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European Journal of Vascular and... Dec 2023This study aimed to test whether the relative growth rate of subthreshold abdominal aortic aneurysms (AAAs) in the first 24 months of surveillance predicts the risk of... (Observational Study)
Observational Study
OBJECTIVE
This study aimed to test whether the relative growth rate of subthreshold abdominal aortic aneurysms (AAAs) in the first 24 months of surveillance predicts the risk of future rupture or repair.
METHODS
This was a single centre retrospective observational analysis of all small (< 45 mm diameter) and medium (45 - 54 mm in men, 45 - 50 mm in women) AAAs entered into ultrasound surveillance between January 2002 and December 2019, which received ≥ 24 months of surveillance. Relative growth rates were calculated from measurements taken in the first 24 months of surveillance. The Kaplan-Meier method was used to estimate intervention and rupture free proportions five years following diagnosis for AAAs growing by < 5% and by ≥ 5% in the first 24 months of surveillance. Multivariable Cox regression analysis was used to further analyse this relationship by adjusting for factors found to be significantly associated with outcome in univariable analysis.
RESULTS
A total of 556 patients with AAAs (409 men, 147 women) were followed for ≥ 24 months. This included 431 small AAAs. Of these, 109 (25.3%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.98 ± 0.05 at five years compared with 0.78 ± 0.05 for the ≥ 5% growth group (p < .001). Of 125 medium AAAs, 26 (20.8%) grew by < 5% in the first 24 months of surveillance and had a cumulative event free proportion of 0.73 ± 0.11 at five years compared with 0.29 ± 0.13 for the ≥ 5% growth group (p = .024). Baseline diameter and early relative growth rate were strongly and independently predictive of future intervention or rupture with hazard ratios of 9.16 (95% CI 5.98 - 14.03, p < .001) and 4.46 (95% CI 2.45 - 8.14, p < .001), respectively.
CONCLUSION
The results suggest that slow expansion of small (< 45 mm) AAAs observed over an isolated 24 month period is indicative of a very low risk of rupture or repair in the medium term. Isolated growth rates may be a useful tool with which to triage low risk AAAs and prevent unnecessary surveillance.
Topics: Male; Humans; Female; Retrospective Studies; Aortic Aneurysm, Abdominal; Ultrasonography; Proportional Hazards Models; Time Factors; Aortic Rupture; Risk Factors
PubMed: 37567340
DOI: 10.1016/j.ejvs.2023.08.006 -
Journal of Vascular Surgery Aug 2018We performed a systematic review and meta-analysis aiming to assess the mortality and morbidity of all published case series on thoracoabdominal aortic aneurysms (TAAAs)... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
We performed a systematic review and meta-analysis aiming to assess the mortality and morbidity of all published case series on thoracoabdominal aortic aneurysms (TAAAs) in experienced centers treated with open repair.
METHODS
A systematic search of the literature published until April 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Separate meta-analyses were conducted for overall in-hospital mortality for TAAA, mortality according to the type of TAAA, spinal cord ischemia, paraplegia and paraparesis, cardiac events, stroke, acute kidney failure, and bowel ischemia. A metaregression analysis was performed with volume of the center, percentage of ruptured cases among the series, length of in-hospital stay, and publication year as covariates.
RESULTS
A total of 30 articles were included in the meta-analysis, corresponding to a total of 9963 patients who underwent open repair for TAAAs (543 ruptured). The pooled mortality rate among all studies was 11.26% (95% confidence interval [CI], 9.56-13.09). Mortality was 6.97% (95% CI, 3.75-10.90), 10.32% (95% CI, 7.39-13.63), 8.02% (95% CI, 6.37-9.81), and 7.20% (95% CI, 4.19-10.84) for Crawford types I, II, III, and IV, respectively. Pooled spinal cord ischemia rate was estimated at 8.26% (95% CI, 6.95-9.67), whereas paraparesis and paraplegia rates were 3.61% (95% CI, 2.25-5.25) and 5% (95% CI, 4.36-5.68), respectively. We estimated a pooled cardiac event rate of 4.41% (95% CI, 1.84-7.95) and a stroke rate of 3.11% (95% CI, 2.36-3.94), whereas the need for permanent dialysis rate was 7.92% (95% CI, 5.34-10.92). Respiratory complications after surgery were as high as 23.01% (95% CI, 14.73-32.49). Metaregression analysis evidenced a statistically significant inverse association between mortality and the volume of cases performed in the vascular center (t = -2.00; P = .005). Interestingly, a more recent year of study publication tended to be associated with decreased in-hospital mortality (t = -1.35; P = .19).
CONCLUSIONS
Our study showed that despite the advances in open surgical techniques, the morbidity and mortality of the technique continue to remain considerable. Despite the focus on mortality and spinal cord ischemia, respiratory complications, permanent postoperative renal dialysis, stroke rate, and cardiac events also affect the outcome. The estimated trend of lower mortality in high-volume centers suggests that perhaps this type of service should be provided in a few reference centers that have an established record and experience in the management of these patients.
Topics: Aged; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Clinical Competence; Hospitals, High-Volume; Hospitals, Low-Volume; Humans; Length of Stay; Middle Aged; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 30037680
DOI: 10.1016/j.jvs.2018.03.410 -
Circulation Journal : Official Journal... 2015The mortality rate due to rupture of aortic dissection and aortic aneurysm is approximately 90%. Acute aortic rupture can be fatal prior to hospitalization and has... (Review)
Review
The mortality rate due to rupture of aortic dissection and aortic aneurysm is approximately 90%. Acute aortic rupture can be fatal prior to hospitalization and has proven difficult to diagnose correctly or predict. The in-hospital mortality rate of ruptured aortic aneurysm ranges from 53 to 66%. Emergency surgical and endovascular treatments are the only options for ruptured aortic dissection and aortic aneurysm. No method of systematic early detection or inspection of vessel injury is available at the prevention stage. Regardless of the improvement in many imaging modalities, aortic diameter has remained a major criterion for recommending surgery in diagnosed patients. Previous reports have suggested a relationship between vulnerable plaque and atherosclerotic aortic aneurysm. Non-obstructive angioscopy is a new method for evaluating intimal injury over the whole aorta. It has been used to identify many advanced atherosclerotic plaques that were missed on traditional imaging modalities before aneurysm formation. Non-obstructive angioscopy has shown that atherosclerosis of the aorta begins before that of the coronary artery, which had been noted on autopsy "in vivo". Strong or repetitive aortic injuries might cause sudden aortic disruption. Aortic atheroma is also a risk factor of stroke and perivascular embolism. Detecting aortic vulnerable atherosclerotic plaque on non-obstructive angioscopy may not only clarify the pathogenesis of acute aortic rupture and "aortogenic" thromboemboli and atheroemboli but also play a role in the pre-emptive medicine.
Topics: Angioscopy; Aorta; Aortic Rupture; Embolism, Cholesterol; Humans; Plaque, Atherosclerotic; Thromboembolism
PubMed: 25766407
DOI: 10.1253/circj.CJ-15-0126 -
Annals of Thoracic and Cardiovascular... Feb 2021Spontaneous rupture of the thoracic aorta is rare. We present a 76-year-old man who developed spontaneous rupture of the aortic arch associated with massive periaortic...
Spontaneous rupture of the thoracic aorta is rare. We present a 76-year-old man who developed spontaneous rupture of the aortic arch associated with massive periaortic hematoma and hypovolemic shock. Because the site of rupture could not be identified, emergency hybrid endovascular aortic repair to shield a long segment of the aorta was performed according to the extent and density of periaortic hematoma on axial CT scans. His blood pressure improved just after deployment of the endograft. Rapid diagnosis by CT and prompt control of aortic hemorrhage by endografting salvaged this patient. Three-dimensional (3D) volume-rendered CT images are useful for identifying the site of aortic rupture, but may not be available in an emergency.
Topics: Aged; Aorta, Thoracic; Aortic Rupture; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Emergencies; Endovascular Procedures; Humans; Male; Rupture, Spontaneous; Stents; Treatment Outcome
PubMed: 29899177
DOI: 10.5761/atcs.cr.18-00020 -
Vascular and Endovascular Surgery Oct 2017Associations between atmospheric pressure and abdominal aortic aneurysm (AAA) rupture risk have been reported, but empirical evidence is inconclusive and largely derived...
BACKGROUND
Associations between atmospheric pressure and abdominal aortic aneurysm (AAA) rupture risk have been reported, but empirical evidence is inconclusive and largely derived from studies that did not account for possible nonlinearity, seasonality, and confounding by temperature.
METHODS
Associations between atmospheric pressure and AAA rupture risk were investigated using local meteorological data and a case series of 358 patients admitted to hospital for ruptured AAA during the study period, January 2002 to December 2012. Two analyses were performed-a time series analysis and a case-crossover study.
RESULTS
Results from the 2 analyses were similar; neither the time series analysis nor the case-crossover study showed a significant association between atmospheric pressure ( P = .627 and P = .625, respectively, for mean daily atmospheric pressure) or atmospheric pressure variation ( P = .464 and P = .816, respectively, for 24-hour change in mean daily atmospheric pressure) and AAA rupture risk.
CONCLUSION
This study failed to support claims that atmospheric pressure causally affects AAA rupture risk. In interpreting our results, one should be aware that the range of atmospheric pressure observed in this study is not representative of the atmospheric pressure to which patients with AAA may be exposed, for example, during air travel or travel to high altitudes in the mountains. Making firm claims regarding these conditions in relation to AAA rupture risk is difficult at best. Furthermore, despite the fact that we used one of the largest case series to date to investigate the effect of atmospheric pressure on AAA rupture risk, it is possible that this study is simply too small to demonstrate a causal link.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; Atmospheric Pressure; Cross-Over Studies; Female; Humans; Male; Middle Aged; Netherlands; Patient Admission; Risk Assessment; Risk Factors; Time Factors
PubMed: 28741441
DOI: 10.1177/1538574417713909 -
Journal of Vascular Surgery Jan 2022Contemporary data on the natural history of large abdominal aortic aneurysms (AAAs) in patients undergoing delayed or no repair are lacking. In this study, we examine...
OBJECTIVE
Contemporary data on the natural history of large abdominal aortic aneurysms (AAAs) in patients undergoing delayed or no repair are lacking. In this study, we examine the impact of large AAA size on the incidence of rupture and mortality.
METHODS
From a prospectively maintained aneurysm surveillance registry, patients with an unrepaired, large AAA (≥5.5 cm in men and ≥5.0 cm in women) at baseline (ie, index imaging) or who progressed to a large size from 2003 to 2017 were included, with follow-up through March 2020. Outcomes of interest obtained by manual chart review included rupture (confirmed by imaging/autopsy), probable rupture (timing/findings consistent with rupture without more likely cause of death), repair, reasons for either no or delayed (>1 year after diagnosis of large AAA) repair and total mortality. Cumulative incidence of rupture was calculated using a nonparametric cumulative incidence function, accounting for the competing events of death and aneurysm repair and was stratified by patient sex.
RESULTS
Of the 3248 eligible patients (mean age, 83.6 ± 9.1 years; 71.2% male; 78.1% white; and 32.0% current smokers), 1423 (43.8%) had large AAAs at index imaging, and 1825 progressed to large AAAs during the follow-up period, with a mean time to qualifying size of 4.3 ± 3.4 years. In total, 2215 (68%) patients underwent repair, of which 332 were delayed >1 year; 1033 (32%) did not undergo repair. The most common reasons for delayed repair were discrepancy in AAA measurement between surgeon and radiologist (34%) and comorbidity (20%), whereas the most common reasons for no repair were patient preference (48%) and comorbidity (30%). Among patients with delayed repair (mean time to repair, 2.6 ± 1.8 years), nine (2.7%) developed symptomatic aneurysms, and an additional 11 (3.3%) ruptured. Of patients with no repair, 94 (9.1%) ruptured. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 3-year cumulative incidence of rupture of 12.8% (95% confidence interval, 7.5%-19.6%) compared with 4.5% (95% confidence interval, 3.0%-6.5%) in men (P = .002).
CONCLUSIONS
In this large cohort of AAA registry patients over 17 years, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. Further analyses are ongoing to identify those at increased risk for aneurysm rupture and may provide targeted surveillance regimens and improve patient counseling.
Topics: Aged; Aged, 80 and over; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Counseling; Disease Progression; Female; Humans; Incidence; Male; Prospective Studies; Registries; Risk Factors; Severity of Illness Index; Sex Factors; Time Factors; Time-to-Treatment; Treatment Outcome
PubMed: 34324972
DOI: 10.1016/j.jvs.2021.07.125 -
International Heart Journal May 2019Aortic complex rupture is one of the most critical complications associated with transcatheter aortic valve implantation (TAVI). Its incidence is rare, and its mechanism...
Aortic complex rupture is one of the most critical complications associated with transcatheter aortic valve implantation (TAVI). Its incidence is rare, and its mechanism varies by case; therefore, it is difficult to identify the predictors of complex rupture. Herein, we report a clinical case series of aortic complex rupture. Within our cohort, the frequency of complex rupture was 0.8% (4/497 consecutive patients) with an in-hospital mortality of 0. Among these four patients with complex rupture, two underwent emergent thoracotomy and surgical hemostasis without a heart-lung machine and surgical aortic valve replacement, whereas the other two were conservatively managed. The case overview revealed the following similarities: all the patients were elderly, small women; balloon-expandable valves were used; the annulus area was small with heavily calcified leaflet; and aggressive treatment strategy was used (i.e., oversizing and post-dilatation). In such cases, TAVI should be performed with a careful strategy. Once aortic complex rupture occurs, damage can be minimized through cooperation with an institutional heart team and calm management.
Topics: Aftercare; Aged, 80 and over; Aortic Rupture; Aortic Valve; Aortic Valve Stenosis; Aortography; Calcinosis; Conservative Treatment; Female; Hemostasis, Surgical; Humans; Thoracotomy; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 31019176
DOI: 10.1536/ihj.18-484 -
Journal of Vascular Surgery Jun 2015Elective abdominal aortic aneurysm (AAA) surgery relies on balancing the risk of the intervention against the risk of the aneurysm causing death. Although much is known... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Elective abdominal aortic aneurysm (AAA) surgery relies on balancing the risk of the intervention against the risk of the aneurysm causing death. Although much is known about intervention at 5.5 cm, little is known about the fate of the patient unfit for elective surgery at this threshold. Medical therapy and endovascular surgery have revolutionized management of aortic aneurysms in the last 20 years and are thought to have affected rupture rates.
METHODS
MEDLINE via PubMed, EMBASE, and the Cochrane Library Database were searched for studies reporting follow-up of untreated large AAA approach from inception to January 2014. Data were pooled using random-effects analysis with standardized mean differences and 95% confidence intervals (CIs) reported. The primary end points were rupture rates and all-cause mortality per year by AAA size.
RESULTS
The search strategy identified 1892 citations, of which 11 studies comprising 1514 patients experiencing 347 ruptured AAA were included. The overall incidence of ruptured AAA in patients with AAA >5.5 cm was 5.3% (95% CI, 3.1%-7.5%) per year. This represented cumulative yearly rupture rates of 3.5% (95% CI, -1.6% to 8.7%) in AAAs 5.5 to 6.0 cm, 4.1% (95% CI, -0.7% to 9.0%) in AAAs 6.1 to 7.0 cm, and 6.3% (95% CI, -1.8% to 14.3%) in AAAs >7.0 cm. There was no heterogeneity between studies (I(2) = 0%). Only 32% of these patients were offered repair on rupturing an AAA, with a perioperative mortality of 58% (95% CI, 32%-83%). The risk of death from causes other than AAA was higher than the risk of death from rupture.
CONCLUSIONS
Rupture rates of untreated AAA were lower than those currently quoted in the literature. Non-AAA-related mortality in this group of patients is high.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Cause of Death; Chi-Square Distribution; Contraindications; Elective Surgical Procedures; Humans; Patient Selection; Prognosis; Risk Assessment; Risk Factors; Time Factors; Vascular Surgical Procedures
PubMed: 25661721
DOI: 10.1016/j.jvs.2014.10.023 -
Role of mechanotransduction in vascular biology: focus on thoracic aortic aneurysms and dissections.Circulation Research Apr 2015Thoracic aortic diseases that involve progressive enlargement, acute dissection, or rupture are influenced by the hemodynamic loads and mechanical properties of the... (Review)
Review
Thoracic aortic diseases that involve progressive enlargement, acute dissection, or rupture are influenced by the hemodynamic loads and mechanical properties of the wall. We have only limited understanding, however, of the mechanobiological processes that lead to these potentially lethal conditions. Homeostasis requires that intramural cells sense their local chemomechanical environment and establish, maintain, remodel, or repair the extracellular matrix to provide suitable compliance and yet sufficient strength. Proper sensing, in turn, necessitates both receptors that connect the extracellular matrix to intracellular actomyosin filaments and signaling molecules that transmit the related information to the nucleus. Thoracic aortic aneurysms and dissections are associated with poorly controlled hypertension and mutations in genes for extracellular matrix constituents, membrane receptors, contractile proteins, and associated signaling molecules. This grouping of factors suggests that these thoracic diseases result, in part, from dysfunctional mechanosensing and mechanoregulation of the extracellular matrix by the intramural cells, which leads to a compromised structural integrity of the wall. Thus, improved understanding of the mechanobiology of aortic cells could lead to new therapeutic strategies for thoracic aortic aneurysms and dissections.
Topics: Aortic Dissection; Animals; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Rupture; Biomechanical Phenomena; Disease Progression; Extracellular Matrix Proteins; Genetic Predisposition to Disease; Hemodynamics; Humans; Mechanotransduction, Cellular; Phenotype; Stress, Mechanical
PubMed: 25858068
DOI: 10.1161/CIRCRESAHA.114.304936 -
The Journal of International Medical... Jun 2020Extracorporeal shockwave lithotripsy (ESWL) is a common and effective treatment method for most renal and upper ureteral calculi. Aortic rupture after ESWL is an... (Review)
Review
Extracorporeal shockwave lithotripsy (ESWL) is a common and effective treatment method for most renal and upper ureteral calculi. Aortic rupture after ESWL is an extremely rare complication. Seven cases of aortic rupture have been reported to date, and only one case involved the rupture of a calcified abdominal aorta. We herein describe a Chinese patient who was hospitalized for rupture of the abdominal aorta 5 days after ESWL for right ureteral calculi. The patient was transferred to the Department of Vascular Surgery and underwent emergency endovascular aortic repair. The patient's recovery was unremarkable. One week after the operation, enhanced computed tomography showed that the size of the hematoma around the periaortic area was constant, and repeat enhanced computed tomography 1 month later showed that the hematoma had been significantly absorbed. ESWL may cause rupture of a heavily calcified abdominal aorta. We suggest that all patients with atherosclerosis being considered for ESWL should be evaluated by imaging examinations both preoperatively and during follow-up.
Topics: Abdomen; Aged; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; China; Female; Hematoma; Humans; Kidney; Kidney Calculi; Lithotripsy; Male; Tomography, X-Ray Computed; Treatment Outcome; Ureteral Calculi
PubMed: 32538691
DOI: 10.1177/0300060520931608