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EJVES Vascular Forum 2024Primary aorto-enteral fistula (PAEF) is a connection between the gastrointestinal tract and the aorta that occurs without previous aortic surgery. The aetiological...
OBJECTIVE
Primary aorto-enteral fistula (PAEF) is a connection between the gastrointestinal tract and the aorta that occurs without previous aortic surgery. The aetiological factors include, but are not limited to, aneurysm, infection, and tumours. It is a life threatening condition if untreated and requires emergency vascular surgical repair. A secondary aorto-enteric fistula (AEF) can occur to a previously reconstructed aorta. This case report presents a unique case of a male patient who developed a primary AEF and subsequent secondary AEF with successful surgical outcomes, suggested to be due to tuberculous aortitis.
REPORT
The patient was diagnosed and treated for tuberculosis and developed a saccular aneurysm within six months. The PAEF was surgically corrected with a tube graft using a bovine pericardial patch, the defect in duodenum was sutured, and a retrocolic omental flap was created between the duodenum and aorta. He developed a small stable pseudoaneurysm during follow up, and then a secondary AEF two and a half years later, in which a connection between the pseudoaneurysm and duodenum was corrected using a new bovine aorto-aortic interposition graft using a bovine pericardium patch. The defect in the duodenum was also sutured in two layers and a new omental flap was created.
DISCUSSION
The mortality rate of AEF is high and it is very unlikely that a patient will survive two AEFs without major complications. It is believed that there are extremely few double AEF cases described in the literature. The aetiological factor in the development of PAEF in this case was most likely the patient's aortic aneurysm, which was most likely of mycotic origin due to tuberculosis. The patient developed a pseudoaneurysm during follow up and it is uncertain whether the pulsatile pressure of the pseudoaneurysm led to the recurrence of the AEF.
PubMed: 38884073
DOI: 10.1016/j.ejvsvf.2024.05.005 -
Research Square Jun 2024Loeys-Dietz syndrome (LDS) is an aneurysm disorder caused by mutations that decrease transforming growth factor-β (TGF-β) signaling. Although aneurysms develop...
Loeys-Dietz syndrome (LDS) is an aneurysm disorder caused by mutations that decrease transforming growth factor-β (TGF-β) signaling. Although aneurysms develop throughout the arterial tree, the aortic root is a site of heightened risk. To identify molecular determinants of this vulnerability, we investigated the heterogeneity of vascular smooth muscle cells (VSMCs) in the aorta of LDS mice by single cell and spatial transcriptomics. Reduced expression of components of the extracellular matrix-receptor apparatus and upregulation of stress and inflammatory pathways were observed in all LDS VSMCs. However, regardless of genotype, a subset of -expressing VSMCs predominantly located in the aortic root intrinsically displayed a less differentiated, proinflammatory profile. A similar population was also identified among aortic VSMCs in a human scRNAseq dataset. Postnatal VSMC-specific deletion reduced aortic root dilation in LDS mice, suggesting that this factor sensitizes the aortic root to the effects of impaired TGF-β signaling.
PubMed: 38883722
DOI: 10.21203/rs.3.rs-4420617/v1 -
Journal of Thoracic Disease May 2024Despite improvements in management, infective endocarditis (IE) is still associated with high mortality and morbidity. The outcome of patients with IE remains unclear in...
Postoperative follow-up of 221 patients with infective endocarditis from Gaoligong mountain area of Yunnan in China: a retrospective, single-center, observational cohort study.
BACKGROUND
Despite improvements in management, infective endocarditis (IE) is still associated with high mortality and morbidity. The outcome of patients with IE remains unclear in high-altitude areas of China. To characterize the epidemiological features and surgical outcomes, a retrospective analysis was conducted to 221 patients diagnosed with IE from a single center. In addition, to assess the prognosis of patients, a multivariate logistic regression model was performed to analyze the affecting risk factors.
METHODS
A retrospective analysis was conducted on the clinical data of 221 patients with IE who underwent surgical treatment at the Department of Cardiac Surgery of Yan'an Hospital Affiliated to Kunming Medical University from January 2013 to December 2019. The analysis evaluated patient demographics, pathogenic bacterial composition, echocardiography results, and surgical treatment outcomes. After a 1-year follow-up period, the mortality rate was statistically analyzed. The patients were divided into two groups based on their survival status: those who survived and those who did not. Relevant factors were compared between the two groups, and a multivariate logistic regression model was used to analyze the risk factors that affect the prognosis of patients with IE.
RESULTS
Out of the 221 patients diagnosed with IE, 164 were male and 57 were female, with an average age of 39.25±14.36 years. The most common underlying heart diseases were bicuspid aortic valve disease (24.9%), congenital heart disease (19.5%), rupture of aortic sinus aneurysm (5.0%) and rheumatic valvular disease (2.3%). The blood culture had a positive rate of 48.42% (107/221), with (29.9%) and (13.1%) being the main specifically pathogenic bacteria identified. Transthoracic echocardiography produced positive results in 89.6% (198/221) of cases. The findings included vegetation formation (100%), valve perforation or tear (21.7%), and perivalvular abscess formation (5.6%). Out of the patients, 174 underwent elective surgery, 47 received emergency surgery, and 11 died within 1 year after surgery, resulting in a mortality rate of 5.0%. However, the death group had longer operation time, cardiopulmonary bypass (CPB) time and higher EuroSCORE II compared to the non-death group (P<0.05). Logistic regression analysis identified preoperative hematocrit decrease, prolonged operation time and CPB time, high New York Heart Association (NYHA) cardiac function grade, and liver diseases as risk factors for 1-year mortality in patients with IE (OR =1.003, 0.000, 1.006, 1.026, 1.624 and 4.746).
CONCLUSIONS
IE primarily affects young and middle-aged men with rheumatic heart valvular disease as the main underlying heart disease and as the main pathogen. Surgical intervention significantly reduces early mortality in IE patients. To improve postoperative prognosis, clinicians should remain vigilant, especially in high-risk groups with preoperative hematocrit, prolonged operation time, and CPB time, high NYHA cardiac function grade, EuroSCORE II, and vegetation formation.
PubMed: 38883629
DOI: 10.21037/jtd-24-470 -
Journal of Thoracic Disease May 2024Although aortic aneurysm is associated with vascular aging and atherosclerosis, carotid and intracranial vascular disease prevalence in patients with aortic arch...
Prevalence of carotid artery stenosis and intra-cranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation and postoperative neurological outcomes.
BACKGROUND
Although aortic aneurysm is associated with vascular aging and atherosclerosis, carotid and intracranial vascular disease prevalence in patients with aortic arch aneurysm remains unclear. Similarly, the effect of carotid and intracranial lesions on postoperative outcomes is unknown. This study aimed to investigate the prevalence of carotid artery stenosis and intracranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation (rScO2) and postoperative neurological outcomes, including delirium and cerebral infarction.
METHODS
This retrospective observational study included 133 patients with true aortic arch aneurysm who underwent preoperative magnetic resonance imaging (MRI). We evaluated the prevalence of carotid and intracranial arterial lesions. Symptomatic cerebral infarction and delirium, defined by the confusion assessment method for the intensive care unit, were evaluated for their association with preoperative cerebrovascular lesions. Additionally, changes in regional saturation of the cerebral tissue at different surgical phases were evaluated for patients with and without cerebrovascular lesions.
RESULTS
Fifteen (11.3%) patients experienced symptomatic cerebral infarction, and 64 (48.1%) had postoperative delirium. Preoperative MRI showed old infarction, microbleeds, significant carotid artery stenosis, and intracranial lesions in 21.1%, 14.3%, 10.5%, and 7.5% of the patients, respectively. White matter hyperintensities with Fazekas scale 2 were observed in 40.6% of the patients, while Fazekas scale 3 were observed in 18.8% of the patients. Preoperative MRI findings and postoperative neurological outcomes were not significantly different. Seventy-six patients underwent rScO2 monitoring intraoperatively. Changes in rScO2 in patients with and without carotid/cerebrovascular lesions were not significantly different. However, rScO2 was significantly lower in patients who developed cerebral infarction.
CONCLUSIONS
Significant carotid artery stenosis and intracranial lesions were observed in 10.5% and 7.5% of the patients, respectively. Although preoperative MRI findings and changes in rScO2 or postoperative outcomes showed no significant association, patients with postoperative cerebral infarction showed significantly lower rScO2 intraoperatively.
PubMed: 38883627
DOI: 10.21037/jtd-24-78 -
Journal of Thoracic Disease May 2024Lung cancer and aortic disease share multiple risk factors. The co-presence of both diseases defines a peculiar type of patient who needs a specific protocol of...
BACKGROUND
Lung cancer and aortic disease share multiple risk factors. The co-presence of both diseases defines a peculiar type of patient who needs a specific protocol of treatment and follow-up. The aim of our study was to evaluate the prevalence of aortic disease in a population of patients with a diagnosis of primary lung cancer.
METHODS
A retrospective, single center analysis of all patients admitted to the Thoracic Surgery Unit from January 2015 to January 2021. Demographic and baseline characteristics were retrieved from hospital electronic charts. All patients were screened for aortic disease, reviewing thoraco-abdominal Computed Tomography with contrast medium administration performed for oncological reasons. A cancer-free control group was obtained for comparison. Multilinear regression analysis was performed to identify the risk factors for the presence of aortic disease.
RESULTS
A total of 264 patients were preliminarily identified. After reviewing for exclusion criteria, a total of 148 patients were included in the analysis. Most of the patients were male (62.2%) with a mean age of 71±8.7 years. Cardiovascular risk factors were extensively prevalent in the population study. The incidence of aortic pathologies in the group of patients suffering from primary lung cancer was 27% (40 patients). The majority presented thoracic aortic aneurysms (11.5%). Comparison between the lung cancer group and the control group highlighted a substantial difference in terms of aortic disease prevalence (27% 2.9%; P<0.0001). The regression analysis revealed that coronary artery disease [odds ratio (OR) 4.6988, P=0.001], peripheral artery disease (OR 7.7093, P=0.002), hypertension (OR 4.0152, P=0.03) and history of previous non-aortic vascular surgery procedures (OR 6.4509, P=0.003) were risk factors for aortic disease in patients with primary lung cancer.
CONCLUSIONS
Patients with lung cancer have a high prevalence of aortic disease, defining a peculiar subset of patients who deserve a specific protocol of treatment and follow-up. Further studies are needed to define a dedicated standardized multidisciplinary approach.
PubMed: 38883621
DOI: 10.21037/jtd-23-1547 -
Cureus May 2024A 78-year-old woman with liver cirrhosis due to chronic hepatitis C visited our department for treatment of a thoracic aortic aneurysm. Her Child-Pugh classification was...
A 78-year-old woman with liver cirrhosis due to chronic hepatitis C visited our department for treatment of a thoracic aortic aneurysm. Her Child-Pugh classification was class A, and her model for end-stage liver (MELD) disease score was 8. As she also had thrombocytopenia associated with splenomegaly and esophageal varices, endoscopic injection sclerotherapy and partial splenic embolization were performed before total arch replacement surgery for treating esophageal varices to reduce the bleeding risk during transesophageal echocardiography and for thrombocytopenia, respectively. After endoscopic injection sclerotherapy and partial splenic embolization, the platelet count increased; hence, total arch replacement surgery was performed. By combining partial splenic embolization and endoscopic injection sclerotherapy, we were able to safely perform transesophageal echocardiography and total arch replacement surgery in the perioperative period.
PubMed: 38882984
DOI: 10.7759/cureus.60365 -
Frontiers in Immunology 2024Abdominal aortic aneurysm (AAA) is a degenerative disease characterized by local abnormal dilation of the aorta accompanied by vascular smooth muscle cell (VSMC)...
Abdominal aortic aneurysm (AAA) is a degenerative disease characterized by local abnormal dilation of the aorta accompanied by vascular smooth muscle cell (VSMC) dysfunction and chronic inflammation. VSMC dedifferentiation, transdifferentiation, and increased expression of matrix metalloproteinases (MMPs) are essential causes of AAA formation. Previous studies from us and others have shown that Anemoside B4 (AB4), a saponin from , has anti-inflammatory, anti-tumor, and regulatory effects on VSMC dedifferentiation. The current study aimed to investigate whether AB4 inhibits AAA development and its underlying mechanisms. By using an Ang II induced AAA model and cholesterol loading mediated VSMC to macrophage transdifferentiation model , our study demonstrated that AB4 could attenuate AAA pathogenesis, prevent VSMC dedifferentiation and transdifferentiation to macrophage-like cells, decrease vascular inflammation, and suppress MMP expression and activity. Furthermore, KLF4 overexpression attenuated the effects of AB4 on VSMC to macrophage-like cell transition and VSMC inflammation . In conclusion, AB4 protects against AAA formation in mice by inhibiting KLF4 mediated VSMC transdifferentiation and inflammation. Our study provides the first proof of concept of using AB4 for AAA management.
Topics: Animals; Aortic Aneurysm, Abdominal; Cell Transdifferentiation; Kruppel-Like Factor 4; Mice; Myocytes, Smooth Muscle; Inflammation; Saponins; Disease Models, Animal; Male; Muscle, Smooth, Vascular; Mice, Inbred C57BL; Macrophages; Angiotensin II; Humans
PubMed: 38881898
DOI: 10.3389/fimmu.2024.1412022 -
Surgery Jun 2024With the aging population in the United States, the incidence of abdominal aortic aneurysms is shifting to older ages. Given changing demographic characteristics and...
BACKGROUND
With the aging population in the United States, the incidence of abdominal aortic aneurysms is shifting to older ages. Given changing demographic characteristics and increasing health care expenditures, the present study evaluated the degree of center-level variation in the cost of elective abdominal aortic aneurysm repair.
METHODS
We identified all adult (≥18 years) hospitalizations for elective repair of nonruptured abdominal aortic aneurysms in the 2017 to 2020 Nationwide Readmissions Database. Hierarchical mixed-effects models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient was used to calculate the amount of variation attributable to hospital-level characteristics. High-cost hospitals were classified as centers in the top decile of costs. The association of high-cost hospitals status with outcomes of interest was examined.
RESULTS
An estimated 62,626 patients underwent abdominal aortic aneurysm repair, and 5,011 (8.0%) were managed at high-cost hospitals. Compared with non-high-cost hospitals, high-cost hospitals were more commonly large (52.6% vs 48.3%) metropolitan (78.3% vs 66.9%) teaching centers (all P < .001). The interclass coefficient found that 28% of the observed variation in cost is attributable to hospital factors. After adjustment, high-cost hospitals were associated with increased odds of gastrointestinal (adjusted odds ratio = 1.42; 95% CI, 1.05-1.90) and infectious (adjusted odds ratio = 1.35; 95% CI, 1.14-1.59) complications. Finally, the Elixhauser index (β = +$2,700/unit; 95% CI, $2,500-$3,000) and open repair (β = +$4,100; 95% CI, $3,100-$5,200) were associated with increased costs.
CONCLUSION
We observed significant variation in cost attributable to center-level differences. Our findings have implications for reimbursement paradigms and the establishment of quality and cost benchmarks in the elective repair of abdominal aortic aneurysm.
PubMed: 38879383
DOI: 10.1016/j.surg.2024.05.012 -
Journal of Cardiothoracic Surgery Jun 2024Women undergoing cardiac surgery have been historically recognized to carry higher periprocedural mortality risk. We aimed to investigate the influence of sex on...
BACKGROUND
Women undergoing cardiac surgery have been historically recognized to carry higher periprocedural mortality risk. We aimed to investigate the influence of sex on clinical presentation, perioperative, and long-term outcomes in patients who undergo surgery for ascending aortic aneurysm.
METHODS
We conducted a retrospective review of 1148 consecutive patients (380 [33.1%] female) who underwent thoracic aortic surgery under moderate hypothermic circulatory arrest for ascending aortic aneurysms between 2001 and 2021. Baseline and operative characteristics, in-hospital mortality, and survival were compared between male and female patients before and after propensity-score-matched (PSM) analysis.
RESULTS
Women were significantly older (median age: 69 [IQR: 63-75] vs. 67 [IQR: 58-73]; P < 0.001), while men had a higher prevalence of aortic valve stenosis, bicuspid valve and coronary artery disease at the time of surgery (P < 0.05). After PSM, EuroSCORE II (4.36 [2.68; 6.87] vs. 3.22 [1.85; 5.31]; p < 0.001), and indexed aortic diameter were significantly higher in female patients (2.94 [2.68; 3.30] vs. 2.58 [2.38; 2.81] cm/m2, p < 0.001). In the matched cohort, men were more likely to experience postoperative delirium (18.1% vs. 11.5%; P = 0.002), and postoperative neurological deficits (6.7% vs. 3.0%, P = 0.044),. Female patients were more likely to receive postoperative packed red blood cells (p = 0.036) and fresh frozen plasma (p = 0.049). In-hospital and 30-day mortality was similar between both groups. Long-term survival was comparable between both groups with 88% vs. 88% at 5 years, 76% vs. 71% at 10 years, and 59% vs. 47% at 15 years.
CONCLUSION
Female patients required more transfusions, while males had a higher incidence of postoperative delirium and neurological deficits. Differences in preoperative age and timing of surgery between the sexes could be attributed to variations in comorbidity profiles and the greater prevalence of concomitant surgery indications in males.
Topics: Humans; Female; Male; Propensity Score; Retrospective Studies; Aged; Middle Aged; Sex Factors; Hospital Mortality; Aortic Aneurysm, Thoracic; Postoperative Complications; Treatment Outcome; Risk Factors; Aneurysm, Ascending Aorta
PubMed: 38877532
DOI: 10.1186/s13019-024-02646-6 -
Scientific Reports Jun 2024Although there is an association between abdominal aortic aneurysm (AAA) and circulating immune cell phenotypes, the exact causal relationship remains unclear. This...
Although there is an association between abdominal aortic aneurysm (AAA) and circulating immune cell phenotypes, the exact causal relationship remains unclear. This study aimed to explore the causal relationships between immune cell phenotypes and AAA risk using a bidirectional two-sample Mendelian randomization approach. Data from genome-wide association studies pertaining to 731 immune cell traits and AAA were systematically analyzed. Using strict selection criteria, we identified 339 immune traits that are associated with at least 3 single nucleotide polymorphisms. A comprehensive MR analysis was conducted using several methods including Inverse Variance Weighted, Weighted Median Estimator, MR-Egger regression, Weighted Mode, and Simple Median methods. CD24 on switched memory cells (OR = 0.922, 95% CI 0.914-0.929, P = 2.62e-79) at the median fluorescence intensities level, and SSC-A on HLA-DR + natural killer cells (OR = 0.873, 95% CI 0.861-0.885, P = 8.96e-81) at the morphological parameter level, exhibited the strongest causal associations with AAA. In the reverse analysis, no significant causal effects of AAA on immune traits were found. The study elucidates the causal involvement of multiple circulating immune cell phenotypes in AAA development, signifying their potential as diagnostic markers or therapeutic targets. These identified immune traits may be crucial in modulating AAA-related inflammatory pathways.
Topics: Aortic Aneurysm, Abdominal; Humans; Mendelian Randomization Analysis; Genome-Wide Association Study; Polymorphism, Single Nucleotide; Genetic Predisposition to Disease; Phenotype; Killer Cells, Natural; Risk Factors
PubMed: 38877212
DOI: 10.1038/s41598-024-64789-9