Management Of Aortic Aneurysms Research Articles

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.

Aortic Aneurysms, an Angiological Overview

Aortic aneurysms represent a critical cardiovascular condition characterized by a localized, abnormal dilation of the aorta, presenting a significant risk of rupture and subsequent morbidity and mortality. This review article explores the angiological approach to aortic aneurysms, encompassing epidemiology, classifications, risk factors, complications, and the nuances of angiological management. Through an in-depth examination of these elements, this review aims to provide comprehensive insights into the management of aortic aneurysms, highlighting key considerations and strategies in clinical practice.

Image Guidance Techniques and Treatment Approach Optimization in the Management of Type-II Endoleak After Endovascular Aortic Aneurysm Repair

Over the past three decades EVAR emerged as the primary approach for abdominal aortic aneurysm management, however the occurrence of endoleak following endograft implantation imposes a high toll on patients and hospitals alike. The early diagnosis and appropriate treatment of endoleaks is associated with better outcomes, which calls for more advanced imaging and a standardized approach for endoleak diagnosis and management following EVAR. Although conventional strategy with non-targeted deployment of coils and embolic material in the aneurysm sac is considered to be the standard approach in many hospitals, it may not prove to be a viable option, given that it affects any further follow-up imaging in the event of sub-optimal therapy and consequent recurrence. Currently various imaging and image guidance tools are available to address this clinical challenge, utilizing a targeted approach to warrant optimal individualized, patient-tailored treatment for each case. We summarize our tertiary aortic referral center experience and describe strategies for optimal selection of various treatment approaches for Type-II Endoleak specifically. Including endovascular, percutaneous and laparoscopic approaches.

Mycotic Aortic Arch Aneurysms: Open versus Endovascular Management – An Institutional Experience

Abstract Background: Mycotic aortic aneurysms are rare disorders, affecting patients with co-morbidities, and associated with a high risk of aneurysm expansion, rupture, and sepsis. Aims and Objectives: In this study, we present our experience on the management of patients with mycotic arch aneurysms. Materials and Methods: From January 2020 till July 2023, eight patients were admitted in our hospital for management of mycotic aortic arch aneurysm. On a case-to-case basis, the management was selected for each patient and consent was taken for the same. Results: Four patients underwent open repair and four endovascular repair, out of which three underwent hybrid arch repair. While only one patient in the open group expired in the immediate postoperative period due to sepsis, the remaining patients have been on follow-up for 1month-1year. There was no mortality in the immediate post TEVAR period. However, three of the patients who underwent TEVAR required re-admissions and re-intervention, with one patient developing aorto-esophageal fistula. Two of these patients expired in a span of 3months-1.5years post TEVAR. Conclusion: In patients with mycotic arch aneurysm, open surgical repair should be the modality of choice in fit surgical patients and endovascular management can be used as a bridge therapy, keeping in mind the risks of residual infection in the aorta which can lead to re-interventions and re-admissions.

Evolving Surgical Management of Complex Thoracoabdominal Aortic Aneurysms

Evolving Surgical Management of Complex Thoracoabdominal Aortic Aneurysms

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series

Background: Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique. Method: Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses. Result: Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient. Conclusion: MSW technique is a simple and effective technique to modify aortic neck/artery angulation in TEVAR or EVAR procedure.

Hospital Incidence, Treatment, and Outcome of 885 Patients with Thoracoabdominal Aortic Aneurysms Treated in Switzerland over 10 Years-A Secondary Analysis of Swiss DRG Data.

Despite the development of fenestrated and branched endovascular aortic repair (f/bEVAR), the surgical management of thoraco-abdominal aortic aneurysms (TAAAs) remains a major challenge. The aim of this study was to analyse the hospital incidence and hospital mortality of patients treated for TAAAs in Switzerland. Secondary data analysis was performed using nationwide administrative discharge data from 2009-2018. Standardised incidence rates and adjusted mortality rates were calculated. A total of 885 cases were identified (83.2% nonruptured (nrTAAA), 16.8% ruptured (rTAAA)), where 69.3% were male. The hospital incidence rate for nrTAAA was 0.4 per 100,000 women and 0.9 per 100,000 men in 2009, which had doubled for both sexes by 2018. For rTAAA, there was no trend over the years. The most common procedure was f/bEVAR (44.2%), followed by OAR (39.5%), and 9.8% received a hybrid procedure. There was a significant increase in endovascular procedures over time. The all-cause mortality was 7.1% with nrTAAA and 55% with rTAAA. The mortality was lower for rTAAA when f/bEVAR or hybrid procedures were used. A ruptured aneurysm and higher comorbidity were associated with higher hospital mortality. This study demonstrates that the treatment approach has changed significantly over the observed period. The use of f/bEVAR nearly tripled in nrTAAA and doubled in rTAAA during this decade.

Perspectives of Patients and Professionals on Patient Education in Complex Endovascular Aortic Repair

Misinterpretation of patient preferences in perioperative education can lead to an undesired treatment decision. This explorative interview study presents differences in perspectives of patients and professionals on patient education in complex endovascular aortic aneurysm management. Using convenience sampling, a cross-sectional interview study was performed among patients who were in various stages of the decision-making process for complex endovascular aortic repair. Five physicians were interviewed, representing the main providers of clinical information. Interviews were transcribed verbatim and analyzed inductively. Twelve patients (mean age 76.6 [standard deviation: 6.4], 83% male) were interviewed. Ten (83%) felt like they had no other realistic option besides undergoing surgery, whereas all professionals (5/5) stressed the importance of delicate patient selection. Five patients out of 10 (50%) who commented on their preferred decisional role considered the professional's advice as decisive. All but 1 patient (11/12) reported that the information was easy to understand, whereas 4 out of 5 professionals (80%) doubted whether patients could fully comprehend everything. Patients experienced a lack of information on the recovery process, although professionals stated that this was addressed during consultation. Several differences were found in the perspectives of patients and professionals on education in complex aortic aneurysm management. In order to optimize patient involvement in decision-making, professionals should be aware of these possible discrepancies and address them during consultation. Future research could focus on these differences in more detail by including more patients depending on their treatment and decision stages.

How Important are Genetics in the Management of Thoracic Aortic Aneurysms and Acute Aortic Syndromes? What do we Know Today?

How Important are Genetics in the Management of Thoracic Aortic Aneurysms and Acute Aortic Syndromes? What do we Know Today?

Management of Inflammatory Aortic Aneurysms – A Scoping Review

Inflammatory abdominal aortic aneurysms (InflAAAs) account for 5 – 10% of aortic aneurysms and are characterised by retroperitoneal fibrosis. Diagnosis is often delayed, and doubts remain about the optimal management strategy. This scoping review describes the current state of knowledge on InflAAAs. Medline, PubMed, EMBASE, and Scopus were searched for relevant studies that evaluated the diagnosis and treatment of InflAAAs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was followed. Fifty-seven papers were selected (low level of evidence), which included 1 554 patients, who were mostly male and heavy smokers. A triad of chronic abdominal or back pain, weight loss, and elevated inflammatory markers was highly suggestive of the diagnosis but rarely present, and fever was noted only randomly. A mantle sign was seen on computed tomography angiography (CTA) in 73 – 100% of patients. Open surgical repair (OSR) and endovascular aortic aneurysm repair (EVAR) was reported in 1 376 and 178 patients, respectively. OSR was associated with significant iatrogenic bowel (n = 22), urinary tract system (n = 7), venous (n = 30), pancreatic (n = 6), and splenic (n = 5) injuries, while EVAR was associated with lower 30 day mortality (0 – 5% vs. 0 – 32%). One and two year mortality rates were similar between the two treatment modalities (0 – 20% and 0 – 36%, respectively). EVAR was more often associated with post-operative progression of inflammation (17% vs. 0.4%), and a higher frequency of persistent hydronephrosis (> 50%) and limb occlusion (20%). Used in < 10% of patients, corticosteroids led to complete pain relief and a reduction in peri-aortic inflammation within 6 – 18 months. InflAAAs are characterised by non-specific symptoms, with the mantle sign on CTA being pathognomonic. Corticosteroids may be considered a basic treatment that all patients should receive initially. Low quality data indicate that EVAR (vs. OSR) is associated with fewer intra-operative complications and lower peri-operative mortality but more late fibrosis related adverse events. International multicentre registries are required to gather more insights into this challenging pathology.

The association between diabetes and abdominal aortic aneurysms in men: results of two Danish screening studies, a systematic review, and a meta-analysis of population-based screening studies

BackgroundA paradoxical protective effect of diabetes on the development and progression of abdominal aortic aneurysms (AAA) has been known for years. This study aimed to investigate whether the protective role of diabetes on AAAs has evolved over the years.MethodsA cross-sectional study, a systematic review and meta-analysis. This study was based on two large, population-based, randomised screening trials of men aged 65–74; VIVA (2008–2011) and DANCAVAS (2014–2018), including measurement of the abdominal aorta by ultrasound or CT, respectively. Analyses were performed using multiple logistic regressions to estimate the odds ratios (ORs) for AAAs in men with diabetes compared to those not having diabetes. Moreover, a systematic review and meta-analysis of population-based screening studies of AAAs to visualise a potential change of the association between diabetes and AAAs. Studies reporting only on women or Asian populations were excluded.ResultsIn VIVA, the prevalence of AAA was 3.3%, crude OR for AAA in men with diabetes 1.04 (95% confidence interval, CI, 0.80-1.34), and adjusted OR 0.64 (CI 0.48-0.84). In DANCAVAS, the prevalence of AAA was 4.2%, crude OR 1.44 (CI 1.11-1.87), and adjusted OR 0.78 (CI 0.59-1.04). Twenty-three studies were identified for the meta-analysis (N = 224 766). The overall crude OR was 0.90 (CI 0.77-1.05) before 2000 and 1.16 (CI 1.03-1.30) after 1999. The overall adjusted OR was 0.63 (CI 0.59-0.69) before 2000 and 0.69 (CI 0.57-0.84) after 1999.ConclusionBoth the crude and adjusted OR showed a statistically non-significant trend towards an increased risk of AAA by the presence of diabetes. If this represents an actual trend, it could be due to a change in the diabetes population.Trial registrationDANCAVAS: Current Controlled Trials: ISRCTN12157806. VIVA: ClinicalTrials.gov NCT00662480.

Endovascular Management of the Ascending Aorta: State of the Art.

Endovascular stent graft repair (EVAR) has revolutionized the management of aneurysms and dissections of the thoracic and abdominal aorta and is considered the first-line treatment in such pathologies. Initially designed for patients unfit for open repair, EVAR and thoracic endovascular aortic stent graft repair are associated with improved morbidity and mortality and a faster recovery process. The endovascular revolution of the aorta continues moving proximally, with fenestrated and branch stent grafts currently in clinical trials for the management of thoracoabdominal aortic aneurysms, and several branched thoracic devices are either approved or in trial for management of aortic arch pathologies. The final frontier in the endovascular management of the aorta is the aortic root and ascending aorta. The first early feasibility trial for management of type A aortic dissection has recently concluded with a multicenter phase 2 study slated for the spring of 2023. The following article updates the reader on the unique challenges of endovascular management of the ascending aorta and a look at the future technologies that will define this space.

A study on the role of inflammatory process of the aorta wall in the development, prognosis, and management of aortic aneurysms

Objective: Abdominal Aortic aneurysms (AAA) are pathological aortic dilations that can rupture and result in up to 90% overall mortality. These lesions have a strong inflammatory substrate since atherosclerosis, which is undoubtedly related to inflammation, also predisposes patients to develop abdominal aorta aneurysms. The primary purpose of the research was to examine the role that inflammation in the aortic wall plays in the development, prognosis, and management of aortic aneurysms. Material and methods: This prospective, non-randomized investigation analyzed the cytosolic levels of interleukin-1b, interleukin-6, and tumor necrosis factor α (TNFα) in the walls of 57 individuals with aneurysms. Study group 1 consisted of patients with ruptured aneurysms (n=11), whereas study group 2 included patients with no symptoms from their aneurysms (n=32). There were 14 kidney recipients in the control group. Result: The walls of rupture aneurysms were shown to have larger and more pronounced inflammatory processes as well as higher levels of the cytokines cytokine IL6(P

Frailty Among Veterans Undergoing Abdominal Aortic Aneurysm Repair

Frailty is a known risk factor for adverse outcomes following surgery and affects at least 3 of every 10 US Veterans aged 65years and older. We designed a study to characterize the association between frailty and complications after endovascular aneurysm repair (EVAR) compared to open aneurysm repair (OAR) at our regional Veterans Affairs Medical Center. Veterans who underwent either OAR or EVAR at our institution between January 1, 2000 and December 31, 2020 were identified. We examined medical history, procedure characteristics, perioperative complications, and frailty as measured by the 5-factor modified frailty index (mFI-5). Frailty was defined as an mFI-5 score ≥2. Primary endpoints were postoperative complications, duration of surgery, and length of hospital stay. Tests of association were performed with t-test and chi-squared analysis. Over the 21-year period, we identified 314 patients that underwent abdominal aortic aneurysm (AAA) repair with 115 (36.6%) OAR and 199 EVAR (63.4%) procedures. Patients undergoing EVAR were older on average (72.1years vs. 70.2years) and had a higher average mFI-5 compared to the open repair group (1.49 vs. 1.23, P=0.036). When comparing EVAR and OAR cohorts, patients undergoing OAR had a larger AAA diameter (6.5cm, standard deviation [SD]: 1.5) compared to EVAR (5.5cm, SD: 1.1 P<0.0001). Fewer frail patients underwent OAR (n=40, 34.8%) compared to EVAR (n=86, 43.2%), and frail EVAR patients had higher AAA diameter (5.8cm, SD: 1.0) compared to nonfrail EVAR patients (5.3cm, SD 1.2), P=0.003. Among OAR procedures, frail patients had longer operative times (296min vs. 253min, P=0.013) and higher incidence of pneumonia (17.5% vs. 5.3%, P=0.035). Among frail EVAR patients, operative time and perioperative complications including wound dehiscence, surgical site infection, and pneumonia were not significantly different than their nonfrail counterparts. Overall, frail patients had more early complications (n=55, 43.7%) as compared to nonfrail patients (n=48, 25.5%, P=0.001). OAR patients had higher rates of postoperative complications including wound dehiscence (7.0% vs. 0.5%, P=0.001), surgical site infections (7.0% vs. 1.0%, P=0.003), and pneumonia (9.6% vs. 0.5%, P=<0.0001). Open repair was also associated with overall longer average intensive care unit stays (11.0days vs. 1.6days, P<0.0001) and longer average hospitalizations (13.5days vs. 2.4days, P<0.0001). Our findings demonstrate that frailty is associated with higher rates of adverse outcomes in open repair compared to EVAR. Patients who underwent open repair had higher rates of wound dehiscence, surgical site infection, and pneumonia, compared to those undergoing endovascular repair. Frailty was associated with larger AAA diameter in the EVAR cohort and longer operative times, with higher frequency of postoperative pneumonia in the OAR cohort. Frailty is a strong risk factor that should be considered in the management of aortic aneurysms.

Clinical Presentation and Management of Primary Mycotic Aortic Aneurysms: A Single Center Experience and Review of the Literature

Background: Primary mycotic aortic aneurysm (PMAA) is a localized dilation of the aortic wall caused by direct spread of bacteria via the bloodstream to the aortic wall and subsequent development of an aneurysm. The term mycotic aortic aneurysm was first used to describe a patient with four aortic aneurysms which have a mushroom-like appearance, and the term has since been used. Aim: To conduct a literature review and to report a series of cases of infra-renal mycotic aortic aneurysms, their presentation and subsequent outcome and management. Methods: Information was gathered retrospectively from medical records for patients who were over the age of 18 and who had presented with PMAAs at Cumberland infirmary o from April 2016 to July 2022. Results: A total of six patients were assessed in our study, mean age was 57-88 years. Presenting complains were: Back pain (n=2), abdominal pain (n=1), fever (n=4), collapsed (n=2), confusion (n=1) and other clinical presentations were leg pain, feeling unwell and malaise each reported in one patient each. Potential risk factors for PMAA identified were malignancy (n=2), diabetes mellitus (n=2), chronic kidney disease (n=2), immunosuppressive medication (n=2) and alcohol misuse (n=1). Potential sources of infection were retroperitoneal inflammation (n=1), pyelonephritis (n=1), retroperitoneal /psoas infection (n=2), duodenitis (n=1), systemic sepsis (n=1). Management can be surgical intervention such as Endovascular aortic repair (EVAR) (n=2), or axillo-bifemoral bypass (n=2) all of them had post-operative antibiotics or only antibiotics (n=3), however two patients of them died. Conclusion: PMAAs are rare but they have high risk of morbidity and mortality. The diagnosis is challenging but CT A-abdomen and pelvis remains valuable for diagnosis. Surgery, either bypass or EVAR with antibiotics, is a cornerstone for management, however other alternatives can be considered.

Use of surgical augmented intelligence maps can reduce radiation and improve safety in the endovascular treatment of complex aortic aneurysms

ObjectiveThe introduction of endovascular procedures has revolutionized the management of complex aortic aneurysms. Although repair has traditionally required longer operative times and increased radiation exposure compared with simple endovascular aneurysm repair, the recent introduction of three-dimensional technology has become an invaluable operative adjunct. Surgical augmented intelligence (AI) is a rapidly evolving tool initiated at our institution in June 2019. In our study, we sought to determine whether this technology improved patient and operator safety. MethodsA retrospective review of patients who had undergone endovascular repair of complex aortic aneurysms (pararenal, juxtarenal, or thoracoabdominal), type B dissection, or infrarenal (endoleak, coil placement, or renal angiography with or without intervention) at a tertiary care center from August 2015 to November 2021 was performed. Patients were stratified according to the findings from intelligent maps, which are patient-specific AI tools used in the operating room in conjunction with real-time fluoroscopic images. The primary outcomes included operative time, radiation exposure, fluoroscopy time, and contrast use. The secondary outcomes included 30-day postoperative complications and long-term follow-up. Linear regression models were used to evaluate the association between AI use and the main outcomes. ResultsDuring the 6-year period, 116 patients were included in the present study, with no significant differences in the baseline characteristics. Of the 116 patients, 76 (65.5%) had undergone procedures using AI and 40 (34.5%) had undergone procedures without AI software. The intraoperative outcomes revealed a significant decrease in radiation exposure (AI group, 1955 mGy; vs non-AI group, 3755 mGy; P = .004), a significant decrease in the fluoroscopy time (AI group, 55.6 minutes; vs non-AI group, 86.9 minutes; P = .007), a decrease in the operative time (AI group, 255 minutes; vs non-AI group, 284 minutes; P = .294), and a significant decrease in contrast use (AI group, 123 mL; vs non-AI group, 199 mL; P < .0001). No differences were found in the 30-day and long-term outcomes. ConclusionsThe results from the present study have demonstrated that the use of AI technology combined with intraoperative imaging can significantly facilitate complex endovascular aneurysm repair by decreasing the operative time, radiation exposure, fluoroscopy time, and contrast use. Overall, evolving technology such as AI has improved radiation safety for both the patient and the entire operating room team.

Transposition of anomalous left vertebral to carotid artery during the management of thoracic aortic dissections and aneurysms.

Preservation of antegrade flow to the left vertebral artery (LVA) is often achieved by transposition or bypass to the left subclavian artery during zone 2 thoracic endovascular aortic repair. An anomalous LVA (aLVA) originating directly from the aortic arch is a common arch variant with a reported incidence of 4% to 6%. In addition, 6% to 10% of vertebral arteries terminate in a posterior inferior cerebellar artery, increasing the risk of stroke if not revascularized. Few series of aLVA to carotid transposition have been reported. The aim of this study was to evaluate the outcomes of patients who underwent aLVA to carotid transposition for the management of aortic disease. A retrospective review of all aLVA-carotid transpositions performed for the management of thoracic aortic dissection or aneurysm at a single center from 2018 to 2021 was performed. The primary outcomes were postoperative stroke and patency of the transposed aLVA. Secondary outcomes were spinal cord ischemia, postoperative cranial nerve injury, and Horner's syndrome. Seventeen patients underwent aLVA to carotid transposition as an adjunct to management of aortic disease during the study period. Most were men (n= 14) and the mean age was 54± 16years. The primary indication for aortic repair was dissection in 10, aneurysm in 6, and Kommerell diverticulum in 1. Nine patients underwent zone 2 thoracic endovascular aortic repair, seven received open total arch repair, and there was one attempted total endovascular arch repair that was aborted owing to unfavorable anatomy. Twelve transpositions were performed before or concomitant with planned aortic repair owing to high-risk cerebrovascular anatomy (three posterior inferior cerebellar artery termination, six dominant aLVA, four intracranial LVA stenosis), and two were performed postoperatively for treatment of type II endoleak. LVA diameter ranged from 2 to 6mm (mean, 3.3mm). The mean operative time for transposition was 178± 38minutes, inclusive of left subclavian artery revascularization, and the mean estimated blood loss was 169± 188mL. No patients experienced 30-day postoperative spinal cord ischemia, stroke, or mortality. There were two cases of postoperative hoarseness, presumably owing to recurrent laryngeal nerve palsy, both of which resolved within 4months. There were no cases of Horner's syndrome. At follow-up (mean, 306days; range, 6-714days), all transpositions were patent. Vertebral-carotid transposition is a safe and effective adjunct in the management of aortic disease with anomalous origin of the LVA.

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

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

MASSIVE PULMONARY ARTERY ANEURYSM: AN UNCOMMON CAUSE OF MYOCARDIAL ISCHEMIA

MASSIVE PULMONARY ARTERY ANEURYSM: AN UNCOMMON CAUSE OF MYOCARDIAL ISCHEMIA

Tandem Kidney: A Case of Left Crossed Fused Renal Ectopia

Crossed fused renal ectopia is a condition in which the ureter of one kidney enters the urinary bladder on the opposite side. It is the second most frequent fusion abnormality of the kidney after the horseshoe kidney. The crossed kidney is horizontally fused to the lower pole of the normal kidney in the case of tandem kidney, which is a kind of crossed fused renal ectopia. A 33-year-old woman was diagnosed with pelvic inflammatory disease and a urinary tract infection. She was found to have left crossed renal ectopia with a Tandem kidney subtype during her ultrasonography assessment. Crossed fused renal ectopia may be asymptomatic, associated with other anomalies such as hydronephrosis, or represent a risk factor for renal neoplasms. It has been associated with genital and anorectal malformations. Fused renal abnormalities are of significance during abdominal surgeries such as malignant kidney excision, renal transplantation, or surgical management of aortic aneurysm. Keywords: Ectopic kidney, Crossed renal ectopia, Tandem kidney, Horseshoe kidney