Management Of Aortic Aneurysms Research Articles

Progression Rate and Early Surgical Experience in the New Aggressive Aneurysms-Osteoarthritis Syndrome

Aneurysms-osteoarthritis syndrome (AOS), caused by SMAD3 mutations, is a recently described autosomal dominant condition characterized by aneurysms throughout the arterial tree in combination with osteoarthritis. The objective of the present study was to evaluate progression rate of aortic dilation and surgical outcome in AOS patients. All AOS patients are regularly monitored according to our clinical AOS protocol. Patients with at least two follow-up visits or who underwent aortic root surgery during follow-up were included in this cohort study. Clinical and surgical data were obtained from chart abstraction. We included 22 patients (aged 38 ± 15 years; 41% male) with the molecular diagnosis of AOS. Follow-up duration was 3.3 years (interquartile range, 1.6 to 5.1). In the 17 patients who were managed conservatively, aortic root diameter increased from 37.5 ± 5.1 mm at baseline to 40.3 ± 6.2 mm at follow-up (p = 0.008). Progression rate of aortic dilation was highest at the level of the sinus of Valsalva (2.5 ± 5.8 mm per year) and significantly correlated with the initial diameter (r = 0.603, p = 0.017). Ten patients successfully underwent valve-sparing aortic root replacement, 5 after previous watchful waiting. Mean preoperative aortic diameter was 46.6 ± 4.0 mm. The operations were not complicated by fragility of tissue. After a postoperative period of 2.8 years (interquartile range, 0.7 to 5.4), no mortality or reoperations had occurred, and all patients remained asymptomatic. Aneurysm growth in AOS patients can be fast and unpredictable, warranting extensive and frequent cardiovascular monitoring. Valve-sparing aortic root replacement is a safe and effective procedure for the management of aortic root aneurysms in AOS patients.

Cost effectiveness of abdominal aortic aneurysm screening and rescreening in men in a modern context: evaluation of a hypothetical cohort using a decision analytical model

Objective To assess the cost effectiveness of different screening strategies for abdominal aortic aneurysm in men, from the perspective of a national health service.Setting Screening units at regional hospitals.Participants Hypothetical...

Repair of Dilated Aortic Root and Sinotubular Junction Using a Stabilizer Ring

Aortic root aneurysm and dissection are potentially life-threatening conditions that involve a structural weakness of the aortic wall. Management of aortic root aneurysm (with or without aortic insufficiency) has recently been the subject of much scholarly discussion which resulted in some modifications. The current trend is a valve-sparing root repair or replacement as well as preserving or restoring the diameter of the aortic annulus and sinutubular junction. This manuscript reviews the etiology and diagnosis of aortic root aneurysm or dilated aortic annulus as well as a novel treatment approach. A newly patented apparatus that restores and repairs the aortic annulus and sinotubular junction is reviewed.

RR15. Multilayer Flow Modulator Stents (MFM) as a Therapeutic Option in the Management of Thoraco-abdominal Aortic Aneurysms

RR15. Multilayer Flow Modulator Stents (MFM) as a Therapeutic Option in the Management of Thoraco-abdominal Aortic Aneurysms

Best surgical option for thoracoabdominal aneurysm repair - the endovascular approach.

Best surgical option for thoracoabdominal aneurysm repair - the endovascular approach.

Cardiovascular imaging in aortic disease. Multimodality approach in clinical practice

In the last decade, remarkable advances have been made in noninvasive imaging of aortic diseases. The aim of this article was to provide a comprehensive review of these imaging modalities. Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly aortic root and proximal ascending aorta. Transoesophageal echocardiography (TEE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TEE should be used in a complementary manner. Although TEE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade and left ventricular function can be easily visualised by TTE. TEE information (entry tear location, mechanisms and severity of aortic regurgitation and true lumen compression) is essential for selecting and monitoring surgical and endovascular treatment and detecting possible complications. Computed tomography has the advantage of providing optimum morphological information of the entire aorta and the accuracy of size measurements. Magnetic resonance imaging offers good morphological and dynamic information on the aorta without radiation, although in clinical practice its availability is lower. The considerable advances in imaging techniques have greatly increased our understanding of aortic diseases. Not only clinical presentation and required information, but also local availability of imaging equipment and staff expertise in this field, should be considered to indicate echocardiography, computed tomography or magnetic resonance, in the assessment of different aortic diseases and their circumstances. Nell’ultima decade si sono avuti notevoli sviluppi dell’imaging non invasivo della patologia aortica. Lo scopo di questo articolo è stato quello di fornire una completa review delle diverse tecniche di imaging. L’ecocardiografia ha un ruolo importante nella diagnosi e follow-up delle patologie dell’aorta. L’ecocardiografia transtoracica (TTE) consente un’adeguata valutazione di alcuni segmenti aortici, in particolare la radice aortica e la porzione prossimale dell’aorta ascendente. L’ecocardiografia transesofagea (TEE) supera le limitazioni della TTE nella valutazione dell’aorta toracica. La TTE e la TEE dovrebbero essere utilizzate in maniera complementare. Benchè la TEE sia la tecnica da scegliere nella diagnosi della dissecazione aortica, la TTE può essere utilizzata come esame iniziale nella fase di emergenza. Il flap intimale nell’aorta ascedente prossimale, il versamento/tamponamento pericardico e la funzione ventricolare sinistra possono essere facilmente visualizzate con l’esame TTE. Le informazioni derivate dalla TEE (localizzazione del foro intimale di ingresso, meccanismi e severità dell’insufficienza aortica e la compressione del vero lume) sono essenziali nella selezione e monitorizzazione del trattamento chirurgico o endovascolare, e nella identificazione delle possibili complicanze. La tomografia computerizzata ha il vantaggio di fornire delle ottime informazioni sulla morfologia dell’intera aorta e una buona accuratezza delle misurazioni. La risonanza magnetica consente una buona valutazione morfologica e dinamica dell’aorta senza l’utilizzo di radiazioni, benché nella pratica clinica la sua disponibilità sia bassa. I notevoli progressi nelle tecniche di imaging hanno notevolmente aumentato la nostra comprensione delle malattie dell’aorta. Nella valutazione delle differenti patologie dell’aorta la scelta di una tecnica di imaging quale l’ecocardiografia, la tomografia computerizzata o la risonanza magnetica, non dipende solamente dalla presentazione clinica e dalle informazioni richieste, ma dovrebbero essere considerate anche altre condizioni quali la disponibilità delle attrezzature e l’esperienza dello staff in questo settore diagnostico.

Successful Treatment for Infected Aortic Aneurysm Using Endovascular Aneurysm Repairs as a Bridge to Delayed Open Surgery

Management of infected aortic aneurysms, which can be life-threatening, remains challenging. Open surgical treatments, including debridement of the infected aorta and the surrounding tissue and either in situ reconstruction or extra-anatomic bypass covering with omentum or muscle flap, are the mainstay of therapy. However, increasing advances in technology have made endovascular treatment of infected aneurysms feasible. The present study describes the first clinical report of successful treatment of an infected aneurysm using endovascular techniques in the acute phase, followed by delayed open surgery.

Is the Incidence of Abdominal Aortic Aneurysm Declining in the 21st Century? Mortality and Hospital Admissions for England & Wales and Scotland

Between 1951 and 1995 there was a steady increase in age-standardised deaths from all aortic aneurysms in men, from 2 to 56 per 100,000 population in England & Wales, supporting an increase in incidence. More recently, evidence from Sweden and elsewhere suggests that now the incidence of abdominal aortic aneurysm (AAA) may be declining. National statistics for hospital admissions and deaths from AAA, after population age-standardisation, were used to investigate current trends in England & Wales and Scotland. Between 1997 and 2009 there has been a reduction in age-adjusted mortality from AAA from 40.4 to 25.7 per 100,000 population for England & Wales and from 30.1 to 20.8 per 100,000 population in Scotland. The decrease in mortality was more marked for men than women. Mortality decreased more than 2-fold in those <75 years versus 25% only in those >75 years. During this same time period the elective hospital admissions for AAA repair have only increased in the population >75 years. These data suggest that the age at which clinically-relevant aneurysms present has increased by 5–10 years and that incidence of clinically-relevant AAA in men in England & Wales and Scotland is declining rapidly. The reasons for this are unclear.

Hospital Competitiveness Influences Ruptured Abdominal Aortic Aneurysm Management

Hospital Competitiveness Influences Ruptured Abdominal Aortic Aneurysm Management

Hybrid Approaches to Complex Aortic Arch Aneurysms

The management of aortic arch aneurysms remains a clinical challenge. Although open operative techniques have been refined with improving results over the last 2 decades, neurologic and cardiovascular complications remain significant causes of morbidity and mortality. This is related to the requirement for hypothermic circulatory arrest with adjunct cerebral perfusion strategies during open aortic arch surgery. In patients thought to be at prohibitively high risk for conventional repair, an alternative therapy is much desired. The recent introduction of thoracic aortic endovascular stent grafting (TEVAR) has provided an alternative surgical option in patients felt to be at prohibitively high risk for conventional open aortic arch repair. Combining conventionalsurgicaltechniqueswithendovasculartechnology,this so-called “hybrid” aortic arch repair seeks to minimize the “operation” by either eliminating or significantly simplifying and shortening the arch reconstruction, thus limiting the duration of circulatory arrest and cerebral ischemia. The arch hybrid repair is a landing zone “0” endovascular repair of the aortic arch and is guided by the 2 following fundamental concepts: (1) brachiocephalic bypass, or revascularization of the great vessels; (2) construction of optimal proximal and distallandingzonesforTEVAR.Therefore,archhybridrepair comprises open surgical techniques for great vessel revascularization and landing zone reconstruction along with endovascular stent grafting performed concomitantly or at a later time. The arch hybrid repair is especially appealing in older patients and in those with significant comorbidities who may not tolerate prolonged cardiopulmonary bypass and circulatory arrest. This report focuses on aortic arch hybrid operative techniques.

Clinical practice change requires more than comparative effectiveness evidence: abdominal aortic aneurysm management in the USA

Adoption of healthcare innovations frequently outpaces the evidence of effectiveness. Endovascular repair (EVAR) for abdominal aortic aneurysms in the USA demonstrates how comparative effectiveness research without evidence-based reimbursement changes may fail to influence clinical practice. Randomized controlled trials for small abdominal aortic aneurysms demonstrate no lasting benefits of EVAR or open surgical repair (OSR) compared with surveillance, and for large abdominal aortic aneurysms demonstrate no lasting survival benefit of EVAR over OSR, and do show poorer durability and higher costs for EVAR. Nonetheless, >50% of elective abdominal aortic aneurysm repairs in the USA use EVAR. Factors that may be driving the high use of EVAR include patient preference, surgeons' desire to appear 'up-to-date' in the procedures they offer, higher hourly surgeon reimbursement for EVAR than OSR, and the expansion of physician specialties able to perform abdominal aortic aneurysm repair from only vascular surgeons with OSR, to vascular surgeons and interventional radiologists/cardiologists with EVAR. By comparison, in Canada, where government health insurance restricts EVAR coverage to high surgical risk patients, only approximately 25% of abdominal aortic aneurysm repairs are performed using EVAR. Country-specific cost studies and a prospective population-based study collecting detailed clinical data to identify patient subgroups that truly benefit from a particular management strategy are needed to inform policy regarding EVAR availability and reimbursement.

Is the Incidence of Abdominal Aortic Aneurysm Declining in the 21st Century? Mortality and Hospital Admissions for England & Wales and Scotland

Background Between 1951 and 1995 there was a steady increase in age-standardised deaths from all aortic aneurysms in men, from 2 to 56 per 100,000 population in England & Wales, supporting an increase in incidence. More recently, evidence from Sweden and elsewhere suggests that now the incidence of abdominal aortic aneurysm (AAA) may be declining. Methods National statistics for hospital admissions and deaths from AAA, after population age-standardisation, were used to investigate current trends in England & Wales and Scotland. Results Between 1997 and 2009 there has been a reduction in age-adjusted mortality from AAA from 40.4 to 25.7 per 100,000 population for England & Wales and from 30.1 to 20.8 per 100,000 population in Scotland. The decrease in mortality was more marked for men than women. Mortality decreased more than 2-fold in those <75 years versus 25% only in those >75 years. During this same time period the elective hospital admissions for AAA repair have only increased in the population >75 years. Conclusions These data suggest that the age at which clinically-relevant aneurysms present has increased by 5–10 years and that incidence of clinically-relevant AAA in men in England & Wales and Scotland is declining rapidly. The reasons for this are unclear.

The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms

Open surgical treatment for an infected aortic aneurysm has a high rate of surgical morbidity and mortality and does not guarantee eradication of the infected nidus. The use of endovascular aortic repair (EVAR) might simplify the procedure and provide a good alternative for this critical condition, but this remains to be proved. This study assessed the efficacy and outcome of EVAR with an adjunctive antibiotic treatment strategy. We focused on the experiences and results of the management of infected aortic aneurysms with positive blood cultures. We drew the blood for culture study, immediately prescribed broad-spectrum antibiotics, performed EVAR procedures, and followed this with sensitive antibiotics and adjunctive procedures. Twelve consecutive patients (mean age, 70 years) were included in this EVAR strategy. Three patients had thoracic, two thoracoabdominal, and the remaining seven had infected abdominal aneurysms. Ten Salmonella, one Staphylococcus, and one Streptococcus spp were identified. There was no hospital death. Three patients underwent computed tomography (CT)-guided drainage, and one underwent open laparotomy debridement. Mean follow-up was 24 months. One late death occurred but was unrelated to reinfection. All patients seemed well, with no evidence of EVAR graft infection at a mean follow-up of 23.6 months. This small multi-institutional study summarizing the experiences of patients with an infected aortic aneurysm managed by EVAR and an aggressive antibiotic strategy revealed that this EVAR strategy might be a suitable approach to treating this disease. These favorable results may be typical for Salmonella infection, which was present in most of the patients. Further experience is needed to assess whether this therapeutic strategy works equally well in aneurysm infection caused by other organisms.

Standardized Off-the-Shelf Components for Multibranched Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Endovascular techniques have been slow to assume a primary role in the management of thoracoabdominal aortic aneurysms (TAAAs) because of the high cost of multiple components, regulatory challenges, manufacturing delays, and the complexity of multibranched stent graft insertion. Standardized off-the-shelf stent grafts have the potential to lower all these barriers to the widespread application of multibranched endovascular technology. Despite the desire for a single design to accommodate all variations of thoracoabdominal aneurysms, different approaches are likely required for patients with extensive aneurysmal disease compared with disease that is more localized to the infradiaphragmatic region or that which does not extend below the renals. This article summarizes the basic concepts and stent graft designs for repair of TAAA using off-the-shelf fenestrated and branched endografts.

National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice

Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use. All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval. Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P < .001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P = NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8-16.7/100,000) than in TEVAR (range, 4.5-6.9/100,000). Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.

Surgical repair of thoracoabdominal aortic aneurysms using the critical artery reattachment technique

In the study, we sought to retrospectively analyze the effectiveness and safety of surgical repair of thoracoabdominal aortic aneurysm using the critical artery reattachment technique. Twenty-three consecutive thoracoab-dominal aortic aneurysm patients were treated using the technique of sequential aortic clamping and critical artery reattachment. The entire procedure was technically successful in all patients. One died of renal failure and the overall hospital mortality was 4.35%. The total incidence of complications was 21.74%. At a median follow-up of 33 months, all patients were alive. We found that the application of critical artery reattachment technique in the management of thoracoabdominal aortic aneurysm provides excellent short- and mid-term results in most patients. It could markedly increase the curing rate and reduce the morbidity of postoperative complications including paraplegia, ischemia of abdominal viscera, and renal failure.

The changing management of primary mycotic aortic aneurysms

The objective of this study is to examine contemporary management of primary mycotic aortic aneurysms in a single center. We have previously reported the management of mycotic aortic aneurysms in 15 patients between 1991 and 2001, and we hypothesized that management would change in the light of the evolution of endovascular aortic repair. A review of a prospectively collected database (2002-2009) of all patients presenting with mycotic aneurysms. A total of 19 aneurysms were identified in 17 patients (12 men, 5 women) with a median age of 66.2 years (range, 49-82 years). All were symptomatic, and nine had contained rupture. There were five infrarenal, two juxtarenal, three Crawford type III, four type IV thoracoabdominal aortic aneurysms, and five descending thoracic aneurysms in the series. All thoracic aneurysms were excluded by thoracic endovascular aneurysm repair. Two patients underwent visceral hybrid endografting for type III thoracic aortic aneurysm; the third was treated with open repair. Four patients underwent open type IV repair. Two of the infrarenal aneurysms were treated with bifurcated endovascular aneurysm repair, and the other three and both juxtarenals with open repair with in situ reconstruction. There were three early (17.6%) and three late deaths (17.6%). The median follow-up was 30.5 months (range, 1-102 months). The results of the latest series show that open surgery is still required in many cases. The introduction of endovascular techniques in the exclusion of mycotic aneurysms can be accomplished with acceptable results, and endovascular treatment has increased the therapeutic options for a difficult condition.

Hybrid repair of aortic arch aneurysm in high-risk patients

Morbidity and mortality after conventional surgery of aortic arch aneurysms remain high. Alternative techniques are the subject of this report. Open surgery requires cardiopulmonary bypass and hypothermic circulatory arrest. Thoracic endovascular aneurysm repair has a less invasive therapeutic alternative. The number of high-risk patients has considerably increased over the past decade. The proximity of the aneurysm to the supraaortic vessels makes it difficult to achieve a satisfactory proximal landing zone for endovascular stenting. Two methods have been proposed to address this issue: branched stent grafts and extraanatomic bypass, defined as a hybrid approach, which combines aortic debranching and endovascular procedures. Experience with hybrid repair is limited. Today there are no formal guidelines for the management of aortic arch aneurysm in high-risk patients. Hybrid repair of aortic arch aneurysm in high-risk patients is a feasible and safer option.

Detection of Macrophages in Aortic Aneurysms by Nanoparticle Positron Emission Tomography–Computed Tomography

Current management of aortic aneurysms (AAs) relies primarily on size criteria to determine whether invasive repair is indicated to preempt rupture. We hypothesized that emerging molecular imaging tools could be used to more sensitively gauge local inflammation. Because macrophages are key effector cells that destabilize the extracellular matrix in the arterial wall, it seemed likely that they would represent suitable imaging targets. We here aimed to develop and validate macrophage-targeted nanoparticles labeled with fluorine-18 ((18)F) for positron emission tomography-computed tomography (PET-CT) detection of inflammation in AAs. Aneurysms were induced in apolipoprotein E-/- mice via systemic administration of angiotensin II. Mice were imaged using PET-CT and a monocyte/macrophage-targeted nanoparticle. AAs were detected by contrast-enhanced micro-CT and had a mean diameter of 1.85 ± 0.08 mm, whereas normal aortas measured 1.07 ± 0.03 (P < 0.05). The in vivo PET signal was significantly higher in aneurysms (standard uptake value, 2.46 ± 0.48) compared with wild-type aorta (0.82 ± 0.05, P < 0.05). Validation with scintillation counting, autoradiography, fluorescence, and immunoreactive histology and flow cytometry demonstrated that nanoparticles localized predominantly to monocytes and macrophages within the aneurysmatic wall. PET-CT imaging with (18)F-labeled nanoparticles allows quantitation of macrophage content in a mouse model of AA.

Cancer and Cardiovascular Disease

Cancer and cardiovascular disease (CVD) are the two most common causes of mortality and morbidity worldwide. The incidence of both cancer and cardiovascular disease increases with age. With increased life expectancy, the burden of both these diseases will increase substantially over the next generation. Advancement in cancer therapy and supportive care has led to increasing number of survivors of childhood cancer. Seventy percent of the children diagnosed with malignancy before the age of 15 years will have a disease-free 5-year survival from diagnosis. Cancer is now being recognized as a chronic disease as evidenced by a growing number of cancer survivors that currently exceeds 11 million. With further improvement in cancer therapy, this number will likely increase in years to come. As the numbers of survivors grow so does the number of patients living with the late effects of cancer-related cardiotoxicity. Amongst Hodgkin lymphoma patients who have received radiation, CVD is one of the most common causes of death. Physicians and ancillary staff frequently have to take care of patients with concomitant cancer and cardiovascular disease. Some cardiac diseases predates the diagnosis of cancer, whereas other conditions like chemotherapy-induced cardiomyopathy and radiation-related heart disease are directly related to the cardiotoxic side effects of cancer therapy. The cardiotoxic side effects of agents like 5-fluouracil, adriamycin, and tyrosine kinase inhibitors are well known. However, the cardiotoxic profiles of newer investigational chemotherapeutic agents are largely unknown. Chemotherapy frequently induces thrombocytopenia, which in itself poses therapeutic challenge in the management of conditions like acute coronary syndrome, atrial fibrillation, stroke, and prosthetic valves. Evidence-based treatment of cardiovascular disease in cancer patients is lacking largely because all cardiology trials have excluded patients with cancer and similarly cancer trials have excluded patients with significant cardiovascular comorbidity. While recently some single-center studies have shown the efficacy of medications like ace inhibitors and beta blockers for the treatment of chemotherapy-induced cardiomyopathy, evidence-based treatment of other major cardiovascular diseases in cancer patients is not well established. In this issue of cancer and cardiovascular disease, we have covered some common conditions like venous thrombosis, cardiovascular effects of radiation therapy, cardiovascular effects of anthracycline in childhood cancer survivors, and management of aortic aneurysm in cancer patients. The use of newer modality, like computed tomographic angiography, may provide a pivotal role in the investigation of cancer patients with concomitant cardiac problem, as outlined in a clinical investigation in this journal. The case reports presented are some conditions that are unique to cancer population. Cardio-oncology is a growing field, and we are encouraged by the number of submissions to our special edition. We hope that the readers will find this special edition useful in their clinical practice. Syed Wamique Yusuf Carlo Cipolla Jean-Bernard Durand Daniel J. Lenihan