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The Annals of Thoracic Surgery Jul 2021This study evaluates sex differences in the natural history of descending thoracic and thoracoabdominal aortic aneurysms (DTTAAs).
BACKGROUND
This study evaluates sex differences in the natural history of descending thoracic and thoracoabdominal aortic aneurysms (DTTAAs).
METHODS
In all, 907 patients with descending thoracic and thoracoabdominal aortic sizes greater than 3 cm were retrospectively reviewed. Growth rate estimates were performed utilizing an instrumental variables approach. Yearly complication rates as a function of aortic size were computed.
RESULTS
There were 615 men (67.8%) and 292 women (32.2%) treated between 1990 and 2018, with mean aortic diameters of 4.1 ± 1.4 cm and 4.8 ± 1.6 cm, respectively (P < .001). The mean growth rate of DTTAAs was 0.17 cm per year in men and 0.25 cm per year in women (P < .001), increasing with increasing aneurysm size. Dissection, rupture, or aortic death or the combination of the three occurred at double the rate for women compared with men (5.8% vs 2.3% per year for the combined endpoint). Diameter of DTTAA greater than 5 cm was associated with 26.3% (male) and 33.1% (female) average yearly rates of the composite endpoint of rupture, dissection, and death (P < .05). The probability of fatal complications (rupture and death) increased sharply at 5.75 cm in both sexes. Between 4.5 and 5.75 cm, there was another hinge-point of higher probability of fatal complications among women.
CONCLUSIONS
Women diagnosed with DTTAA fare worse. Faster aneurysm growth and higher rates of dissection, rupture, and aortic death are apparent among women. Current guidelines recommend surgical intervention at 5.5 to 6 cm for DTTAAs without sex considerations. Our findings suggest that increased virulence of DTTAA in women may indicate surgery at a somewhat smaller diameter.
Topics: Aged; Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Rupture; Aortography; Female; Follow-Up Studies; Humans; Male; Retrospective Studies; Risk Assessment; Risk Factors; United States
PubMed: 33075319
DOI: 10.1016/j.athoracsur.2020.08.026 -
Radiology and Oncology Apr 2022Endovascular abdominal aortic aneurysm repair (EVAR) has become a mainstay of abdominal aorta aneurysm treatment. Long term follow-up on specific stent grafts is needed.
BACKGROUND
Endovascular abdominal aortic aneurysm repair (EVAR) has become a mainstay of abdominal aorta aneurysm treatment. Long term follow-up on specific stent grafts is needed.
PATIENTS AND METHODS
This study included 123 patients (104 men; mean age 73.0 years, range 51-89) with abdominal aorta aneurysm, treated with Excluder stent graft between October 2002 and June 2008. Periprocedural and follow-up data were retrieved by reviewing the records of our institution, while time and cause of death were retrieved from the National Institute of Public Health. If an abdominal aortic aneurysm rupture was listed as the cause of death, records were retrieved from the institution that issued the death certificate. Our primary goal was to assess the primary technical success rate, type 1 and type 2 endoleak, reintervention free survival, 30-day mortality, the overall survival and aneurysm rupture-free survival.
RESULTS
The median follow-up was 9.7 years (interquartile range, 4.6-13.8). The primary technical success was 98.4% and the 30-day mortality accounted for 0.8%. Secondary procedures were performed in 29 (23.6%) patients during the follow-up period. The one-, five-, ten-, fifteen- and seventeen-year overall survival accounted for 94.3%, 74.0%, 47.2%, 35.8% and 35.8%, while the aneurysm-related survival was 98.4%, 96.3%, 92.6%, 92.6%, 92.6%. In seven (5.7%) patients, abdominal aortic rupture was found as the primary cause of death during follow-up.
CONCLUSIONS
Our data showed that EVAR with Excluder stent graft offers good long-term results. More than 75% of patients can be treated completely percutaneously. Late ruptures do occur in the first ten years, raising awareness about regular medical controls.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Male; Middle Aged; Stents
PubMed: 35417109
DOI: 10.2478/raon-2022-0008 -
European Radiology Jun 2024Abdominal aortic aneurysm (AAA) rupture prediction based on sex and diameter could be improved. The goal was to assess whether aortic calcification distribution could...
BACKGROUND
Abdominal aortic aneurysm (AAA) rupture prediction based on sex and diameter could be improved. The goal was to assess whether aortic calcification distribution could better predict AAA rupture through machine learning and LASSO regression.
METHODOLOGY
In this retrospective study, 80 patients treated for a ruptured AAA between January 2001 and August 2018 were matched with 80 non-ruptured patients based on maximal AAA diameter, age, and sex. Calcification volume and dispersion, morphologic, and clinical variables were compared between both groups using a univariable analysis with p = 0.05 and multivariable analysis through machine learning and LASSO regression. We used AUC for machine learning and odds ratios for regression to measure performance.
RESULTS
Mean age of patients was 74.0 ± 8.4 years and 89% were men. AAA diameters were equivalent in both groups (80.9 ± 17.5 vs 79.0 ± 17.3 mm, p = 0.505). Ruptured aneurysms contained a smaller number of calcification aggregates (18.0 ± 17.9 vs 25.6 ± 18.9, p = 0.010) and were less likely to have a proximal neck (45.0% vs 76.3%, p < 0.001). In the machine learning analysis, 5 variables were associated to AAA rupture: proximal neck, antiplatelet use, calcification number, Euclidian distance between calcifications, and standard deviation of the Euclidian distance. A follow-up LASSO regression was concomitant with the findings of the machine learning analysis regarding calcification dispersion but discordant on calcification number.
CONCLUSION
There might be more to AAA calcifications that what is known in the present literature. We need larger prospective studies to investigate if indeed, calcification dispersion affects rupture risk.
CLINICAL RELEVANCE STATEMENT
Ruptured aneurysms are possibly more likely to have their calcification volume concentrated in a smaller geographical area.
KEY POINTS
• Abdominal aortic aneurysm (AAA) rupture prediction based on sex and diameter could be improved. • For a given calcification volume, AAAs with well-distributed calcification clusters could be less likely to rupture. • A machine learning model including AAA calcifications better predicts rupture compared to a model based solely on maximal diameter and sex alone, although it might be prone to overfitting.
Topics: Humans; Male; Female; Aortic Aneurysm, Abdominal; Aortic Rupture; Aged; Retrospective Studies; Machine Learning; Tomography, X-Ray Computed; Vascular Calcification; Predictive Value of Tests; Aged, 80 and over; Aorta, Abdominal
PubMed: 37999728
DOI: 10.1007/s00330-023-10429-1 -
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 -
JAMA Nov 2022
Topics: Humans; Aortic Aneurysm; Aortic Aneurysm, Abdominal; Aortic Rupture; Data Science; Mass Screening; Risk Factors; Ultrasonography
PubMed: 36378223
DOI: 10.1001/jama.2022.9164 -
The Journal of Cardiovascular Surgery Dec 2020The use of thoracic endovascular aortic repair (TEVAR) has rapidly increased following Food and Drug Administration (FDA) approval in 2005. Initially used for the repair... (Review)
Review
The use of thoracic endovascular aortic repair (TEVAR) has rapidly increased following Food and Drug Administration (FDA) approval in 2005. Initially used for the repair of intact thoracic aneurysms and aortic dissections, TEVAR is now routinely used for the treatment of ruptured thoracic aortic aneurysm as well. Emergent TEVAR for the repair of ruptured aneurysm has demonstrated improved perioperative mortality and morbidity compared to traditional open repair. Spinal cord ischemia and permanent paraplegia rates are also lower following TEVAR compared to open repair. However, TEVAR requires routine surveillance and has demonstrated the need for reintervention compared to open repair. Furthermore, the perioperative survival benefits of TEVAR were attenuated on mid-term and long-term survival analysis.
Topics: Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Emergencies; Endovascular Procedures; Hospital Mortality; Humans; Postoperative Complications; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 33185076
DOI: 10.23736/S0021-9509.20.11595-7 -
The British Journal of Surgery Jun 2021Previous studies have suggested that finite element analysis (FEA) can estimate the rupture risk of an abdominal aortic aneurysm (AAA); however, the value of...
BACKGROUND
Previous studies have suggested that finite element analysis (FEA) can estimate the rupture risk of an abdominal aortic aneurysm (AAA); however, the value of biomechanical estimates over measurement of AAA diameter alone remains unclear. This study aimed to compare peak wall stress (PWS) and peak wall rupture index (PWRI) in participants with ruptured and asymptomatic intact AAAs.
METHODS
The reproducibility of semiautomated methods for estimating aortic PWS and PWRI from CT images was assessed. PWS and PWRI were estimated in people with ruptured AAAs and those with asymptomatic intact AAAs matched by orthogonal diameter on a 1 : 2 basis. Spearman's correlation coefficient was used to assess the association between PWS or PWRI and AAA diameter. Independent associations between PWS or PWRI and AAA rupture were identified by means of logistic regression analyses.
RESULTS
Twenty individuals were included in the analysis of reproducibility. The main analysis included 50 patients with an intact AAA and 25 with a ruptured AAA. Median orthogonal diameter was similar in ruptured and intact AAAs (82·3 (i.q.r. 73·5-92·0) versus 81·0 (73·2-92·4) mm respectively; P = 0·906). Median PWS values were 286·8 (220·2-329·6) and 245·8 (215·2-302·3) kPa respectively (P = 0·192). There was no significant difference in PWRI between the two groups (P = 0·982). PWS and PWRI correlated positively with orthogonal diameter (both P < 0·001). Participants with high PWS, but not PWRI, were more likely to have a ruptured AAA after adjusting for potential confounders (odds ratio 5·84, 95 per cent c.i. 1·22 to 27·95; P = 0·027). This association was not maintained in all sensitivity analyses.
CONCLUSION
High aortic PWS had an inconsistent association with greater odds of aneurysm rupture in patients with a large AAA.
Topics: Aged; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Asymptomatic Diseases; Case-Control Studies; Female; Finite Element Analysis; Humans; Male; Retrospective Studies; Risk Factors
PubMed: 34157087
DOI: 10.1002/bjs.11995 -
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 -
Arteriosclerosis, Thrombosis, and... Jul 2024Most abdominal aortic aneurysms (AAAs) are small with low rupture risk (<1%/y) when diagnosed but slowly expand to ≥55 mm and undergo surgical repair. Patients and... (Review)
Review
CLINICAL PROBLEM
Most abdominal aortic aneurysms (AAAs) are small with low rupture risk (<1%/y) when diagnosed but slowly expand to ≥55 mm and undergo surgical repair. Patients and clinicians require medications to limit AAA growth and rupture, but drugs effective in animal models have not translated to patients.
RECOMMENDATIONS FOR INCREASING TRANSLATION FROM MOUSE MODELS
Use models that simulate human AAA tissue pathology, growth patterns, and rupture; focus on the clinically relevant outcomes of growth and rupture; design studies with the rigor required of human clinical trials; monitor AAA growth using reproducible ultrasound; and perform studies in both males and females.
SUMMARY OF STRENGTHS AND WEAKNESSES OF MOUSE MODELS
The aortic adventitial elastase oral β-aminopropionitrile model has many strengths including simulating human AAA pathology and modeling prolonged aneurysm growth. The Ang II (angiotensin II) model performed less well as it better simulates acute aortic syndrome than AAA. The elastase plus TGFβ (transforming growth factor-β) blocking antibody model displays a high rupture rate, making prolonged monitoring of AAA growth not feasible. The elastase perfusion and calcium chloride models both display limited AAA growth.
Topics: Animals; Aortic Aneurysm, Abdominal; Disease Models, Animal; Humans; Aortic Rupture; Pancreatic Elastase; Mice; Aorta, Abdominal; Female; Disease Progression; Male
PubMed: 38924435
DOI: 10.1161/ATVBAHA.124.320823 -
Interactive Cardiovascular and Thoracic... Jun 2022The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture.
OBJECTIVES
The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture.
METHODS
Patient and outcome characteristics of all emergent endovascular treatments for thoracic aortic rupture between January 2009 and December 2019 were analysed.
RESULTS
Thoracic aortic rupture occurred in patients with aortic aneurysms (n = 42, 49%), aortic dissection (n = 13, 16%) or after trauma (n = 30, 35%). Preoperative cerebrospinal fluid drainage was placed in 9 patients (11%) and 18 patients (21%) underwent perioperative supra-aortic transposition. The proximal landing zones were: zone 1 (n = 1, 1%), zone 2 (n = 23, 27%), zone 3 (n = 52, 61%) and zone 4 (n = 9, 11%). Temporary spinal cord injury occurred in 1 patient (1%), permanent spinal cord injury in 7 patients (8%). Two patients (2%) experienced a postoperative stroke. Seventeen patients (20%) expired in-hospital. Aortic dissection (odds ratio: 16.246, p = 0.001), aneurysm (odds ratio: 9.090, P = 0.003) and preoperative shock (odds ratio: 4.646, P < 0.001) were predictive for mortality. Eighteen patients (21%) required a stent-graft-related aortic reintervention for symptomatic supra-aortic malperfusion (n = 3, 4%), endoleaks (n = 6, 7%), a second aortic rupture (n = 4, 5%), retrograde type A aortic dissection (n = 2, 2%), aortic-oesophageal fistulation (n = 2, 2%) and stent-graft kinking (n = 1, 1%).
CONCLUSIONS
Thoracic endovascular aortic repair in patients with aortic rupture has become a valuable treatment modality to stabilize patients. However, a significant risk of postoperative morbidity and mortality remains, particularly in patients with aortic dissections, aneurysms or shock. Patients require thorough follow-up ideally in an aortic clinic with a staff having the entire spectrum of cardiovascular and thoracic surgical expertise.
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Retrospective Studies; Spinal Cord Injuries; Stents; Treatment Outcome
PubMed: 35167665
DOI: 10.1093/icvts/ivac042