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The Journal of Thoracic and... Feb 2015Congenital diseases of the aorta tend to be obstructive when they present early in life, and aneurysmal when they present later in life. The latter group also tends to... (Review)
Review
Congenital diseases of the aorta tend to be obstructive when they present early in life, and aneurysmal when they present later in life. The latter group also tends to be associated with connective tissue disorders and with repaired conotruncal lesions. The indications for intervention in the aneurysm group are still in evolution but are clearly age- and lesion-dependant. Disorders such as Loeys-Dietz syndrome and Turner syndrome may deserve aggressive prophylactic surgery, as well as Marfan syndrome to a lesser extent. The natural history of the dilated aorta after repair of congenital heart lesions is probably more benign than de novo aneurysms and therefore should be treated conservatively.
Topics: Aortic Dissection; Aortic Aneurysm; Aortic Rupture; Cardiac Surgical Procedures; Decision Support Techniques; Genetic Predisposition to Disease; Heart Defects, Congenital; Humans; Patient Selection; Prognosis; Risk Assessment; Risk Factors; Vascular Surgical Procedures
PubMed: 25726075
DOI: 10.1016/j.jtcvs.2014.10.084 -
Circulation Aug 2017Ultrasmall superparamagnetic particles of iron oxide (USPIO) detect cellular inflammation on magnetic resonance imaging (MRI). In patients with abdominal aortic...
BACKGROUND
Ultrasmall superparamagnetic particles of iron oxide (USPIO) detect cellular inflammation on magnetic resonance imaging (MRI). In patients with abdominal aortic aneurysm, we assessed whether USPIO-enhanced MRI can predict aneurysm growth rates and clinical outcomes.
METHODS
In a prospective multicenter open-label cohort study, 342 patients with abdominal aortic aneurysm (diameter ≥40 mm) were classified by the presence of USPIO enhancement and were monitored with serial ultrasound and clinical follow-up for ≥2 years. The primary end point was the composite of aneurysm rupture or repair.
RESULTS
Participants (85% male, 73.1±7.2 years) had a baseline aneurysm diameter of 49.6±7.7 mm, and USPIO enhancement was identified in 146 (42.7%) participants, absent in 191 (55.8%), and indeterminant in 5 (1.5%). During follow-up (1005±280 days), 17 (5.0%) abdominal aortic aneurysm ruptures, 126 (36.8%) abdominal aortic aneurysm repairs, and 48 (14.0%) deaths occurred. Compared with those without uptake, patients with USPIO enhancement have increased rates of aneurysm expansion (3.1±2.5 versus 2.5±2.4 mm/year, =0.0424), although this was not independent of current smoking habit (=0.1993). Patients with USPIO enhancement had higher rates of aneurysm rupture or repair (47.3% versus 35.6%; 95% confidence intervals, 1.1-22.2; =0.0308). This finding was similar for each component of rupture (6.8% versus 3.7%, =0.1857) or repair (41.8% versus 32.5%, =0.0782). USPIO enhancement was associated with reduced event-free survival for aneurysm rupture or repair (=0.0275), all-cause mortality (=0.0635), and aneurysm-related mortality (=0.0590). Baseline abdominal aortic aneurysm diameter (<0.0001) and current smoking habit (=0.0446) also predicted the primary outcome, and the addition of USPIO enhancement to the multivariate model did not improve event prediction (c-statistic, 0.7935-0.7936).
CONCLUSIONS
USPIO-enhanced MRI is a novel approach to the identification of aortic wall cellular inflammation in patients with abdominal aortic aneurysms and predicts the rate of aneurysm growth and clinical outcome. However, it does not provide independent prediction of aneurysm expansion or clinical outcomes in a model incorporating known clinical risk factors.
CLINICAL TRIAL REGISTRATION
URL: http://www.isrctn.com. Unique identifier: ISRCTN76413758.
Topics: Aged; Aorta; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Pressure; Contrast Media; Dextrans; Disease-Free Survival; Female; Humans; Inflammation; Magnetic Resonance Imaging; Magnetite Nanoparticles; Male; Middle Aged; Proportional Hazards Models; Prospective Studies; Sex Factors; Smoking; Survival Rate
PubMed: 28720724
DOI: 10.1161/CIRCULATIONAHA.117.028433 -
Journal of Endovascular Therapy : An... Apr 2023The purpose of the paper is to report the clinical outcomes of 4 patients with ruptured abdominal aortic aneurysm (AAA) during (3 patients) or immediately after (1...
PURPOSE
The purpose of the paper is to report the clinical outcomes of 4 patients with ruptured abdominal aortic aneurysm (AAA) during (3 patients) or immediately after (1 patient) moderate-severe SARS-CoV-2 infection. We discuss COVID-19-related mechanisms which could impact AAA rupture.
PATIENTS AND METHODS
During the period of the pandemic (March 2020-May 2021), we performed surgery in 18 patients with ruptured AAA. Four patients were affected by moderate or severe SARS-CoV-2 infection (in 3 patients the rupture occurred during the infection and in 1 patient 3. months after discharge from the hospital). Two patients underwent open repair and 2 endovascular surgery.
RESULTS
No postoperative mortality and no major complication occurred. Rapid growth of the AAA in comparison with a previous Duplex scan was evident in all 4 patients.
CONCLUSIONS
Family doctors and vascular surgeons should be aware about the possibility of AAA degeneration in patients with moderate-severe COVID19 infection. The risk is increased by steroid therapy which is essential in more advanced stages of the infection. In this clinical setting, endovascular repair is a valid choice.
Topics: Humans; Treatment Outcome; COVID-19; SARS-CoV-2; Aortic Aneurysm, Abdominal; Aortic Rupture; Endovascular Procedures; Risk Factors; Blood Vessel Prosthesis Implantation
PubMed: 35098775
DOI: 10.1177/15266028221075221 -
Seminars in Vascular Surgery Jun 2023For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured... (Review)
Review
For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Aortic Aneurysm, Thoracoabdominal; Aortic Aneurysm, Thoracic; Treatment Outcome; Prosthesis Design; Stents; Endovascular Procedures; Aortic Rupture; Aortic Aneurysm, Abdominal
PubMed: 37330232
DOI: 10.1053/j.semvascsurg.2023.04.004 -
Journal of Vascular Surgery May 2016The management of degenerative aneurysms of the aortic arch requires careful selection of patients, taking into consideration risk of rupture and operative risks, which...
OBJECTIVE
The management of degenerative aneurysms of the aortic arch requires careful selection of patients, taking into consideration risk of rupture and operative risks, which is more relevant with the emergence of hybrid debranching and branched and fenestrated endovascular options. The natural history of true arch aneurysms has not been previously studied. We aimed to determine the expansion rate of thoracic aortic arch aneurysm and to identify predictors for rupture.
METHODS
Consecutive patients with known true thoracic aortic arch aneurysms monitored with serial computed tomography from 2000 to 2014 were retrospectively reviewed. Thoracoabdominal aneurysms and aneurysms due to aortic dissection and connective tissue diseases were excluded. Variables studied included patient demographics, aneurysm morphology, and ascending aorta diameter. A size expansion curve for each patient was plotted with serial computed tomography scan data, and the slope obtained by linear interpolation was taken as the expansion rate. Multiple logistic regression analysis was performed to identify independent predictors of rupture. Average yearly risks of rupture for overall and expansion rate substrata were calculated from life-table analysis.
RESULTS
A total of 45 arch aneurysms were followed up for a mean of 36.6 months (3-104). Aneurysm growth was largely linear, with an average rate of 2.5 mm/y (0-16). During surveillance, 10 aneurysms ruptured (22%) and 8 patients died. There was one additional arch aneurysm-related death during follow-up, whereas 14 patients (31%) died of other causes. Aneurysms expanding at >5.5 mm/y have a 67% likelihood of rupture compared with 8.3% of those expanding at <5.5 mm/y. Aneurysm size >6.5 cm (P = .0001) and hyperlipidemia (P = .0321) were positively correlated with fast expansion. On univariate analysis, only aneurysm size and expansion rate were significant predictors of rupture. On multivariate analysis, aneurysm expansion rate was the sole independent risk factor of aneurysm rupture (odds ratio, 1.43; 95% confidence interval, 1.06-1.92; P = .018).
CONCLUSIONS
Aneurysm expansion rate >5.5 mm/y is a significant rupture predictor in addition to size compared with aneurysm morphology and other demographic factors. Aneurysm size >6.5 mm and hyperlipidemia are determining factors of expansion rate. These may have implications in selection of patients for surgery. Better control of hyperlipidemia may alleviate the risk of rupture.
Topics: Aged; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Rupture; Aortography; Chi-Square Distribution; Computed Tomography Angiography; Disease Progression; Female; Humans; Hyperlipidemias; Logistic Models; Male; Multivariate Analysis; Odds Ratio; Retrospective Studies; Risk Factors; Time Factors
PubMed: 26926929
DOI: 10.1016/j.jvs.2015.12.043 -
Journal of Vascular Surgery Jan 2023At present, the rupture risk prediction of abdominal aortic aneurysms (AAAs) and, hence, the clinical decision making regarding the need for surgery, is determined by... (Review)
Review
OBJECTIVE
At present, the rupture risk prediction of abdominal aortic aneurysms (AAAs) and, hence, the clinical decision making regarding the need for surgery, is determined by the AAA diameter and growth rate. However, these measures provide limited predictive information. In the present study, we have summarized the measures of local vascular characteristics of the aneurysm wall that, independently of AAA size, could predict for AAA progression and rupture.
METHODS
We systematically searched PubMed and Web of Science up to September 13, 2021 to identify relevant studies investigating the relationship between local vascular characteristics of the aneurysm wall and AAA growth or rupture in humans. A quality assessment was performed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) tool. All included studies were divided by four types of measures of arterial wall characteristics: metabolism, calcification, intraluminal thrombus, and compliance.
RESULTS
A total of 20 studies were included. Metabolism of the aneurysm wall, especially when measured by ultra-small superparamagnetic iron oxide uptake, and calcification were significantly related to AAA growth. A higher intraluminal thrombus volume and thickness had correlated positively with the AAA growth in one study but in another study had correlated negatively. AAA compliance demonstrated no correlation with AAA growth and rupture. The aneurysmal wall characteristics showed no association with AAA rupture. However, the metabolism, measured via ultra-small superparamagnetic iron oxide uptake, but none of the other measures, showed a trend toward a relationship with AAA rupture, although the difference was not statistically significant.
CONCLUSIONS
The current measures of aortic wall characteristics have the potential to predict for AAA growth, especially the measures of metabolism and calcification. Evidence regarding AAA rupture is scarce, and, although more work is needed, aortic wall metabolism could potentially be related to AAA rupture. This highlights the role of aortic wall characteristics in the progression of AAA but also has the potential to improve the prediction of AAA growth and rupture.
Topics: Humans; Risk Factors; Aortic Rupture; Aortography; Aortic Aneurysm, Abdominal; Thrombosis; Aorta, Abdominal
PubMed: 35843510
DOI: 10.1016/j.jvs.2022.07.008 -
International Angiology : a Journal of... Dec 2018Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to... (Review)
Review
BACKGROUND
Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to propose the most rationale strategy during open repair (OR) of RAAA in the presence of HK.
METHODS
We identified and analyzed all patients treated at the clinic due to RAAA and HK. An extensive search was performed on all articles published up to August of 2017 describing open and endovascular repair of RAAA with concomitant horseshoe kidney. The following data were extracted and analyzed: patient number, number of renal arteries, Crawford classification of horseshoe kidney vascularization, type of aortic reconstruction, management with renal arteries, 30-day kidney failure and outcome.
RESULTS
Transperitoneal approach followed by supraceliac aortic cross clamping without the division of the renal isthmus occurred in all our six cases. Four of them required additional procedures with accessory renal arteries after aortic replacement. Three of patients (50%) died during the first 30 postoperative days, while one developed transitory renal insufficiency. The renal isthmus was preserved in 43.90% and divided in 46.34% of cases. Crawford type I of HK vascularization was presented in 21.95% of cases, type II also in 39.02%, while the type III in 19.51% of cases. In 46.33% of cases a procedure with renal arteries was necessary. In 26.82% accessory renal arteries were ligated, while in 19.51% preserved (reattachment or aorto-renal bypass). Thirty-day mortality was 21.95%, while the incidence of postoperative renal failure was also 21.95%. There was not significant correlation between the renal artery ligation and the postoperative renal failure (r=-0.81, P=0.59).
CONCLUSIONS
Transperitoneal approach should be preferred during urgent OR of RAAA with concomitant HK. A supraceliac aortic cross clamping and the placement of occlusive Fogarty catheters into both iliac arteries are recommended for proximal and distal bleeding control. Preservation of accessory renal arteries that are larger than 3 mm in diameter or supply more than 30% of renal parenchima is recommended. The division of the renal isthmus should be avoided if vascularized. It seems that renal arteries could be covered in emergency EVAR without any implications on postoperative kidney function, allowing broader aplication of endovascular treatment for thesse patients.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Clinical Decision-Making; Fused Kidney; Humans; Male; Renal Insufficiency; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 30256051
DOI: 10.23736/S0392-9590.18.04039-7 -
Arteriosclerosis, Thrombosis, and... Apr 2022The goal of this study was to determine whether boosting mitochondrial respiration prevents the development of fatal aortic ruptures triggered by atherosclerosis and...
BACKGROUND
The goal of this study was to determine whether boosting mitochondrial respiration prevents the development of fatal aortic ruptures triggered by atherosclerosis and hypertension.
METHODS
Ang-II (angiotensin-II) was infused in ApoE (Apolipoprotein E)-deficient mice fed with a western diet to induce acute aortic aneurysms and lethal ruptures.
RESULTS
We found decreased mitochondrial respiration and mitochondrial proteins in vascular smooth muscle cells from murine and human aortic aneurysms. Boosting NAD levels with nicotinamide riboside reduced the development of aortic aneurysms and sudden death by aortic ruptures.
CONCLUSIONS
Targetable vascular metabolism is a new clinical strategy to prevent fatal aortic ruptures and sudden death in patients with aortic aneurysms.
Topics: Angiotensin II; Animals; Aortic Rupture; Atherosclerosis; Death, Sudden; Humans; Mice; Mitochondrial Proteins
PubMed: 35196876
DOI: 10.1161/ATVBAHA.121.317346 -
International Journal of Environmental... Nov 2022Background: Abdominal aortic aneurysm (AAA) is a complex vascular disease characterized by progressive and irreversible local dilatation of the aortic wall. Currently,...
Background: Abdominal aortic aneurysm (AAA) is a complex vascular disease characterized by progressive and irreversible local dilatation of the aortic wall. Currently, the indication for repair is linked to the transverse diameter of the abdominal aorta, using computed tomography angiography imagery, which is one of the most used markers for aneurysmal growth. This study aims to verify the predictive role of imaging markers and underlying risk factors in AAA rupture. Methods: The present study was designed as an observational, analytical, retrospective cohort study and included 220 patients over 18 years of age with a diagnosis of AAA, confirmed by computed tomography angiography (CTA), admitted to Vascular Surgery Clinic of Mures County Emergency Hospital in Targu Mures, Romania, between January 2018 and September 2022. Results: Patients with a ruptured AAA had higher incidences of AH (p = 0.006), IHD (p = 0.001), AF (p < 0.0001), and MI (p < 0.0001), and higher incidences of all risk factors (tobacco (p = 0.001), obesity (p = 0.02), and dyslipidemia (p < 0.0001)). Multivariate analysis showed that a high baseline value of all imaging ratios markers was a strong independent predictor of AAA rupture (for all p < 0.0001). Moreover, a higher baseline value of DAmax (OR:3.91; p = 0.001), SAmax (OR:7.21; p < 0.001), and SLumenmax (OR:34.61; p < 0.001), as well as lower baseline values of DArenal (OR:7.09; p < 0.001), DACT (OR:12.71; p < 0.001), DAfemoral (OR:2.56; p = 0.005), SArenal (OR:4.56; p < 0.001), SACT (OR:3.81; p < 0.001), and SThrombusmax (OR:5.27; p < 0.001) were independent predictors of AAA rupture. In addition, AH (OR:3.33; p = 0.02), MI (OR:3.06; p = 0.002), and PAD (OR:2.71; p = 0.004) were all independent predictors of AAA rupture. In contrast, higher baseline values of SAmax/Lumenmax (OR:0.13; p < 0.001) and ezetimibe (OR:0.45; p = 0.03) were protective factors against AAA rupture. Conclusions: According to our findings, a higher baseline value of all imaging markers ratios at CTA strongly predicts AAA rupture and AH, MI, and PAD highly predicted the risk of rupture in AAA patients. Furthermore, the diameter of the abdominal aorta at different levels has better accuracy and a higher predictive role of rupture than the maximal diameter of AAA.
Topics: Humans; Adolescent; Adult; Computed Tomography Angiography; Retrospective Studies; Aortic Rupture; Aortic Aneurysm, Abdominal; Thrombosis; Tomography, X-Ray Computed; Risk Factors; Predictive Value of Tests
PubMed: 36498041
DOI: 10.3390/ijerph192315961 -
European Journal of Vascular and... 2022This study aimed to derive a novel classification of blood flow pattern in abdominal aortic aneurysms (AAA) based on computational fluid dynamics (CFDs), and to...
OBJECTIVES
This study aimed to derive a novel classification of blood flow pattern in abdominal aortic aneurysms (AAA) based on computational fluid dynamics (CFDs), and to determine the predictive value of flow patterns in AAA rupture.
METHODS
This was an age and sex matched case control study. Cases were identified as patients who underwent emergency endovascular or open repair due to ruptured or AAA at risk of impending rupture. Controls were age and sex matched with patients with an AAA who were asymptomatic and had a confirmed unruptured AAA from computed tomography angiography images from the same period. Classification of blood flow pattern (type I: non-helical main flow channel with multiple vortices; type II: non-helical main flow channel with single vortices; and type III, helical main flow channel with helical vortices) and haemodynamic parameters (areas of low wall shear stress [A], aneurysm pressure drop [Δ pressure], etc) were derived from CFD analyses. Multivariable regression was used to determine independent AAA rupture risk factors. The incremental discriminant and reclassification abilities for AAA rupture were compared among different models.
RESULTS
Fifty-three ruptured and 53 intact AAA patients were included. Ruptured AAA showed a higher prevalence of type III flow pattern than intact AAA (60.4% vs. 15.1%; p < .001). Type III flow pattern was associated with a significantly increased risk of aneurysm rupture (odds ratio 10.22, 95% confidence interval 3.43 - 30.49). Among all predicting models, the combination of AAA diameter, haemodynamic parameters (A or Δ pressure), and flow pattern showed highest discriminant abilities in both the overall population (c-index = 0.862) and subgroup patients with AAAs < 55 mm (c-index = 0.972). Compared with AAA diameter, adding the flow pattern could significantly improve the reclassification abilities in both the overall population (net reclassification index [NRI] = 0.321; p < .001) and the subgroup of AAAs < 55 mm (NRI = 0.732; p < .001).
CONCLUSION
Type III flow pattern was associated with a significantly increased risk of AAA rupture. The integration of blood flow pattern may improve the identification of high risk aneurysms in both overall population and in those with AAAs < 55 mm.
Topics: Humans; Aortic Aneurysm, Abdominal; Aortic Rupture; Case-Control Studies; Hydrodynamics; Hemodynamics; Risk Factors
PubMed: 35605907
DOI: 10.1016/j.ejvs.2022.05.027