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Revista Medica de Chile Jun 2022Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents... (Review)
Review
Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents in a primary hospital without resolution capacity, survival will depend on early transfer to a center with adequately trained specialists. This article reviews the evidence supporting the centralization of AAAR treatment in qualified centers, specifying the criteria used for the selection of referral centers and the role of a coordinating unit. Our current referral system, which is based primarily on costs, is also described. Patients with AAAR who consult in non-resolving centers should be rapidly transferred to a qualified referral center, following a transfer protocol, and guided by a coordinating unit acting according to technical and established criteria based on results, quality, and costs. Qualified referral centers should have an accredited vascular surgeon and a high institutional aortic surgery volume, adequate infrastructure, endovascular resolution capacity, support services (intensive care, hemodialysis, etc.) and specialized personnel permanently available.
Topics: Humans; Aortic Rupture; Hospitals; Hospital Mortality; Aortic Aneurysm, Abdominal; Treatment Outcome; Endovascular Procedures; Retrospective Studies; Risk Factors
PubMed: 37906914
DOI: 10.4067/S0034-98872022000600788 -
European Journal of Vascular and... Oct 2022To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm related mortality (ARM) in England, and examine the impact of... (Observational Study)
Observational Study
OBJECTIVE
To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm related mortality (ARM) in England, and examine the impact of endovascular repair on mortality for the years 1998 to 2020.
METHODS
Hospital admission and operative approach (thoracic endovascular aortic repair, [TEVAR] or open surgical repair) using Hospital Episodes Statistics, and ARM data from the Office for National Statistics for England standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998 - 2008) and the endovascular era (2009 - 2019).
RESULTS
A rising trend in hospital admission incidence has been observed, mainly due non-ruptured admissions (4.11 per 100 000 in 1998; 95% confidence interval (CI) 3.71 - 4.50 to 12.61 per 100 000 in 2020; 95% CI 12.00 - 13.21 in 2020; r = .98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100 000; 95% CI 1.91 - 2.41 in 2020 vs. 0.26 per 100 000; 95% CI 0.16 - 0.36 in 2006; r = .90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females aged > 80 years with ruptured disease (15.26 deaths per 100 000 vs. 9.50 deaths per 100 000; p < .001).
CONCLUSION
A significant increase in hospital admissions for non-ruptured TAA has been observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM, irrespective of sex and age. The significant reductions in age standardised death rates from ruptured and non-ruptured TAA in the endovascular era, particularly for females aged > 80 years with ruptured disease, affirm the positive impact of an endovascular approach to TAA.
Topics: Male; Female; Humans; Aortic Aneurysm, Thoracic; Endovascular Procedures; Treatment Outcome; Hospitals; Blood Vessel Prosthesis Implantation; Risk Factors; Hospital Mortality; Aortic Rupture; Retrospective Studies
PubMed: 35842176
DOI: 10.1016/j.ejvs.2022.07.003 -
Journal of the American College of... Apr 2021The increasing proportion of elderly patients being treated for abdominal aortic aneurysm (AAA) in the endovascular era is controversial. (Comparative Study)
Comparative Study
BACKGROUND
The increasing proportion of elderly patients being treated for abdominal aortic aneurysm (AAA) in the endovascular era is controversial.
OBJECTIVES
This study compared 30-day outcomes of endovascular aortic repair (EVAR) in nonagenarians (NAs) with non-nonagenarians (NNAs).
METHODS
This retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database included EVAR procedures performed from 2011 to 2017. Multivariate logistic regression in the unadjusted cohort, followed by propensity-score matching (PSM), was performed. Primary outcomes were 30-day mortality and 30-day major adverse events.
RESULTS
A total of 12,267 patients were included (365 NAs). Ruptured aneurysms accounted for 6.7% (n = 819): 15.7% (n = 57) in NAs versus 6.5% (n = 762) in NNAs (p < 0.001). Mean aneurysm diameter was 6.5 ± 1.8 cm in NAs versus 5.8 ± 1.7 cm in NNAs (p < 0.001). The unadjusted 30-day mortality was 9.9% in NA versus 2.2% in NNAs (p < 0.001). Multivariate analysis revealed age ≥90 years (odds ratio [OR]: 3.36), male sex (OR: 1.78), functional status (OR: 4.22), pre-operative ventilator dependency (OR: 3.80), bleeding disorders (OR: 1.52), dialysis (OR: 2.56), and ruptured aneurysms (OR: 17.21) as independent predictors of mortality. After PSM, no differences in 30-day mortality (intact AAA [iAAA]: 5.3% NA vs. 3% NNA [p = 0.15]; ruptured AAA [rAAA]: 38% NA vs. 28.6% NNA [p = 0.32]) or 30-day major adverse events (iAAA: 7% NA vs. 4.6% NNA [p = 0.22]; rAAA: 28% NA vs. 36.7% NNA [p = 0.35]) were observed.
CONCLUSIONS
Age was identified as an independent predictor of 30-day mortality after EVAR on multivariate analysis. However, no differences were found after PSM, suggesting that being ≥90 years of age but with similar comorbidities to younger patients is not associated with a higher short-term mortality after EVAR. Age ≥90 years alone should not exclude patients from EVAR, and tailored indications and carefully balanced risk assessment are advised.
Topics: Age Factors; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Databases, Factual; Endovascular Procedures; Female; Humans; Male; Retrospective Studies
PubMed: 33858626
DOI: 10.1016/j.jacc.2021.02.042 -
Internal Medicine (Tokyo, Japan) Jan 2021We herein report a unique case of aortic rupture due to co-localization of aortic intimal myofibroblastic sarcoma (IMFS) and urothelial carcinoma (UC). A 76-year-old man...
We herein report a unique case of aortic rupture due to co-localization of aortic intimal myofibroblastic sarcoma (IMFS) and urothelial carcinoma (UC). A 76-year-old man who was being followed up after surgery for UC 5 years earlier developed aortic rupture and underwent emergency surgery. Intraoperatively, a tumorous mass on the luminal side of the aortic arch was found near the rupture. A histopathological analysis of the mass revealed aortic IMFS. Furthermore, co-localization of IMFS and UC cells was found near the rupture. The fragility of the aortic wall due to co-localization of IMFS and UC was believed to contribute to the aortic rupture.
Topics: Aged; Aorta; Aorta, Thoracic; Aortic Rupture; Carcinoma, Transitional Cell; Humans; Male; Sarcoma
PubMed: 32921685
DOI: 10.2169/internalmedicine.5191-20 -
Pathology Oncology Research : POR Oct 2020Acute aortic catastrophes (AAC), mainly ruptured aneurysms and dissections, lead all other vascular conditions in morbidity and mortality, even if intervention occurs....
Acute aortic catastrophes (AAC), mainly ruptured aneurysms and dissections, lead all other vascular conditions in morbidity and mortality, even if intervention occurs. The aim of our study was to give a descriptive overview of the demographic and pathological characteristics of AAC. Between 1994 and 2013, 80,469 autopsies were performed at Semmelweis University hospitals in Budapest. After collecting the autopsy reports we were able to create the AAC database upon which we conducted our analysis. We found 567 cases of AAC. The cause of death in 120 of them was classified as a non-ruptured aorta with malperfusion or distal embolization. Of the remaining 447 cases, in 305 the cause of death was a ruptured aortic aneurysm (rAA), and in 142 it was a ruptured aortic dissection (rAD). The distribution of rAA cases was 34.4% thoracal, 4.3% thoracoabdominal, and 61.3% abdominal. We found female dominance where the rAA was thoracal. In rAD cases, 84% were Stanford A and 16% Stanford B type. In both groups we found different pathological distributions. In the prehospital group, the number of thoracal ruptures was considerable. 88% of the patients with Stanford A dissection died in the prehospital or perioperative period. The most progressive AACs were ruptures of intrapericardial aneurysms and Stanford A dissections., however survival rate can be elevated by using rapid imaging examination and immediate surgical intervention. We want to highlight that our study contains such gender differences, which are worth to be taken into consideration.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aortic Dissection; Aortic Rupture; Autopsy; Databases, Factual; Female; Humans; Hungary; Male; Middle Aged; Young Adult
PubMed: 32548697
DOI: 10.1007/s12253-020-00835-x -
Basic & Clinical Pharmacology &... Jul 2021Fluoroquinolones (FQ) are associated with an increased risk of tendinopathy, including rupture. Our study aimed to investigate whether FQ use triggered the rupture of...
Fluoroquinolones (FQ) are associated with an increased risk of tendinopathy, including rupture. Our study aimed to investigate whether FQ use triggered the rupture of aortic aneurysms using a self-controlled design. We hypothesised that the use of FQ was associated with aortic rupture shortly after redeemed FQ prescriptions. Using nationwide data sources, we performed a case-crossover study of cases with ruptured aortic aneurysms. From 1996 to 2016, 58 persons presented with rupture of an aortic aneurysm and a redeemed prescription for any FQ within 28 days. 67% were men, and the median age was 77 years. Some 82.9% presented with a ruptured abdominal aneurysm. In our conditional regression, the crude OR for having rupture with a recent FQ redemption was 1.36 (CI 1.00-1.86). After adjusting for potential confounders, the OR was 1.35 (CI 0.98-1.85). Changing the hazard period to FQ redemption within 60 and 90 days, the OR was 2.16 (CI 1.70-2.76) and 2.21 (CI 1.78-2.75), respectively. In conclusion, we demonstrated an association between FQ use within 60 and 90 days and a diagnosis of ruptured aortic aneurysm.
Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Aortic Rupture; Cross-Over Studies; Denmark; Drug Prescriptions; Female; Fluoroquinolones; Humans; Male; Retrospective Studies; Risk Assessment; Risk Factors
PubMed: 33887112
DOI: 10.1111/bcpt.13591 -
International Journal of Legal Medicine Mar 2023Chronic aortic dissections and pseudoaneurysms caused by chest trauma are rare and generally have to be critically distinguished from non-traumatic dissections and...
Chronic aortic dissections and pseudoaneurysms caused by chest trauma are rare and generally have to be critically distinguished from non-traumatic dissections and aneurysms. We present a well-documented case of a post-traumatic aortic dissection that ruptured about 9 months after chest trauma. A motorcyclist sustained fractures of the forearm and chest trauma with paravertebral rib serial fractures and hemopneumothorax. Nine months after the accident, echocardiography revealed a pseudoaneurysm that ruptured 3 months later and 1 month prior to the planned surgery. An autopsy showed pericardial tamponade following a rupture of the dissected aorta. Accident scene documentation was consistent with a head-on collision of the motorcycle against the left front side of the car. The relative speed was about 55 km/h. Aggravation of unspecific symptoms after discharge, initial CT imaging, and the absence of atherosclerosis or medial necrosis hold for a post-traumatic genesis of the dissection in our case. Initially, the accident insurance company rejected the regulation. In the second instance, they revised rejection based on our interdisciplinary expert opinion.
Topics: Humans; Wounds, Nonpenetrating; Aortic Dissection; Aorta; Cardiac Tamponade; Diagnostic Imaging; Thoracic Injuries; Aortic Rupture
PubMed: 36527463
DOI: 10.1007/s00414-022-02935-6 -
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 -
Journal of Internal Medicine Jul 2020Abdominal aortic aneurysm (AAA) rupture is a common cause of death in adults. Current AAA treatment is by open surgical or endovascular aneurysm repair. Rodent model and... (Review)
Review
Abdominal aortic aneurysm (AAA) rupture is a common cause of death in adults. Current AAA treatment is by open surgical or endovascular aneurysm repair. Rodent model and human epidemiology, and genetic and observational studies over the last few decades have highlighted the potential of a number of drug therapies, including medications that lower blood pressure, correct dyslipidaemia, or inhibit thrombosis, inflammation or matrix remodelling, as approaches to managing small AAA. This review summarizes prior AAA pathogenesis data from animal and human studies aimed at identifying targets for the development of drug therapies. The review also systematically assesses past randomized placebo-controlled drug trials in patients with small AAAs. Eleven previously published randomized-controlled clinical trials testing different drug therapies aimed at slowing AAA progression were identified. Five of the trials tested antibiotics and three trials assessed medications that lower blood pressure. Meta-analyses of these trials suggested that neither of these approaches limit AAA growth. Allocation to blood pressure-lowering medication was associated with a small reduction in AAA rupture or repair, compared to placebo (relative risk 0.94, 95% confidence intervals 0.89, 1.00, P = 0.047). Three further trials assessed the effect of a mast cell inhibitor, fibrate or platelet aggregation inhibition and reported no effect on AAA growth or clinical events. Past trials were noted to have a number of design issues, particularly small sample sizes and limited follow-up. Much larger trials are needed to properly test potential therapeutic approaches if a convincingly effective medical therapy for AAA is to be identified.
Topics: Animals; Anti-Bacterial Agents; Anti-Inflammatory Agents; Antihypertensive Agents; Aortic Aneurysm, Abdominal; Aortic Rupture; Coronary Artery Disease; Disease Models, Animal; Epigenesis, Genetic; Genetic Predisposition to Disease; Humans; Hypertension; Hypolipidemic Agents; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Risk Factors; Smoking
PubMed: 31278799
DOI: 10.1111/joim.12958