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Cell Reports. Medicine May 2021Aortic rupture and dissection are life-threatening complications of ascending thoracic aortic aneurysms (aTAAs), and risk assessment has been largely based on the...
Aortic rupture and dissection are life-threatening complications of ascending thoracic aortic aneurysms (aTAAs), and risk assessment has been largely based on the monitoring of lumen size enlargement. Temporal changes in the extracellular matrix (ECM), which has a critical impact on aortic remodeling, are not routinely evaluated, and cardiovascular biomarkers do not exist to predict aTAA formation. Here, Raman microspectroscopy and Raman imaging are used to identify spectral biomarkers specific for aTAAs in mice and humans by multivariate data analysis (MVA). Multivariate curve resolution-alternating least-squares (MCR-ALS) combined with Lasso regression reveals elastic fiber-derived (Ce1) and collagen fiber-derived (Cc6) components that are significantly increased in aTAA lesions of murine and human aortic tissues. In particular, Cc6 detects changes in amino acid residues, including phenylalanine, tyrosine, tryptophan, cysteine, aspartate, and glutamate. Ce1 and Cc6 may serve as diagnostic Raman biomarkers that detect alterations of amino acids derived from aneurysm lesions.
Topics: Aortic Dissection; Animals; Aorta; Aorta, Thoracic; Aortic Aneurysm; Aortic Aneurysm, Thoracic; Aortic Rupture; Biomarkers; Humans; Mice; Spectrum Analysis, Raman; Stress, Mechanical; Tensile Strength
PubMed: 34095874
DOI: 10.1016/j.xcrm.2021.100261 -
The Journal of Thoracic and... Dec 2020
Topics: Aortic Aneurysm; Aortic Rupture; Humans; Mitral Valve
PubMed: 31619330
DOI: 10.1016/j.jtcvs.2019.09.013 -
Expert Opinion on Drug Safety Nov 2019: Ciprofloxacin, levofloxacin, and moxifloxacin belong to the fluoroquinolone class of antibiotics and are amongst the most commonly prescribed antibiotics. In 2018 and... (Review)
Review
An evaluation of reports of ciprofloxacin, levofloxacin, and moxifloxacin-association neuropsychiatric toxicities, long-term disability, and aortic aneurysms/dissections disseminated by the Food and Drug Administration and the European Medicines Agency.
: Ciprofloxacin, levofloxacin, and moxifloxacin belong to the fluoroquinolone class of antibiotics and are amongst the most commonly prescribed antibiotics. In 2018 and 2019, Food and Drug Administration (FDA) and the European Medicine Agency (EMA) requested that manufacturers harmonize FQ safety information related to neuropsychiatric, aortic dissection, and long-term disability. The authors hypothesize that FDA and EMA epidemiologists support a strong association between these drugs and the three toxicities. : Studies of FQ-associated neuropsychiatric toxicity, long-term disability, and aortic ruptures/dissections. Clinical sources include FDA Advisory Committee documents, a 2014 Citizen Petition filed with the FDA requesting safety information additions to FQ labels for neuropsychiatric toxicities (partially granted in 2018), an under-review Citizen Petition under review by the FDA requesting a FQ Risk Evaluation and Mitigation Strategy, and safety notifications from the EMA. : FDA and the EMA report state that neuropsychiatric toxicity, long-term disability, and aortic dissections//aneurysms occur with all FQs. Disability and neuropsychiatric toxicity can occur after one dose or several months after FQs. United States' and European' regulators warn physicians not to prescribe FQs for uncomplicated acute urinary tract infection, sinusitis, or bronchitis, unless other possible choices are tried first, as risks outweigh benefits in these settings.
Topics: Aortic Dissection; Animals; Anti-Bacterial Agents; Aortic Aneurysm; Aortic Rupture; Ciprofloxacin; Disability Evaluation; European Union; Humans; Levofloxacin; Moxifloxacin; Neurotoxicity Syndromes; United States; United States Food and Drug Administration
PubMed: 31500468
DOI: 10.1080/14740338.2019.1665022 -
Annals of Vascular Surgery Feb 2022Coronavirus disease 2019 (COVID-19) has become a global pandemic which may compromise the management of vascular emergencies. An uncompromised treatment for ruptured...
BACKGROUND
Coronavirus disease 2019 (COVID-19) has become a global pandemic which may compromise the management of vascular emergencies. An uncompromised treatment for ruptured abdominal aortic aneurysm (rAAA) during such a health crisis represents a challenge. This study aimed to demonstrate the treatment outcomes of rAAA and the perioperative prevention of cross-infection under the COVID-19 pandemic.
METHODS
In cases of rAAA during the pandemic, a perioperative workflow was applied to expedite coronavirus testing and avoid pre-operative delay, combined with a strategy for preventing cross-infection. Data of rAAA treated in 11 vascular centers between January-March 2020 collected retrospectively were compared to the corresponding period in 2018 and 2019.
RESULTS
Eight, 12, and 14 rAAA patients were treated in 11 centers in January-March 2018, 2019, and 2020, respectively. An increased portion were treated at local hospitals with a comparable outcome compared with large centers in Guangzhou. With EVAR-first strategy, 85.7% patients with rAAA in 2020 underwent endovascular repair, similar to that in 2018 and 2019. The surgical outcomes during the pandemic were not inferior to that in 2018 and 2019. The average length of ICU stay was 1.8 ± 3.4 days in 2020, tending to be shorter than that in 2018 and 2019, whereas the length of hospital stay was similar among 3 years. The in-hospital mortality of 2018, 2019, and 2020 was 37.5%, 25.0%, and 14.3%, respectively. Three patients undergoing emergent surgeries were suspected of COVID-19, though turned out to be negative after surgery.
CONCLUSIONS
Our experience for emergency management of rAAA and infection prevention for healthcare providers is effective in optimizing emergent surgical outcomes during the COVID-19 pandemic.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; COVID-19; COVID-19 Testing; China; Cross Infection; Emergencies; Female; Humans; Infection Control; Male; Middle Aged; Patient Safety; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Vascular Surgical Procedures; Workflow
PubMed: 34644628
DOI: 10.1016/j.avsg.2021.08.006 -
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 -
Journal of Vascular Surgery Aug 2019Randomized controlled trials (RCTs) constitute level I evidence and are used as the backbone of guidelines and recommendations for treatment. Although RCTs are... (Review)
Review
OBJECTIVE
Randomized controlled trials (RCTs) constitute level I evidence and are used as the backbone of guidelines and recommendations for treatment. Although RCTs are theoretically the studies of choice for the assessment of the effectiveness of health care interventions, these trials (and their interpretation) may sometimes result in erroneous conclusions, erroneous therapeutic decisions, and incorrect recommendations. We aimed to check the applicability of the results of RCTs to everyday practice.
METHODS
We reviewed the literature for studies comparing the results of RCTs with observational or population-based studies in the field of vascular surgery, focusing on two specific topics: the results of carotid artery stenting vs carotid endarterectomy for the management of carotid artery stenosis; and the results of open surgical repair vs endovascular aneurysm repair for the management of ruptured abdominal aortic aneurysms.
RESULTS
We found considerable discrepancy in the results of RCTs with real-life registries and observational studies in both topics. In the management of carotid artery stenosis, observational studies reported worse outcomes after carotid artery stenting compared with carotid endarterectomy. Regarding ruptured abdominal aortic aneurysms, population-based studies reported better results for endovascular aneurysm repair compared with open repair. In contrast, RCTs in both topics reported similar results for the two procedures.
CONCLUSIONS
There is evidence that RCTs sometimes do not reflect clinical reality and are therefore potentially misleading to the reader. Every RCT has to be interpreted and applied carefully using complete available evidence and good clinical judgment.
Topics: Aortic Aneurysm; Aortic Rupture; Blood Vessel Prosthesis Implantation; Carotid Stenosis; Endarterectomy, Carotid; Endovascular Procedures; Evidence-Based Medicine; Humans; Observational Studies as Topic; Randomized Controlled Trials as Topic; Research Design; Stents; Treatment Outcome; Vascular Surgical Procedures
PubMed: 30878256
DOI: 10.1016/j.jvs.2019.01.052 -
Journal of Vascular Surgery Feb 2022Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite...
BACKGROUND
Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite improvements in patient management, the reduced surgical volume has raised concerns for potentially worsened outcomes in the contemporary era (2014-2019) compared with an earlier era in which OSR was more widely practiced (2005-2010). In the present study, we compared the 30-day outcomes of open AAA repair between these two eras.
METHODS
The American College of Surgeons National Quality Improvement Program general database was queried for open AAA repair using the Current Procedural Terminology and International Classification of Diseases, 9th and 10th, codes. The cases were stratified into two groups by operation year: 2005 to 2010 (early) and 2014 to 2019 (contemporary). In each era, the cases were further divided into elective and ruptured groups. The 30-day outcomes, including mortality, major morbidity, postoperative sepsis, and unplanned reoperation, were compared between the contemporary and early eras in the elective and ruptured groups. Preoperative variables with a P value <.25 were adjusted for in the multivariate analysis.
RESULTS
In the contemporary and early eras, 3749 and 3798 patients had undergone elective OSR and 1148 and 907 had undergone ruptured OSR, respectively. These samples were of similar sizes owing to the National Quality Improvement Program sampling process and our relatively strict inclusion criteria. In the contemporary era, fewer patients were elderly and fewer were smokers or had hypertension or dyspnea in the elective and rupture cohorts. More patients had had American Society of Anesthesiologists class >3 in the elective contemporary era (39% vs 24%; P < .0001). The contemporary elective repair group demonstrated increased 30-day mortality (3.7% vs 3.2%; adjusted odds ratio [aOR], 1.36; P = .006), major adverse cardiac events (5.7% vs 3.4%; aOR, 1.87; P < .0001), and bleeding requiring transfusion (58.5% vs 13.7%; aOR, 8.96; P < .0001). The incidence of pulmonary complications (12.1% vs 15.2%; aOR, 0.80; P = .02) and sepsis (3.7% vs 8.4%; aOR, 0.47; P < .0001) had decreased in the contemporary era, with a similar rate of unplanned reoperations (8.4% vs 7.7%; aOR, 1.16; P = .09). The incidence of renal complications in the contemporary era had increased, with a statistically significant difference. However, the absolute increase of <0.5% was likely not clinically relevant (5.5% vs 5.1%; aOR, 1.23; P = .049). In the ruptured cohort, contemporary repair was associated with increased 30-day mortality (41.4% vs 40%; aOR, 1.53; P < .0001), major adverse cardiac events (25.8% vs 12.8%; aOR, 2.49; P < .0001), and bleeding requiring transfusion (88.2% vs 27%; aOR, 23.03; P < .0001). The incidence of pulmonary complications (36.9% vs 48.1%; aOR, 0.67; P < .0001), sepsis (14.6% vs 23%; aOR, 0.75; P = .03), and unplanned reoperations (18.1% vs 22.7%; aOR, 0.74; P = .008) had decreased in the contemporary OSR group. No differences were detected in the incidence of renal complications.
CONCLUSIONS
The 30-day mortality has worsened after open AAA repair in the elective and rupture settings despite the improvements in perioperative management over the years. These complications likely stem from increased bleeding events and major cardiac events, which were increased in the contemporary era.
Topics: Aged; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Elective Surgical Procedures; Endovascular Procedures; Female; Follow-Up Studies; Humans; Incidence; Male; Postoperative Complications; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Survival Rate; Time Factors; Treatment Outcome; United States
PubMed: 34555478
DOI: 10.1016/j.jvs.2021.08.078 -
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 -
Journal of Digital Imaging Dec 2019Aortic dissections and ruptures are life-threatening injuries that must be immediately treated. Our national radiology practice receives dozens of these cases each...
Aortic dissections and ruptures are life-threatening injuries that must be immediately treated. Our national radiology practice receives dozens of these cases each month, but no automated process is currently available to check for critical pathologies before the images are opened by a radiologist. In this project, we developed a convolutional neural network model trained on aortic dissection and rupture data to assess the likelihood of these pathologies being present in prospective patients. This aortic injury model was used for study prioritization over the course of 4 weeks and model results were compared with clinicians' reports to determine accuracy metrics. The model obtained a sensitivity and specificity of 87.8% and 96.0% for aortic dissection and 100% and 96.0% for aortic rupture. We observed a median reduction of 395 s in the time between study intake and radiologist review for studies that were prioritized by this model. False-positive and false-negative data were also collected for retraining to provide further improvements in subsequent versions of the model. The methodology described here can be applied to a number of modalities and pathologies moving forward.
Topics: Aortic Dissection; Aorta; Aortic Rupture; Contrast Media; Female; Humans; Male; Middle Aged; Neural Networks, Computer; Prospective Studies; Radiographic Image Enhancement; Radiographic Image Interpretation, Computer-Assisted; Reproducibility of Results; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 31515752
DOI: 10.1007/s10278-019-00281-5