aneurysm diameter were also associated with TVV instability in the univariable analysis (P = .002 and P = .008, respectively). The only factor predisposing to TVV instability in the multivariable logistic regression analysis was the use of Gore VBX as a BSG (odds ratio, 2.9; 95% confidence interval, 1.0-8.0; P = .043). Kaplan-Meier analysis showed a significantly higher risk of TVV instability in the VBX group (P < .001). ConclusionsOverall midterm outcomes in this cohort were satisfactory. Patency rates were similar between the two stents. Nevertheless, VBX seems to be associated with worse TVV instability. These results may be correlated with a higher incidence of type Ic endoleaks, which require an extensive learning curve for correct stent selection and deployment.

Sex disparities in popliteal artery aneurysms

ObjectiveOnly 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe’s largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. MethodsPOPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. ResultsOf the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. ConclusionsWomen have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Impact of the Lumbar Arteries on Aneurysm Diameter and Type 2 Endoleak after Endovascular Aneurysm Repair

Prophylactic embolization of the inferior mesenteric artery (IMA) during endovascular aneurysm repair (EVAR) is recommended to prevent type 2 endoleak (T2EL). However, the impact of patent lumbar arteries (LAs) on T2ELs and aneurysm diameter has not been elucidated. Fifty-seven consecutive patients who underwent EVAR at our institution between January 2013 and September 2022 and whose IMA had been occluded preoperatively or newly occluded postoperatively were included in the study. Predictive factors for aneurysm sac enlargement, sac shrinkage, and T2EL were investigated. T2ELs occurred in 22.8% of the patients. The 4-year cumulative incidence rates of sac enlargement and shrinkage were 6.7% and 64.6%, respectively. The number of postoperative patent LAs was identified as a risk factor for T2ELs (95% confidence interval [CI]: 1.54-12.7, P=0.0065). The number of postoperative patent LAs was found to be a significant predictor of sac enlargement (adjusted hazard ratio [AHR] 3.15, 95% CI: 1.43-6.96, P=0.0045) and shrinkage (AHR 0.63, 95% CI: 0.43-0.91, P=0.014). The current study demonstrated that the number of postoperative patent LAs had a significant impact on the development of T2ELs and the change in aneurysm diameter in patients in whom the IMA was occluded after EVAR.

Middle cerebral artery bifurcation aneurysms are associated with patient age, sex, bifurcation angle, and vascular diameters

To investigate the relationship of the middle cerebral artery (MCA) bifurcation aneurysms with patients’ age and sex, vascular angles at the bifurcation, and diameters of the M1 and two M2 arteries, patients with and without MCA aneurysms were retrospectively enrolled. The lateral angles, MCA bifurcation angle and arterial diameter were measured and analyzed. Totally, 121 (19.0%) patients with and 517 (81.0%) without MCA aneurysms were enrolled. Most (n = 88 or 72.7%) aneurysms were present in the age range of 40–70 years, and significantly (P = 0.01) more women than men had the bifurcation aneurysms. The MCA bifurcation angle was significantly greater (149.2° ± 32.6° vs. 107.2° ± 26.3°; P < 0.0001) while both the smaller and larger lateral (M1/M2) angles were significantly smaller in patients with than without aneurysms (82.0° ± 23.7° vs. 109.1° ± 22.7° with P < 0.001 for the smaller and 123.2° ± 25.2° vs. 139.5° ± 16.9° with P < 0.001 for the larger lateral angle). 109 (90.1%) bifurcation aneurysms deviated towards the smaller lateral angle, and 103 (85.1%) aneurysms deviated towards the thinner M2 branch. The maximal aneurysm diameter ranged 1.6–13.8 (mean 5.4 ± 2.4) mm and was significantly (P < 0.05) positively correlated with the diameter of both M2 arterial branches (R = 0.57 and P = 0.01 for the smaller M2, and R = 0.69 and P = 0.002 for the larger M2) or the MCA bifurcation angle. A significant (P < 0.0001) negative correlation was detected between age and the smaller lateral angle but a significant (P < 0.0001) positive correlation between age and the MCA bifurcation angle in patients without MCA bifurcation aneurysms or in the total patients. MCA bifurcation angle was the only significant (P = 0.0001, odds ratio 2.7, 95% confidence interval 1.6–3.8) independent risk factor for MCA bifurcation aneurysm presence, with the bifurcation angle threshold of 124.1° and an area under the ROC curve of 0.86. In conclusion, significantly more MCA bifurcation aneurysms are present in older patients, females, and patients with a wider MCA bifurcation angle, and deviate towards the smaller lateral angle and the thinner M2 segment. MCA bifurcation angle is the only independent risk factor for presence of MCA bifurcation aneurysms with the threshold of 124.1°.

Effect of Antiplatelet Agents on Abdominal Aortic Aneurysm Process: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aims to investigate whether antiplatelet agents are associated with the reduction, expansion, and rupture of abdominal aortic aneurysm (AAA). A thorough exploration was conducted on four prominent databases, namely EMBASE, Ovid, PubMed, and Scopus, to identify studies that reported the influence of antiplatelet agents on the sac development of AAA. The assessment was carried out until March 2023. R software v.4.1 was used for statistical analysis. After reviewing 13 publications which included a total of 5392 patients (1446 in the antiplatelet group and 2540 in the control group), a meta-analysis was conducted. The results of the analysis revealed that there was no significant difference in the annual growth rate of AAA diameter between those who received antiplatelet agents and those who did not (mean difference (MD) = -0.04, 95% CI = [-0.37, 0.30]; heterogeneity: p 0.01, = 91%, 2 = 0.1278). Additionally, there was no difference in the number of patients who experienced aneurysm diameter expansion between the two groups, significantly (odds ratio (OR) = 0.96, 95% CI = [0.41, 2.25]; heterogeneity: p 0.01, = 78%, 2 = 0.5849). Antiplatelet agents do not affect AAA's reduction, expansion, or rupture. There is no benefit to AAA patients taking antiplatelet agents for the purpose of slowing down growth rates of sac diameter.

Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair

ObjectivePost implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. MethodsSystematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. ResultsAfter screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. ConclusionsThis systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.

Predictors for a Collar Sign and its Association with Outcomes in Aneurysms after Pipeline Embolization

The collar sign has been previously described as an angiographic indicator of incomplete occlusion after deployment of a pipeline embolization device (PED) for intracranial aneurysms. In the present study, we explore the predictors for a collar sign in aneurysms treated with the PED. Aneurysms with a collar sign at the initial follow-up angiogram were identified in a retrospective review of single-center data. The predictors of a collar sign were analyzed through univariate and multivariate analyses. A total of 492 cases of cerebral aneurysm treated with the PED were identified. Among them, 53 were found to have a collar sign on the initial follow-up angiogram. Univariate analysis showed that previous treatment of the same aneurysm (odds ratio [OR], 2.46; P= 0.01), a branch vessel from the aneurysm neck or dome (OR, 6.2; P < 0.001), and a smaller aneurysm neck size (OR, 0.75; P= 0.01) were all predictors for the presence of a collar sign. A larger diameter (OR, 0.92; P= 0.06), increased dome/neck ratio (OR, 1.38; P= 0.1), increased aspect ratio (OR, 1.14; 0 P=.17), and previous treatment showed a trend toward an association with a collar sign. However, after multivariate analysis, a branch from the aneurysm neck or dome (OR, 6.23; P < 0.001), aneurysm diameter (OR, 0.75; P= 0.032), an increased dome/neck ratio (OR, 4.62; P= 0.006), and previous treatment were the strongest predictors for a collar sign. The presence of a branch vessel arising from the aneurysm neck or dome, an increased dome/neck ratio, aneurysm diameter, and previous treatment are the strongest predictive factors for a collar sign in the angiographic follow-up of PED-treated aneurysms.

Outcomes of Clampless Real Chimney Technique with Dacron Graft and Sleeve Banding of the Ascending Aorta for Total Debranching Endovascular Arch Repair

Background: Hybrid aortic arch repair with debranching of the supra-aortic vessels carries a high risk of cerebral infarction and fatal complications associated with side clamping of the ascending aorta. A previous study had reported the “real chimney” technique, a novel method for clamp-free total debranching thoracic endovascular aortic repair with the ascending aortic sleeve banding with dacron. In this study, we aim to build upon this foundation by presenting our experience with the early and midterm outcomes of this technique. Methods: We retrospectively reviewed the medical records of 61 consecutive older adult patients with aortic arch pathologies and a high risk of open repair who underwent total debranching thoracic endovascular aortic repair using the real chimney technique at our institution between January 2014 and June 2022. This technique was used to anastomose the ascending aorta with the main trunk of the triple-branched prosthetic graft. Results: The mean patient age was 75.1 years, and 54% of patients were transferred from medical facilities with cardiothoracic surgery departments. The comorbidities included chronic obstructive pulmonary disease (49.2%), chronic kidney disease (63.9%), coronary artery disease (27.9%), and history of stroke (31.1%). No 30-day mortality was observed. Complications included postoperative renal failure requiring permanent hemodialysis (4; 6.6%), stroke (modified Rankin scale score: ≥2 in 5; 8.2%), permanent paraplegia (1; 1.6%), and permanent paraparesis (4; 6.6%). The median follow-up period was 40.5±28.5 months. The postoperative survival rates at 5 years were 66.8%. No patients experienced complications associated with the aorta or anastomosis site; only 1 patient required an additional procedure for stenosis of the anastomosis site (midterm). An aneurysmal diameter reduction of ≥3 mm was observed in 37 cases (60.7%), and the mean aneurysmal diameter reduction was 5.3 mm. Conclusions: The postoperative outcome of total debranching thoracic endovascular aortic arch repair is not only acceptable but also promising, particularly in patients at high risk of open repair. Clinical Impact Our novel real chimney technique for total debranching thoracic endovascular aortic repair of aortic arch pathologies in patients who were at a high-risk for open repair resulted in no 30-day mortality and no complications related to the aorta or the real chimney anastomosis site. The real chimney technique is effective for managing aortic arch pathologies and enables less invasive total debranching thoracic endovascular aortic arch repair without the need for extracorporeal circulation and clamping of the ascending aorta

Antiplatelet Therapy, Abdominal Aortic Aneurysm Progression, and Clinical Outcomes

Preclinical studies suggest a potential role for aspirin in slowing abdominal aortic aneurysm (AAA) progression and preventing rupture. Evidence on the clinical benefit of aspirin in AAA from human studies is lacking. To investigate the association of aspirin use with aneurysm progression and long-term clinical outcomes in patients with AAA. This was a retrospective, single-center cohort study. Adult patients with at least 2 available vascular ultrasounds at the Cleveland Clinic were included, and patients with history of aneurysm repair, dissection, or rupture were excluded. All patients were followed up for 10 years. Data were analyzed from May 2022 to July 2023. Clinical outcomes were time-to-first occurrence of all-cause mortality, major bleeding, or composite of dissection, rupture, and repair. Multivariable-adjusted Cox proportional-hazard regression was used to estimate hazard ratios (HR) for all-cause mortality, and subhazard ratios competing-risk regression using Fine and Gray proportional subhazards regression was used for major bleeding and composite outcome. Aneurysm progression was assessed by comparing the mean annualized change of aneurysm diameter using multivariable-adjusted linear regression and comparing the odds of having rapid progression (annual diameter change >0.5 cm per year) using logistic regression. A total of 3435 patients (mean [SD] age 73.7 [9.0] years; 2672 male patients [77.5%]; 120 Asian, Hispanic, American Indian, or Pacific Islander patients [3.4%]; 255 Black patients [7.4%]; 3060 White patients [89.0%]; and median [IQR] follow-up, 4.9 [2.5-7.5] years) were included in the final analyses, of which 2150 (63%) were verified to be taking aspirin by prescription. Patients taking aspirin had a slower mean (SD) annualized change in aneurysm diameter (2.8 [3.0] vs 3.8 [4.2] mm per year; P = .001) and lower odds of having rapid aneurysm progression compared with patients not taking aspirin (adjusted odds ratio, 0.64; 95% CI, 0.49-0.89; P = .002). Aspirin use was not associated with risk of all-cause mortality (adjusted HR [aHR], 0.92; 95% CI, 0.79-1.07; P = .32), nor was aspirin use associated with major bleeding (aHR, 0.88; 95% CI, 0.76-1.03; P = .12), or composite outcome (aHR, 1.16; 95% CI, 0.93-1.45; P = .09) at 10 years. In this retrospective study of a clinical cohort of 3435 patients with objectively measured changes in aortic aneurysm growth, aspirin use was significantly associated with slower progression of AAA with a favorable safety profile.

Influence of size ratio on retreatment after coil embolization for unruptured bifurcation aneurysms

BackgroundAneurysm size is considered a risk factor for aneurysm rupture, and even small aneurysms may rupture, especially bifurcation aneurysms (BAs), which are occasionally detected. Therefore, we aimed to investigate the predictors of retreatment after coil embolization for unruptured BAs, with a particular focus on the absolute and relative size of the aneurysm (size ratio [SR]). MethodsTo evaluate the predictors of retreatment, patients were divided into two groups: those with and those without retreatment. Patient characteristics and radiographic assessments were compared between the groups. SR was defined as the ratio of the maximum aneurysm diameter and the average diameter of the parent artery. ResultsOverall, 181 unruptured BAs in 176 patients were investigated. The mean age of the patients was 63.8 ± 9.6 years. The mean aneurysm size and SR were 7.18 ± 2.94 mm and 2.49 ± 1.32, respectively. Further, 12 aneurysms with retreatment (6.6 %) and 169 aneurysms without retreatment were compared. In univariate analysis, SR was significantly higher in the group with retreatment (P = 0.02), but aneurysm size was not significantly different between the groups (P = 0.09). Multivariable analysis revealed that SR > 2.6 was a significant predictor of retreatment (P = 0.03; odds ratio: 10.41; 95 % confidence interval: 2.1–51.73). ConclusionsThis study showed that SR influences retreatment after coil embolization for unruptured BAs. Therefore, if the aneurysm size and parent artery diameter were small, as in cases with a large SR, meticulous follow-up after coil embolization is required to detect recurrence and recanalization.

A dedicated risk prediction model of 1-year mortality following endovascular aortic aneurysm repair involving the renal-mesenteric arteries

ObjectiveTreatment goals of prophylactic endovascular aortic repair of complex aneurysms involving the renal-mesenteric arteries (complex endovascular aortic repair [cEVAR]) include achieving both technical success and long-term survival benefit. Mortality within the first year after cEVAR likely indicates treatment failure owing to associated costs and procedural complexity. Notably, no validated clinical decision aid tools exist that reliably predict mortality after cEVAR. The purpose of this study was to derive and validate a preoperative prediction model of 1-year mortality after elective cEVAR. MethodsAll elective cEVARs including fenestrated, branched, and/or chimney procedures for aortic disease extent confined proximally to Ishimaru landing zones 6 to 9 in the Society for Vascular Surgery Vascular Quality Initiative were identified (January 2012 to August 2023). Patients (n = 4053) were randomly divided into training (n = 3039) and validation (n = 1014) datasets. A logistic regression model for 1-year mortality was created and internally validated by bootstrapping the AUC and calibration intercept and slope, and by using the model to predict 1-year mortality in the validation dataset. Independent predictors were assigned an integer score, based on model beta-coefficients, to generate a simplified scoring system to categorize patient risk. ResultsThe overall crude 1-year mortality rate after elective cEVAR was 11.3% (n = 456/4053). Independent preoperative predictors of 1-year mortality included chronic obstructive pulmonary disease, chronic renal insufficiency (creatinine >1.8 mg/dL or dialysis dependence), hemoglobin <12 g/dL, decreasing body mass index, congestive heart failure, increasing age, American Society of Anesthesiologists class ≥IV, current tobacco use, history of peripheral vascular intervention, and increasing extent of aortic disease. The 1-year mortality rate varied from 4% among the 23% of patients classified as low risk to 23% for the 24% classified as high risk. Performance of the model in validation was comparable with performance in the training data. The internally validated scoring system classified patients roughly into quartiles of risk (low, low/medium, medium/high and high), with 52% of patients categorized as medium/high to high risk, which had corresponding 1-year mortality rates of 11% and 23%, respectively. Aneurysm diameter was below Society for Vascular Surgery recommended treatment thresholds (<5.0 cm in females, <5.5 cm in males) in 17% of patients (n = 679/3961), 41% of whom were categorized as medium/high or high risk. This subgroup had significantly increased in-hospital complication rates (18% vs 12%; P = .02) and 1-year mortality (13% vs 5%; P < .0001) compared with patients in the low- or low/medium-risk groups with guideline-compliant aneurysm diameters (≥5.0 cm in females, ≥5.5 cm in males). ConclusionsThis validated preoperative prediction model for 1-year mortality after cEVAR incorporates physiological, functional, and anatomical variables. This novel and simplified scoring system can effectively discriminate mortality risk and, when applied prospectively, may facilitate improved preoperative decision-making, complex aneurysm care delivery, and resource allocation.

One-year clinical and radiologic outcomes of Surpass Evolve flow diverter for large unruptured intracranial aneurysms.

Surpass Evolve Flow Diverter (SE-FD; Stryker Neurovascular, Kalamazoo, MI, USA) was launched in 2019 as a new generation FD of Surpass Streamline. The aim of this study was to report the effectiveness and safety of SE-FD insertion for unruptured intracranial aneurysm at one-year follow-up. Between November 2019 and October 2021, a total of 106 patients with 108 aneurysms were treated with FD in single institution. Of these, SE-FD insertion was performed in 40 patients with 41 aneurysms. At one-year follow-up, clinical and angiographic outcomes were retrospectively evaluated from electronic medical record and aneurysm database. There were 12 male and 28 female patients (mean age 59.1 years, 95% CI: 55.3-62.9). Fusiform aneurysm dissection was 46.3% (19/41). Mean maximum aneurysm diameter was 13.2 mm (SD 5.53), and 34.1% (14/41) of aneurysms were 15 mm or bigger. Among 41 aneurysms, complex aneurysm (recurred, thrombosed, or branch artery-incorporated) was accounted for 41.5% (17/41). All procedures were successfully conducted with 7.3% (3/41) of procedure-related complications. At one-year follow-up (N.=40), neurologic morbidity was noted in 2 cases (5.0%; both with modified Rankin Scale [mRS] 1) without any mortality. At one-year follow-up (N.=41), radiologic outcomes were adequate occlusion in 33 (80.5%) and complete occlusion in 29 (70.7%). There was no retreatment in our cohort. Surpass Evolve Flow Diverter seemed to be safe and effective for the treatment of dissecting/fusiform or complex aneurysms at one-year follow-up. However, further study is needed to evaluate long term results.

Atrial septal defect occluder combined with stent graft for the management of post-dissection aortic aneurysm previously treated with unsuccessful coils: a case report

BackgroundAlthough the candy-plug technique has been reported to be useful for the treatment of post-dissection aortic aneurysm, the stent graft needs be to customized to accommodate the size of vascular occluders.Case presentationWe present a case of a persistent false lumen successfully treated with endovascular stent-graft and atrial septal defect occluder in a patient with Stanford Type B dissection. A covered stent graft was implanted into the false cavity through a distal rupture, and an atrial septal defect occluder was inserted into the covered stent to seal of the false cavity. Decreased aneurysmal diameter and false lumen thrombosis were noted by CT scan at 6-month follow-up.ConclusionsOur case showed that combined use of a stent graft and atrial septal defect occluder is safe, technically feasible and effective in sealing of the false lumen in post-dissection aortic aneurysm patients with previously failed false lumen thrombosis.

The association of ruptured abdominal aortic aneurysm diameter with mortality in the International Consortium of Vascular Registries

BackgroundThe mortality after ruptured abdominal aortic aneurysm (rAAA) repair is high, despite improvements in perioperative care, centralization of emergency vascular surgical services, and the introduction of endovascular aneurysm repair (EVAR). The diameter of intact AAA has been shown to be a predictor of short- and long-term survival. The aim of this study was to analyze the impact of AAA diameter on mortality for rAAA repair using contemporary data collected from the International Consortium of Vascular Registries and compare outcomes by sex and the type of repair patients received. MethodsProspective registry data on repair of rAAA from seven countries were collected from 2010 to 2016. The primary outcome was perioperative mortality after EVAR and open surgical repair (OSR). Data were stratified by type of repair and sex. Logistic regression models were used to estimate odds ratio (OR) for the association between AAA diameter and perioperative mortality and the association between type of repair and mortality. Multivariable logistic regression models were used to adjust for differences in patient characteristics. ResultsThe study population consisted of 6428 patients with a mean age ranging from 70.2 to 75.4 years; the mean AAA diameter was 7.7 ± 1.8 cm. Females had a significantly smaller AAA diameter at presentation compared with males (6.9 ± 1.6 cm vs 7.9 ± 1.8 cm; P < .001). who underwent OSR had larger AAA diameters compared with those who underwent EVAR (P < .001). Females who underwent repair were significantly older (P < .001). Males were more likely to have cardiac disease, diabetes mellitus, and renal impairment. Overall, AAA diameter was a predictor of mortality in univariate and multivariate analysis. When analyzing EVAR and OSR separately, the impact of AAA diameter per cm increase on mortality was apparent in both males and females undergoing EVAR, but not OSR (EVAR: male OR, 1.09 [95% confidence interval, 1.03-1.16] and EVAR: female OR, 1.17 [95% confidence interval, 1.02-1.35]). The early mortality rate for males and females who underwent EVAR was 18.9% and 25.9% (P < .001), respectively. The corresponding mortality for males and females who underwent OSR was 30.2% and 38.6% (P < .001), respectively. ConclusionsIn these real-world international data, there is a significant association between rAAA diameters and early mortality in males and females. This association was more evident in patients undergoing EVAR, but not shown in OSR. Despite improvements in overall AAA repair outcomes, the risk of mortality after rAAA repair is consistently higher for females.

Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair

This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR). Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (> 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan-Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling. One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 - 5.37; p= .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 - 5.26; p= .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 - 5.96; p= .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 - 1.09; p= .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 - 0.96; p= .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 - 285] cm3vs. 223 [95% CI 197 - 248] cm3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time. Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.

The Impact of Serum Interleukin-4, Interleukin-10, Interleukin-17a, and Interleukin-22 Levels on the Development of Sporadic Ascending Aortic Aneurysms

Introduction: Aortic aneurysms are chronic diseases associated with inflammatory/immunological mechanisms. Interleukins (ILs) with pro-inflammatory and anti-inflammatory activities are shown to be related to the development of aortic damage. In this context, this study aims to evaluate the serum IL-4, IL-10, IL-17A, and IL-22 in patients with sporadic thoracic ascending aortic aneurysms. Patients and Methods: The population of this prospective study consisted of all consecutive patients with sporadic ascending aortic aneurysms who underwent thoracic aortic aneurysm repair between November 2019 and September 2022. In the end, 29 patients (the patient group) and 19 healthy voluntary participants without aortic pathology (the control group) were included in the study. The study’s primary outcome was the differences in serum IL levels between the groups. Results: The patient group was significantly older than the control group (p= 0.042). Significantly higher neutrophil-to-lymphocyte ratio (NLR) values were detected in the patient group (p= 0.031). The median IL10 (p= 0.001), IL-17A (p&lt; 0.001), and IL-4 (p&lt; 0.001) levels were significantly lower in the patient group than in the control group. There were no significant correlations between serum IL levels and the aneurysm diameter (p&gt; 0.05). On the other hand, there were moderate correlations between IL-10 and IL-17A (r= 0.409, p= 0.038), IL-10 and IL-22 (r= 0.464, p= 0.017), and IL-17A and IL-4 (r= 0.496, p= 0.006). NLR ≥1.95 was found to be an independent risk factor for sporadic ascending aortic aneurysms [Odds Ratio (OR)= 4.53, 95% confidence interval (CI)= 1.12-21.17, p= 0.040]. Conclusion: IL-10, IL-17A, and IL-4 were significantly lower in patients with sporadic ascending aortic aneurysms larger than 55 mm. NLR was an independent risk factor for sporadic ascending aortic aneurysms. The diameter of the aneurysm was not correlated with ILs. There were positive correlations between IL-10, IL-17A, and IL-4 levels.

Establishment and Validation of an Animal Model of Abdominal Aortic Aneurysm in Beagles Through Vascular Patch Angioplasty and Elastase Infusion

To evaluate the effect of an abdominal aortic aneurysm (AAA) animal model established in beagles by way of vascular patch angioplasty combined with elastase infusion. A total of 60 beagle dogs were included in this study. Among them, 10 beagles were assigned to a control group to obtain normal abdominal aortic wall tissue, while the other 50 underwent vascular patch angioplasty combined with elastase infusion in order to establish the AAA disease model. In order to evaluate the outcome of modeling, abdominal vascular ultrasonography was performed 14 days after the modeling surgery was performed and ultrasound and computed tomographic angiography (CTA) were performed 28 days after the modeling surgery. The criterion for evaluating modeling success is that the maximum diameter of the abdominal aortic aneurysm is 50% greater than the diameter of the normal abdominal aorta below the renal artery. A total of 20 beagles of the modelling group and 5 control beagles were sacrificed 35 days after the modeling surgery and infrarenal abdominal aortic wall tissues were harvested. Then, hematoxylin and eosin (H&E) staining, Masson's trichrome staining, and elastic van Gieson (EVG) staining were conducted to observe the pathology features of abdominal aortic wall tissues. A total of 50 beagles underwent the AAA modeling procedures, with the average operative and anesthesia time being (119.4±18.9) and (137.4±15.8) minutes, respectively, the average blood loss volume being (43.6±7.7) mL, the average abdominal aorta block time being (39.7±5.3) minutes during the modeling surgery, and the average abdominal aorta diameter measured during the surgery being (6.5±0.4) mm. Intraoperative mortality was 0%. Mortality within 30 days after the surgery was 2% (1 out of the 50 beagles). Postoperative ultrasound and CTA results revealed that the success rate of AAA modeling was 100%. Pathology examination suggested that the animal model rather successfully simulated the pathophysiologic changes associated with human AAA in regard to the morphological and pathological changes. Vascular patch angioplasty combined with elastase infusion can be used to successfully establish AAA model in beagles. The AAA modeling method described in our report demonstrates stability and reliability in aneurysm formation effect and the surgical procedures are easy to replicate. The method integrates the advantages of previous animal modeling methods and can be used to study the pathogenesis of AAA.

Mechanics of ascending aortic aneurysms based on a modulus of elasticity dependent on aneurysm diameter and pressure

The mechanical stresses and strains are examined, in ascending thoracic aortic aneurysm (aTAA) models, in a patient-specific aTAA as well as in healthy thoracic aortic models, via Finite Element Analysis. The aneurysms are assumed spherical, 1.5 mm thick, with diameters between 47 mm and 80 mm, eccentrically positioned. The geometry and wall thickness distribution of the aorta along its length are based on open literature data for an average patient age of 66.25 years, accounting for the Body Surface Area (BSA) parameter. The vessel wall material is assumed isotropic and incompressible, with its Young’s modulus varying with the aneurysm diameter and the applied intraluminal pressure (120 mmHg to 240 mmHg). In the aTAAs, peak stresses were found to increase nonlinearly with aneurysm diameter (for a given pressure) tending to reach a plateau, appearing at the proximal area of the aneurysm, whereas lower stresses were found at its distal part and even smaller at the aneurysm maximum diameter. Regarding the patient-specific aTAA model, the peak stresses appeared at the distal part of the aneurysm where a tear of the intima layer was detected during surgical intervention. Peak strains exhibited for each pressure a maximum at a certain aneurysm diameter beyond which they dropped so that essentially the vessel wall’s distensibility was thus reduced. Examining more than 100 geometry cases and employing a failure stress criterion, the rupture diameter thresholds were estimated to be 65, 52.5, 50 and 47.5 mm for a pressure of 120, 160, 200 and 240 mmHg respectively.

The Outcome of Sac Filling With Fibrin Sealant and Gentamicin After Endovascular Aortic Repair of Brucella-Related Aorto-Iliac Artery Aneurysms: A Retrospective Single-Center Study.

This study aimed to analyze the experience of our center and assess the efficacy of sac filling with fibrin sealant (FS) and gentamicin after endovascular aortic repair (EVAR) in patients with Brucella-related aorto-iliac artery aneurysms. All patients who received sac filling with FS and gentamicin after EVAR for Brucella-related aorto-iliac artery aneurysms between March 2019 and September 2022 were reviewed. Before and after sac filling with FS and gentamicin, aneurysm sac thrombosis and endoleak were evaluated using a preloaded catheter to monitor immediate repair outcome. Short- to mid-term outcomes were assessed by the incidence of vascular graft infection (VGI), all-cause mortality, maximum aneurysm diameter, aneurysm sac thrombosis, and other adverse events. There were 14 patients with Brucella-related aorto-iliac artery aneurysms who underwent sac filling with FS and gentamicin after EVAR. Perioperative death due to myocardial infarction in 1 patient resulted in a postoperative all-cause mortality rate of 7.1% (1/14). All patients received anti-Brucella drugs for a median of 6.0 (range: 3-12) months postoperatively. During a median follow-up period of 15.0 (range 0.5-36) months, the absolute and sagittal maximum diameters of the aorto-iliac aneurysm sac were significantly smaller than preoperation (from 46.3 ± 17.0 to 27.2 ± 16.3 mm, P<.001, and from 39.2 ± 13.1 to 24.0 ± 13.8 mm, P<.001). Two of these patients had a postoperative disappearance of the pseudoaneurysm. One patient was reintervened for bilateral femoral artery bypass surgery. Except for sac filling with gentamicin, all patients received anti-brucella medication for a median of 6.0 (range: 3-12) months. There were no allergic reactions, nephrotoxicity, endoleak, recurrence, VGI, aorta-related or infection-related deaths during the perioperative period and follow-up. Sac filling with FS and gentamicin adjunctive to EVAR, with targeted drug delivery to the sites of Brucella-related aorto-iliac artery aneurysm infection lesions, may be an effective solution to control pseudoaneurysm infection and rupture. Previous Brucella-associated aorto-iliac artery aneurysms have been limited to case reports. This study significantly increased the number of Brucella-associated aorto-iliac aneurysms by 19.7% (14/71) and extended the follow-up to 3 years. In this retrospective study of 14 patients with Brucella-associated aorto-iliac aneurysms treated endovascularly with fibrin sealant and gentamicin for sac filling and targeted administration to infection-related aneurysms, there were no aneurysm-related deaths or infection-related complications and may be an effective solution for controlling aneurysm infection and rupture. And, this approach is an attractive treatment for moving away from long-term dependence on antibiotics but still needs further evaluation.

Prevalence of aortic aneurysmal sac expansion using CTA in type II endoleak: comparison between endoleak visualization in CTA phase and in delayed phase

BackgroundTo compare the prevalence of aneurysmal sac expansion in type II endoleak (T2E) presenting on CTA phase with T2E presenting on delayed phase.MethodsA retrospective study at a single tertiary care center in Bangkok, Thailand. Serial measurement of aneurysmal sac diameters was obtained and the prevalence of aneurysmal sac expansion was compared.Results130 patients were enrolled from January 2005 to December 2019. The prevalence of aneurysmal sac expansion in T2E patients presenting in the CTA phase and delayed phase in this 2-year observational study were 16% and 0%, respectively (P = 0.065). Age > 80 years (25.8% vs. 8.8%; P = 0.028) and initial aneurysmal sac diameter (71.3 mm vs. 57.7 mm; P = 0.035) were associated with the aneurysmal sac expansion. Aneurysmal sac expansion occurred in 18.3% of patients with patent IMA and 6% of patients with occluded IMA (P = 0.053). The number and diameter of lumbar artery feeder, and the presence of intrastent thrombus were not associated with aneurysmal sac expansion. T2E presenting on CTA phase resolved in 9.2% of cases compared with 7.14% of delayed phase cases (P = 1.0).ConclusionsThe prevalence of aneurysmal sac expansion in T2E patients presenting on CTA phase was not statistically significantly higher than in patients on delayed phase. Age more than 80 years and initial aneurysmal sac diameter were significantly associated with aneurysmal sac expansion.