Treatment Of Abdominal Aortic Aneurysms Research Articles

The relationship between computed tomography-derived body composition, systemic inflammation, and survival in patients with abdominal aortic aneurysm

ObjectivePatient selection and risk stratification for elective repair of abdominal aortic aneurysm (AAA), either by open surgical repair or by endovascular aneurysm repair, remain challenging. Computed tomography (CT)-derived body composition analysis (CT-BC) and systemic inflammation-based scoring systems such as the systemic inflammatory grade (SIG) appear to offer prognostic value in patients with AAA undergoing endovascular aneurysm repair. The relationship between CT-BC, systemic inflammation, and prognosis has been explored in patients with cancer, but data in noncancer populations are lacking. The present study aimed to examine the relationship between CT-BC, SIG, and survival in patients undergoing elective intervention for AAA. MethodsA total of 611 consecutive patients who underwent elective intervention for AAA at three large tertiary referral centers were retrospectively recruited for inclusion into the study. CT-BC was performed and analyzed using the CT-derived sarcopenia score (CT-SS). Subcutaneous and visceral fat indices were also recorded. SIG was calculated from preoperative blood tests. The outcomes of interest were overall and 5-year mortality. ResultsMedian (interquartile range) follow-up was 67.0 (32) months, and there were 194 (32%) deaths during the follow-up period. There were 122 (20%) open surgical repair cases, 558 (91%) patients were male, and the median (interquartile range) age was 73.0 (11.0) years. Age (hazard ratio [HR]: 1.66, 95% confidence interval [CI]: 1.28-2.14, P < .001), elevated CT-SS (HR: 1.58, 95% CI: 1.28-1.94, P < .001), and elevated SIG (HR: 1.29, 95% CI: 1.07-1.55, P < .01) were independently associated with increased hazard of mortality. Mean (95% CI) survival in the CT-SS 0 and SIG 0 subgroup was 92.6 (84.8-100.4) months compared with 44.9 (30.6-59.2) months in the CT-SS 2 and SIG ≥2 subgroup (P < .001). Patients with CT-SS 0 and SIG 0 had 90% (standard error: 4%) 5-year survival compared with 34% (standard error: 9%) in patients with CT-SS 2 and SIG ≥2 (P < .001). ConclusionsCombining measures of radiological sarcopenia and the systemic inflammatory response offers prognostic value in patients undergoing elective intervention for AAA and may contribute to future clinical risk predication strategies.

An Epidemiologic Study of the Incidence and Mortality of Abdominal Aortic Aneurysms in Koreans Aged ≥50 Years from 2009 to 2018 Based on a National Database.

Large-scale population studies of the incidence of and mortality from abdominal aortic aneurysm (AAA) are needed to develop healthcare policies and priorities. The aim of this study was to estimate the incidence of AAA and the all-cause mortality from it among Koreans aged ≥50 years from 2009 to 2018 using data from the Korean National Health Insurance System Database. The crude and standardized incidence and all-cause mortality of the disease among patients with unruptured AAA were calculated. A total of 73,933 AAA patients were identified. The overall incidence of AAA in adults ≥50 years during the study period was 37.5 per 100,000 population (49.7 per 100,000 in men and 26.8 per 100,000 in women), with an increase from 32.33 per 100,000 persons in 2009 to 46.85 per 100,000 in 2018. The crude all-cause mortality rate of patients with untreated AAA was 21.26/100 person-years in 2009 and 8.87/100 person-years in 2018, with decreasing trends observed both in men and women. This nationwide study showed that the incidence of AAA in Koreans aged ≥50 years in 2018 was 63.40 per 100,000 in men and 32.07 per 100,000 in women. The overall rates were 0.06% and 0.03%, respectively, with an increasing trend. Mortality has decreased in both treated and untreated patients. The observed increase in incidence suggests a rising burden of AAA in the Korean population, particularly among men. The decreasing mortality rates may indicate improvements in the management and treatment of AAA over the study period.

Early outcomes of the Conformable endograft in severe neck angulation from the Triveneto Conformable Registry

ObjectiveThe study reports retrospective evaluation of early outcomes from a multicentric experience with the Excluder conformable endograft with active control system (CEXC Device) in the treatment of abdominal aortic aneurysms. Its design allows more flexibility, given by proximal unconnected stent rows and a bending wire within the delivery catheter enables control of proximal angulation. This study specifically focuses on the severe neck angulation (SNA) subgroup (≥60°). MethodsAll patients treated with CEXC Device in nine vascular surgery centers of Triveneto area (Northeast Italy) between January 2019 and July 2022 were enrolled prospectively and analyzed retrospectively. Demographic and aortic anatomical characteristics were evaluated. Endovascular aneurysm repair in SNA were selected for analysis. Major investigated outcomes were technical success, endoleaks, morbidity, mortality, and reinterventions at 30 days and during follow-up. Endograft migration and postoperative aortic neck angulation changes were also analyzed. ResultsA total of 129 patients were enrolled. An infrarenal angle of ≥60° was observed in 56 patients (43%) (SNA group) and their data analyzed. The mean patient age was 78.9 ± 5.9 years and median abdominal aortic aneurysm diameter 59 mm (range, 45-94 mm). Median aortic infrarenal neck length, angulation and diameter were 22 mm (range, 13-58 mm), 77° (range, 60°-150°), and 22.0 ± 3.5 mm respectively. Analysis revealed a technical success rate of 100% and perioperative major complication rate of 1.7%. Intraoperative and perioperative morbidity and mortality rates were 3.5% (one buttock claudication and one inguinal surgical cutdown) and 0%, respectively. No perioperative type I endoleaks were observed. The median follow-up was 13 months (range, 1-40 months). Five patients died during follow-up from aneurysm-unrelated causes. Two reinterventions occurred (3.5%): one conversion for a type IA endoleak and one sac embolization for a type II endoleak. Aneurysm sac shrinkage was observed in 15 patients (26%) and aneurysm stability in 35 patients (62%), respectively. Estimated freedom from reinterventions at 24 months was 92%. Aortic neck median postoperative angulation was 75° (range, 45°-139°). ConclusionsThe Triveneto Conformable Registry shows good early results of the CEXC device in severely angulated aortic infrarenal necks. These data need confirmation on longer follow-up and a wider cohort of patients to further increase endovascular aneurysm repair eligibility in SNA.

Mathematical analysis of unsteady blood flow through bifurcated abdominal aorta featured aneurysm

An abdominal aortic aneurysm (AAA) is a localized dilatation of abdominal aorta. This study investigates a 2-dimensional unsteady and laminar flow through a bifurcated artery with an aneurysm that is computationally and mathematically simulated using 3-dimensional geometry. The fluid used in this simulation is blood which is Newtonian for high shear rate. The computational technique is used to solve the equations that governs due to the flow. The flow of blood is analyzed with the assist of cut planes of pressure and velocity in the abdominal aortic aneurysm (AAA) for t=1s and t=4s. The pressure on the wall and complete velocity profile are also displayed with the assist of graphs. The streamlines are also shown with the help of graphs for t=1s and t=4s. The results can be used in the treatment of abdominal aortic aneurysm.

Increased plasma renin by vasodilators promotes the progression of abdominal aortic aneurysm.

Background: It is well-accepted that antihypertensive therapy is the cornerstone of treatment for abdominal aortic aneurysm (AAA) patients with hypertension. Direct-acting vasodilators were used in the treatment of hypertension by directly relaxing vascular smooth muscle but may have destructive effects on the aortic wall by activating the renin-angiotensin system axis. Their roles in AAA disease remain to be elucidated. In this study, we used hydralazine and minoxidil, two classical direct-acting vasodilators, to investigate their influence and potential mechanisms on AAA disease. Methods and results: In this study, we investigated the plasma renin level and plasma renin activity in AAA patients. Simultaneously, age and gender ratio-matched patients diagnosed with peripheral artery disease and varicose veins were selected as the control group using a ratio of 1:1:1. Our regression analysis suggested both the plasma renin level and plasma renin activity are positively associated with AAA development. In view of the well-established relationship between direct-acting vasodilators and increased plasma renin concentration, we established a porcine pancreatic elastase-infused AAA mouse model, followed by oral administration of hydralazine (250mg/L) and minoxidil (120mg/L) to investigate effects of direct-acting vasodilators on AAA disease. Our results suggested both hydralazine and minoxidil promoted the progression of AAA with increased aortic degeneration. Mechanistically, the vasodilators aggravated aortic inflammation by increased leukocyte infiltration and inflammatory cytokine secretion. Conclusion and relevance: The plasma renin level and plasma renin activity are positively associated with AAA development. Direct vasodilators aggravated experimental AAA progression, which raised cautionary concerns about their applications in AAA disease.

PRDM16 deficiency in vascular smooth muscle cells aggravates abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is usually asymptomatic until life-threatening complications occur, predominantly involving aortic rupture. Currently, no drug-based treatments are available, primarily due to limited understanding of AAA pathogenesis. The transcriptional regulator PR domain-containing protein 16 (PRDM16) is highly expressed in the aorta, but its functions in the aorta are largely unknown. By RNA-seq analysis, we found that vascular smooth muscle cell-specific (VSMC-specific) Prdm16-knockout (Prdm16SMKO) mice already showed extensive changes in the expression of genes associated with extracellular matrix (ECM) remodeling and inflammation in the abdominal aorta under normal housing conditions without any pathological stimuli. Human AAA lesions displayed lower PRDM16 expression. Periadventitial elastase application to the suprarenal region of the abdominal aorta aggravated AAA formation in Prdm16SMKO mice. During AAA development, VSMCs undergo apoptosis because of both intrinsic and environmental changes, including inflammation and ECM remodeling. Prdm16 deficiency promoted inflammation and apoptosis in VSMCs. A disintegrin and metalloproteinase 12 (ADAM12) is a gelatinase that can degrade various ECMs. We found that ADAM12 is a target of transcriptional repression by PRDM16. Adam12 knockdown reversed VSMC apoptosis induced by Prdm16 deficiency. Our study demonstrated that PRDM16 deficiency in VSMCs promoted ADAM12 expression and aggravates AAA formation, which may provide potential targets for AAA treatment.

Impact of patient demographics and intraoperative characteristics on abdominal aortic aneurysm sac following endovascular repair.

Endovascular aortic repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA). Its main aim is to seal the perfusion of the aneurysmal sac and, thus, induce sac regression and subsequent aortic remodelling. Aneurysmal sac regression has been linked to the short- and long-term clinical outcomes post-EVAR. It has also been shown to be influenced by endograft device choice, with several of these available commercially. This review summarises and discusses current evidence on the influence of pre- and intraoperative factors on sac regression. Additionally, this review aims to highlight the device-specific variations in sac regression to provide an overall holistic approach to treating AAAs with EVAR. A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data. Female sex, >70 mm original sac diameters, higher pre-procedural fibrinogen levels, smoking and low intra-aneurysmal pressure were found to positively impact sac regression. Whereas renal impairment, ischemic heart disease, high intra-aneurysmal pressure and aneurysm neck thrombus negatively influenced sac regression. Patent lumbar arteries, age, statins and hypercholesterolaemia displayed conflicting evidence regarding sac regression. Regarding the EVAR endografts compared, newer generation devices such as the Anaconda mainly showed the most optimal results. Sac regression following EVAR in AAA is an important prognostic factor for morbidity and mortality. Nevertheless, several pre- and intraoperative factors can have an influence on sac regression. Therefore, it is necessary to take them into account when assessing AAA patients for EVAR to optimise outcomes. The choice of EVAR stent-graft can also affect sac regression, with evidence suggesting that the Fenestrated Anaconda is associated with the most favourable results.

The Enigma of Treating Colorectal Cancer and an Abdominal Aortic Aneurysm

As the average lifespan of individuals increases, malignancies and cardiovascular diseases are becoming a common cause of morbidity and mortality. The treatment of abdominal aortic aneurysms (AAAs) with concomitant diagnosis of colorectal cancer (CRC) is challenging. We aim to review the experience of a single tertiary institution in the management of patients with concurrent diagnosis of AAA and CRC hoping to glean information on how better to treat these patients. This is a retrospective review of all individuals treated between 2009 and 2022 at a large tertiary care center who had a documented diagnosis of CRC and AAA. A careful review of 102 patients resulted in a sample of 89 patients. Of the 89 patients in our cohort, 39 (43.8%) were diagnosed with CRC over 1 year before their AAA diagnosis. Fifteen (16.9%) patients were diagnosed with an AAA over 1 year before their CRC diagnosis and 35 (39.3%) were diagnosed concurrently with both CRC and AAA (Fig). In the concurrent subgroup, AAA was found on cancer staging workup CT scans, and we found the following in regard to their treatment: 12 (34.3%) individuals underwent CRC resection and surveillance of an AAA between 3 and 4 cm, 14 (40.0%) underwent CRC resection and surveillance of an AAA between 4 and 5 cm, and 3 (8.6%) had an AAA of over 5 cm and met criteria for repair; however, they had metastatic CRC and passed on hospice. There were no incidents of aneurysm rupture during surveillance. Ultimately, of the 35 individuals with concomitant AAA and CRC, 6 (17.1%) required treatment for both conditions—3 individuals had an endovascular aneurysm repair (EVAR) 4 to 6 months before CRC surgical resection, 2 had an EVAR after completing chemoradiation, and 1 individual had an EVAR 1.5 weeks after fecal diversion for obstructing CRC. In this group, there were no incidents of operative mortality. The treatment of both CRC and AAA has limited guidelines on how to proceed with the Society of Vascular Surgery level 2C recommendation for concomitant treatment. Our retrospective review of a single tertiary center identified 35 patients who were found to have an AAA during CRC workup. Although the majority had a small AAA that could be surveilled, of those who required repair, we found that EVAR was the sole approach. Further studies are needed to assess long-term outcomes with larger patient volumes from multiple institutions to recommend a definitive treatment algorithm.

The Impact Associated with Changing Practice Patterns for the Treatment of Abdominal Aortic Aneurysms in the United States

We have witnessed an evolution in the treatment of abdominal aortic aneurysm (AAA) from open to endovascular repair. The implications that these changes have had on outcomes, have not been thoroughly studied. We evaluated the trends in volume of open and endovascular AAA repairs done nationwide in a recent 20-year period, and the outcomes associated with each type of repair, to assess how outcomes may have changed over this period. Patients with AAA undergoing elective open and endovascular repair between 2000 and 2020 were identified using the TriNetX Analytics Network, a federated network of nationwide healthcare organizations that provides deidentified patient data. Patients undergoing first-time elective endovascular or open AAA repair (infrarenal and visceral) from 2001 to 2020 were separated, plotted over time, and propensity score matched. Primary outcome was mortality; secondary outcomes included myocardial infarction (MI), pneumonia and acute kidney injury (AKI). Over the 20-year period we identified 21,368 endovascular patients and 6473 open patients. The endovascular volume surpassed open volume between 2004 and 2005 and we saw a steady increase in endovascular repairs (Fig 1). From 2001 to 2010, mortality was 2.35% for open and 0.98% for endovascular (P < .001); MI was 1.40% for open and 0.90% for endovascular (P = .0004); pneumonia was 2.77% for open and 1.03% for endovascular (P < .001); and AKI was 1.85% for open and 0.91% for endovascular (P = .0014). From 2011 to 2020 mortality was 5.07% for open and 3.89% for endovascular (P = .09); MI was 2.48% for open and 2.39% for endovascular (P = .375); pneumonia was 4.21% for open and 3.10% for endovascular (P = .02); and AKI was 6.53% for open and 4.65% for endovascular (P = .07). When mortality was plotted over time for endovascular and open repairs they both increased (Fig 2). With respect to open repairs the mortality for infrarenal AAA increased from 2001 to 2010 by 2.07% and from 2011 to 2020 by 16.20% (P = .004); visceral AAA increased from 2001 to 2010 by 5.45% and from 2010 to 2020 by 15.73% (P = .016). Endovascular AAA repair has steadily increased over time, while open repair decreased and subsequently increased to a steady state over the recent 20-year period. It appears our mortality has increased for both endovascular and open repair types despite our increased exposure to endovascular cases in practice. Mortality for endovascular repair was significantly higher from 2000 to 2009, but not for 2010 to 2020. Mortality increased significantly from the first decade for both infrarenal and visceral aneurysms.

Assessing the Robustness of Positive Vascular Surgery Randomized Controlled Trials Using Their Fragility Index

The fragility index (FI) measures the robustness of statistically significant findings in randomized controlled trials (RCTs) calculated as the minimum number of event conversions required to alter the result’s statistical significance. In vascular surgery, many clinical guidelines and critical decision-making points are informed by a handful of key RCTs, especially regarding open surgical vs endovascular treatment. The objective of this study is to evaluate the FI of RCTs with statistically significant primary outcomes that compared open vs endovascular surgery. MEDLINE, Embase, and CENTRAL were searched for RCTs comparing open vs endovascular treatments for abdominal aortic aneurysms, carotid artery stenosis, and peripheral arterial disease to December 2022. RCTs with statistically significant primary dichotomous outcomes were included. Data screening and extraction were conducted in duplicate. The FI was calculated by adding an event to the group with the smaller number of events while subtracting a nonevent to the same group until the Fisher exact test produced a non-statistically significant result (P > .05, Table I). The primary outcome measures were FI and proportion of outcomes where loss to follow-up was greater than FI. Secondary analyses were performed to determine whether FI varied by study disease state, presence of commercial funding, and study design. Overall, 5133 articles were captured in the initial search with 21 RCTs reporting 23 primary outcomes being included in the final analysis. The median FI [first quartile, third quartile] was 3 [3, 20] with 16 outcomes (70%) reporting loss to follow-up greater than its FI. The Mann-Whitney U test revealed that commercially funded RCTs and composite outcomes had greater FIs (20 vs 3, P = .035; 21 vs 3, P = .01, respectively). The FI did not vary between disease states (P = .285) or between index trials vs follow-up analyses (P = .147, Table II). There were significant correlations between FI and P value (Pearson r = 0.901, P < .001) and number of events (r = 0.832, P < .001). A small number of event conversions (median 3) are needed to alter the statistical significance of primary outcomes in vascular surgery RCTs evaluating open surgical and endovascular treatments. Most studies had loss to follow-up greater than its FI, which can call into question trial results, and commercially funded studies had a greater FI. The FI and these findings should be considered in future trial design in vascular surgery.Table ITwo-by-two contingency tables highlighting the calculation of the fragility index (FI), with the FI calculated (FI = 70) for the BEST-CLI trial as an exampleTrial 2 × 2 contingency tableCalculation of the FIEventNo eventEventNo eventOpen surgical treatmentABOpen surgical treatmentA + FIB − FIEndovascular treatmentCDEndovascular treatmentCDFisher exact test: P < .05Fisher exact test: P ≥ .05BEST-CLI 2 × 2 contingency tableCalculation of the FI in the BEST-CLI trialMajor adverse limb event or deathNo eventMajor adverse limb event or deathNo eventBypass with single segment great saphenous vein302416Open surgical treatment372 (302 + 70)346 (416 − 70)Endovascular treatment408308Endovascular treatment408308Fisher exact test: P < .05 (P = .00000002)Fisher exact test: P ≥ .05 (P = .05002)BEST-CLI, Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia. Open table in a new tab Table IICharacteristics of the fragility index (FI) of primary outcomes of statistically significant RCTs evaluating open vs endovascular treatment in vascular surgeryCategoryOutcomes, nMedian FI [Q1, Q3]Disease state AAA103 [3, 3] CAS910 [3, 20] PAD415 [5, 46]Study design Index trial133 [3, 4] Follow-up study1014 [3, 21]Funding Commerciala920 [5, 25] Noncommercial143 [2, 6]Outcome Single163 [2, 9] Compositea721 [8, 38]Loss to follow-up <FI73 [3, 8] ≥FI1616 [6, 2, 21]AAA, Abdominal aortic aneurysm; CAS, carotid artery stenting; PAD, peripheral arterial disease.aP < .05. Open table in a new tab

Access-related Outcomes After Infrarenal Endovascular Aortic Aneurysms Repair: A Multicenter Retrospective Cohort Study

Endovascular aortic repair (EVAR) is the first-line treatment for abdominal aortic aneurysms (AAAs) in fit patients. Percutaneous vascular access (pEVAR) allows to ulteriorly decrease the invasivity of EVAR procedures in comparison to femoral cutdown (sEVAR); however, controversies remain regarding postoperative complications and mortality. The aim of this study is to compare the outcomes of these techniques and their impact on operative time, hospitalization, short-term complications, and mortality. This is a retrospective, observational cohort study from four tertiary referral university hospitals. Baseline and peripoperative data of all patients undergoing EVAR procedures were collected in a prospectively managed dataset at each institution and merged in the Italian Collaborators for EVAR (ICE) registry. Study cohort included standard EVAR interventions between January 2018 and February 2021. Mortality and complication risks have been calculated with dedicated scores (Society for Vascular Surgery/American Association for Vascular Surgery score system, American College of Surgeons [ACS] risk calculator). Primary outcomes were pEVAR technical success (absence of surgical conversion), 30-day mortality, and access-related complications. Operative time, length of hospital stay (LOS), 90-day readmission rate, and type of anesthesia were considered secondary outcomes. During the study time, 608 consecutive patients underwent standard EVAR procedures: 373 (61.3%) pEVAR and 202 (33.2%) sEVAR; 33 (5.4%) patients with one surgical and one percutaneous access were excluded from the final analysis. A higher estimated ACS risk for surgical site infection (0.80% ± 0.65% vs 0.65% ± 0.53%; P = .008) and death (1.66% ± 3.55% vs 0.76% ± 1.60%; P = .001) was found in the pEVAR group. Operative time (median, 80.00 minutes [interquartile range (IQR), 60.00-110.00 minutes] vs 112.50 minutes [IQR, 90.00-144.00 minutes]; P < .001), 90-day readmission rate (1.4% vs 6.9%; P = .001), and LOS (4.00 days [IQR, 3.00-7.00 days] in pEVAR vs 5.00 days [IQR, 3.25-8.00 days] in sEVAR; P = .012) were lower among pEVAR group. Higher rates of local anesthesia were observed in the percutaneous group (71.7% vs 22.8%; P < .001). Technical success rate of pEVAR was 97.3% with lower rates of 30-day mortality (1.4% pEVAR vs 6% sEVAR; P = .004). Early access-related complications showed a higher rate in sEVAR group (5.4% in sEVAR vs 1.6% in pEVAR; P = .02). Percutaneous access for EVAR is safe and feasible when compared with surgical access with a high technical success rate and low complication rate. The results of our analysis demonstrate that percutaneous access was associated with decreasing operative time, length of hospital stay, the use of general anesthesia, and readmission rate. The lower mortality rate, despite a higher estimate, is certainly a promising factor; however, further studies are needed to assess the significance of this results.

A Pilot Program to Educate High-School Students Regarding Vascular Disease: The Western New York Model

Public education and awareness are critical to addressing issues related to vascular health and disease. However, to date, little work has been done at the community level with regard to outreach to at-risk populations and to address these knowledge gaps. We describe an intervention to educate high-school students regarding vascular disease with aims to improve community knowledge and to also promote further inquiry into the field of vascular surgery. An educational initiative was commenced in three public high schools. A team of vascular surgeons, vascular residents/fellows, medical students, and vascular lab technicians provided in-class education sessions for the length of a class period (approximately 50 minutes). During each session, there was an interactive presentation on risk factors, presentation, and treatment of peripheral arterial disease, stroke, and abdominal aortic aneurysms. This was followed by hands-on stations where students were introduced to endovascular tools and 3D-printed aortic models, as well as a station where students performed ultrasound examinations of their own carotid arteries and abdominal aortas, and ankle brachial indexes were performed. Before and after each session, substantive quizzes regarding vascular disease were administered, and results of the quizzes were tracked. A total of 155 students completed pre-educational session quizzes, and 132 students completed postsession quizzes (Table). Five questions were included on the pre- and postsession quizzes: peripheral arterial disease risk factors (question 1), smoking-related risks (question 2), abdominal aortic aneurysm symptoms (question 3), stroke symptoms (question 4), and smoking pathophysiology (question 5). An improvement was seen in the aggregate number of correct responses for each question (Table). There was also an increase in the total number of students who scored four correct: 7 (4.5%) presession to 20 (15.2%) postsession, and those who scored five correct: 0 (0%) presession to 11 (8.3%) postsession. Targeted programs aimed at high-school students by vascular surgeons, trainees, and staff can provide a sustainable model for public education and awareness of vascular disease that increases knowledge and may also spur interest in vascular surgery. Further work is needed to determine if these interventions can increase knowledge not only in students in the community at large but also in populations at risk surrounding these schools.TablePre- and posteducational session quiz resultsPresession correct responses, No. (%)Postsession correct responses, No. (%)Question 1: risk for developing PAD106 (68.4)101 (76.5)Question2: smoking-related risks59 (38.1)59 (44.7)Question3: most common AAA symptom12 (7.7)45 (34.1)Question 4: signs of stroke33 (21.3)44 (33.3)Question 5: smoking pathophysiology75 (48.4)75 (56.8)Total N = 155Total N = 132Total no. of correct responses 018 (11.6)9 (6.8) 144 (28.4)31 (23.5) 248 (31.0)32 (24.2) 338 (24.5)29 (22.0) 47 (4.5)20 (15.2) 50 (0)11 (8.3)AAA, Abdominal aortic aneurysm; PAD, peripheral arterial disease. Open table in a new tab

Family History of Aortic Disease Has No Effect on Outcomes of Fenestrated-branched Endovascular Aortic Repair in Patients with Complex Aortic Aneurysms

Prior reports have indicated an increased risk of aneurysm-related complications after endovascular repair in patients with familial aortic aneurysms. The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) for the treatment of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) in patients with familial history of aortic aneurysms or dissections (FAA). The clinical data of 506 consecutive patients (69% male; 74 ± 8 years old) enrolled in a prospective non-randomized study to investigate outcomes of F-BEVAR for the treatment of CAAAs and TAAAs between 2013 and 2022 was reviewed. Outcomes were analyzed in patients with FAA affecting a first or second-degree relative and compared with patients with sporadic aortic aneurysms (SAAs). Endpoints included differences in the distribution of aortic disease, procedural metrics, 30-day mortality, and major adverse events (MAEs), patient survival, and mid-term stent-graft-related outcomes. There were 68 patients (13%) with FAAs and 438 (87%) with SAAs. Both groups had similar cardiovascular risk factors, history of aortic dissection, and aneurysm extent. FAA patients had significantly (P < .05) longer fluoroscopy time (82 vs 71 minutes) and higher radiation dose (1782 vs 1210 mGy). Technical success was achieved in 94.1% of the FAA group and in 96.6% of SAA group (P = .51). Median follow-up was 19 months. There was no difference in 30-day mortality and MAEs, and long-term patient survival, freedom from aortic-related mortality, and freedom from secondary interventions. Patients with FAA had higher sac shrinkage >5mm as compared with patients with SAAs (P = .006). FB-EVAR was performed with high technical success, low mortality, and low incidence of MAEs regardless of the presence of FAAs. There was no difference in the distribution of aortic disease nor in stent graft-related outcomes.TableVariablesFAA (n = 68)SAA (n = 438)P valueAneurysm type (Crawford class)0.862 Extent I4 (8.0)23 (7.4) Extent II22 (44.0)103 (33.1) Extent III8 (16.0)47 (15.1) Infrarenal short neck0 (0.0)1 (0.2) Pararenal18 (26.5)125 (28.6)30-day mortality1 (1.5)4 (0.9)1.00030-day MAESpinal cord injury0.588 No62 (91.2)411 (94.3) Motor (able to ambulate)2 (2.9)7 (1.6) Non-ambulatory4 (5.9)18 (4.1)Myocardial infarction2 (2.9)10 (2.3)1.000Major stroke0 (0.0)3 (0.7)1.000Respiratory failure5 (7.4)12 (2.8)0.111Acute kidney injury0.016 No61 (89.7)396 (90.8) Creatinine >2 but no dialysis3 (4.4)34 (7.8) Temporary dialysis3 (4.4)2 (0.5) Permanent dialysis1 (1.5)4 (0.9)Long-term secondary intervention17 (25.4)96 (22.5)0.721Aneurysm sac behavior Stable17 (25.4)199 (47.2)0.001 Enlarged >5 mm3 (4.5)33 (7.8)0.471 Shrunk >5 mm47 (70.1)189 (44.8)<0.001Final sac diameter53.8 (14.9)59.3 (15.1)0.006FAA, Familial history of aortic aneurysms or dissections; MAE, major adverse event; SAA, sporadic aortic aneurysms.Data are presented as number (%) or mean (standard deviation).Boldface P values indicate statistical significance. Open table in a new tab

Mitochondrial quality control in abdominal aortic aneurysm: From molecular mechanisms to therapeutic strategies.

Mitochondria are the energy supply sites of cells and are crucial for eukaryotic life. Mitochondrial dysfunction is involved in the pathogenesis of abdominal aortic aneurysm (AAA). Multiple mitochondrial quality control (MQC) mechanisms, including mitochondrial DNA repair, biogenesis, antioxidant defense, dynamics, and autophagy, play vital roles in maintaining mitochondrial homeostasis under physiological and pathological conditions. Abnormalities in these mechanisms may induce mitochondrial damage and dysfunction leading to cell death and tissue remodeling. Recently, many clues suggest that dysregulation of MQC is closely related to the pathogenesis of AAA. Therefore, specific interventions targeting MQC mechanisms to maintain and restore mitochondrial function have become promising therapeutic methods for the prevention and treatment of AAA.

In Vitro Radiological Evaluation of Different Types of Chimney Stents Using a Silicon Flow Model with Adjustable Physiological Simulating Conditions

To evaluate invitro the performance of invivo published covered or bare metal chimney stents (ChSs) in combination with the Endurant II abdominal endograft (Medtronic) as the only CE approved main graft (MG) in the treatment of juxtarenal abdominal aortic aneurysms with the chimney endovascular aneurysm repair (chEVAR) technique. Bench top experimental study. A silicon flow model with adjustable physiological simulating conditions and patient based anatomy was used to test nine different MG-ChS combinations: Advanta V12 (Getinge); BeGraft+ (Bentley); VBX (Gore & Associates Inc.); LifeStream (Bard Medical); Dynamic (Biotronik); Absolute Pro (Abbott); double Absolute Pro; Viabahn (Gore) lined with Dynamic; and Viabahn lined with EverFlex (Medtronic). Angiotomography was performed after each implantation. DICOM data were analysed blindly twice per observer by three independent experienced observers. Each blinded evaluation was performed at one month intervals. The main analysed parameters were the area of gutters, MG and ChS maximum compression, and the presence of infolding. Bland-Altman analysis confirmed adequate results correlation (p < .05). Each employed ChS showed significantly different performance favouring the balloon expandable covered stent (BECS). The smallest gutter area was seen in the combination with Advanta V12 (0.26 cm2). MG infolding was observed in all tests. The lowest ChS compression was observed in the combination with BeGraft+ (compression 4.91%, D ratio 0.95). In our model, BECSs showed higher angulations than bare metal stents (BMSs) (p < .001). This invitro study shows the variability of performance with each theoretically possible ChS and explains the divergent ChS outcomes in the published literature. BECS in combination with the Endurant abdominal device confirms their superiority vs. BMS. The presence of MG infolding in each test underlines the need for prolonged kissing ballooning. Angulation evaluation and comparison with other invitro and invivo publications demands the need for further investigation in transversely or upwardly oriented target vessels.

Assessment of Available Online Website and YouTube Resources for Patients with Abdominal Aortic Aneurysms

Over the last decade, patients displayed a greater tendency to search for online information related to their health before seeking advice from a clinician. This study aims to determine the current quality and educational content of online patient information for abdominal aortic aneurysms (AAA). In March 2022, the three most popular search engines by market shares (Google, Yahoo! and Bing) and the video platform YouTube were interrogated for the term "abdominal aortic aneurysm". Validated scoring tools were used to assess quality and readability of the top 50 results for each search engine and to evaluate reliability and educational quality of the first 20 YouTube videos returned by the search. A custom-made scoring system was used to assess content. 45 unique websites were analysed, 29% of which held Health on the Net (HoN) Certification. Median FRE (IQR) was 56.4 (50.4-62.75), with the average website falling under the "difficult to read" category. Median Michigan score (IQR) was 38.5 (32-43.5), reflecting "weak" quality. Websites with higher content-specific score had significantly higher median Michigan score. Sixty percent of websites discussed benefit and risks related to AAA treatment and only 31% discussed advantages and disadvantages of open vs endovascular treatment. No websites mentioned the volume-outcome relationship in aneurysm surgery. 8 unique YouTube videos were assessed. Median JAMA score (IQR) was 2 (2-2.25). Median Global Quality Score (GQS) score (IQR) was 3 (2-4). Median content score was 1 (0-2). The current average online information on AAA is of 'weak' quality and 'difficult' (i.e., above the standard reading ability of a 13 to 15 years old) readability. Healthcare providers should focus on the provision of better AAA-focused patient information (e.g. appropriately referenced, regularly reviewed and limiting advertisements where possible). The involvement of patient advisory groups during resource development is highly recommended.

Pulsatile Changes of the Aortic Diameter May Be Irrelevant Regarding Endograft Sizing in Patients With Aortic Disease.

Endovascular aortic repair has become the preferred elective treatment of infrarenal aortic aneurysms. Aortic pulsatility may pose problems regarding endograft sizing. The aims of this study are to determine the aortic pulsatility in patients with aortic disease and to evaluate the effect of pulsatility on the growth of aneurysms. In this retrospective study, analyses of computed tomography angiography (CTA) images of 31 patients under conservative treatment for small abdominal aortic aneurysms were performed. Reconstructions of the raw electrocardiography (ECG) gated dataset at 30% and 90% of the R-R cycle were used. After lumen segmentation, total aortic cross-sectional area was measured in diastole and systole in the following zones: Z0, Z3, Z5, Z6, Z8, and Z9. Effective diameters (EDs) were calculated from the systolic (EDsys) and diastolic (EDdia) cross-sectional areas to determine absolute (EDsys - EDdia, mm) and relative pulsatility [(EDsys - EDdia) / EDdia, %]. Diameter of the aneurysms was measured on baseline images and the last preoperative follow-up study of each patient. A total of 806 measurements were completed, 24 pulsatility and 2 growth measurements per patient. The mean pulsatility values at each point were as follows: Z0: 0.7±0.8 mm, Z3: 1.0±0.6 mm, Z5: 1.0±0.6 mm, Z6: 0.8±0.7 mm, Z8: 0.7±1.0 mm, Z9: 0.9±0.9 mm. Follow-up time was 5.5±2.2 years during which a growth of 13.42±9.09 mm (2.54±1.55 mm yearly) was observed. No correlation was found between pulsatility values and growth rate of the aneurysms. The pulsatility of the aorta is in a submillimetric range for the vast majority of patients with aortic disease, thus probably not relevant regarding endograft sizing. Pulsatility of the ascending aorta is smaller than that of the descending segment, making an additional oversize of a Z0 implantation questionable. Endovascular aortic repair reqiures precise preoperative planning. Pulsatile changes of the aortic diameter may pose issues regarding endograft sizing. In our retrospective single-centre study, aortic pulsatility of patients with AAA was measured on ECG gated CTA images. Pulsatility values reached a maximum at the descending aorta, however absolute pulsatility values did not exceed 1 mm at any point along the aorta. Therefore, significance of aortic pulsatility regarding the sizing of EVAR prostheses is questionable. Correlation between pulsatility and AAA growth was not found.

Computational Fluid Dynamics (CFD) and Finite Element Analysis (FEM) of a Customized Stent-Graft for Endovascular (EVAR) Treatment of Abdominal Aortic Aneurism (AAA)

Background: The treatment of abdominal aortic aneurysm (AAA) is today commonly treated by inserting a stent-graft by the endovascular route, without resorting to open surgery. However, some clinical cases do not allow this less invasive approach, meaning that the stent-graft cannot be inserted and open surgery is used. Methods: In the study, we propose a fluid–structure interaction (FSI) analysis of an aneurysmatic aorta that could not be treated with Endovascular Aneurysm Repair (EVAR). The vessel is reconstructed through segmentation from CT scans and subsequently modeled on CAD software to create the surface and thickness of the vessel itself. Subsequently, we proceeded to carry out Computational Fluid Dynamics (CFD) and FSI simulation. We propose a computational study on a vessel geometry that is faithful to reality and customized. Results: Hemodynamic variable results of the carried out simulations indicate that low velocity and consequently very low WSS areas located in aneurysmal site are no longer found when conventional or patient-specific grafts are inserted. The wall stress distribution of aorta FEM analysis enabled the identification of the area at risk of failure, that is, in the posterior part of the aneurysm (∼107 Pa), while FSI analysis of the patient-specific graft led to a uniform von Mises stresses distribution (∼105 Pa), except for the junctions where peak stress occurred. Conclusion: The importance of this study is to highlight the benefits of the personalized stent/graft. As the authors expected, the study shows the numerous benefits of the customized stent/graft in terms of blood flow trend and wall stress compared to a traditional stent/graft by supporting the tendency to want to shift the target towards customized stents/grafts, also in the vascular surgery sector.

Treatment of Abdominal Aortic Aneurysm in Nonagenarians: National Figures For 30 Day Mortality and Long Term Survival in Norway Support Treatment in Selected Cases

Treatment of Abdominal Aortic Aneurysm in Nonagenarians: National Figures For 30 Day Mortality and Long Term Survival in Norway Support Treatment in Selected Cases

Systematic Review and Meta-Analysis of Physician Modified Endografts For Treatment of Thoraco-Abdominal and Complex Abdominal Aortic Aneurysms

Objective: Complex endovascular aortic repair with fenestrated and branched grafts has allowed extension of treatment to a wider variety of patients, including those who are less suitable or unfit for open surgery. Custom made devices have been at the cornerstone of this improvement in outcomes. However, the limitation of this technique is the time needed for graft manufacturing, which can take up to three months, increasing the risk for aneurysm related complications during this period. Patients with very large aneurysms, symptomatic or ruptured aneurysms cannot wait this time, which calls for alternative solutions. Physician modified endografts (PMEGs) have been proposed as an option for these situations and studies have reported acceptable results. However, data regarding this technique are dispersed and no multicentre studies have been performed. This means that a systematic review and meta-analysis of the literature analysing the techniques and outcomes of this surgical option would aid in clinical decision making.