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Annals of Vascular Diseases Jun 2024Hereditary aortic aneurysms and dissections, such as Marfan syndrome, differ in that they occur in younger patients without generally recognized risk factors, have a... (Review)
Review
Hereditary aortic aneurysms and dissections, such as Marfan syndrome, differ in that they occur in younger patients without generally recognized risk factors, have a predilection for the thoracic rather than the abdominal aorta, and are at risk for dissection even at smaller aortic diameters. Early diagnosis, careful follow-up, and early intervention, such as medication to reduce aortic root growth and prophylactic aortic replacement to prevent fatal aortic dissection, are essential for a better prognosis. Molecular genetic testing is extremely useful for early diagnosis. However, in actual clinical practice, the question often arises as to when and to which patient genetic testing should be offered since the outcome of the tests can have important implications for the patient and the relatives. Pre- and post-test genetic counseling is essential for early intervention to be effective. (This article is a secondary translation of Jpn J Vasc Surg 2023; 32: 261-267.).
PubMed: 38919319
DOI: 10.3400/avd.ra.24-00013 -
Annals of Vascular Diseases Jun 2024A 79-year-old man underwent 1-debranched thoracic endovascular aortic repair (TEVAR) for a saccular aneurysm of the distal arch of the aorta. Computed tomography...
A 79-year-old man underwent 1-debranched thoracic endovascular aortic repair (TEVAR) for a saccular aneurysm of the distal arch of the aorta. Computed tomography performed 3 years after surgery revealed a significant displacement of the distal side of the stent graft and severe deformity due to displacement of the aorta. There were no obvious findings after aortic dissection. Endovascular treatment was selected, and surgery was performed semiemergency. Additional TEVAR was performed to restore the aortic shape and displacement to its normal position.
PubMed: 38919318
DOI: 10.3400/avd.cr.23-00081 -
The Journal of Clinical Investigation Jun 2024Aortic aneurysm is a life-threatening disease with limited interventions, closely related to vascular smooth muscle cells (VSMCs) phenotypic switching. SLC44A2, a member...
Aortic aneurysm is a life-threatening disease with limited interventions, closely related to vascular smooth muscle cells (VSMCs) phenotypic switching. SLC44A2, a member of solute carrier series 44 (SLC44) family, remains under-characterized in the context of cardiovascular diseases. Venn diagram analysis based on microarray and single-cell RNA sequencing identified SLC44A2 as a major regulator of VSMCs phenotypic switching in aortic aneurysm. Screening for Slc44a2 amongst aortic cell lineages demonstrated its predominant location in VSMCs. Elevated levels of SLC44A2 were evidenced in the aorta of both abdominal aortic aneurysm patients and angiotensin II (Ang II)-infused Apoe-/- mice. In vitro, SLC44A2 silencing promoted VSMCs towards a synthetic phenotype, while SLC44A2 overexpression attenuated VSMCs phenotypic switching. VSMCs-specific SLC44A2 knockout mice were more susceptible to aortic aneurysm under Ang II infusion, while SLC44A2 overexpression showed protective effects. Mechanistically, SLC44A2 interaction with NRP1 and ITGB3 activates TGF-β/SMAD signaling, thereby promoting contractile genes expression. Elevated SLC44A2 in aortic aneurysm is associated with upregulated runt-related transcription factor 1 (RUNX1). Furthermore, low dose of lenalidomide (LEN) suppressed aortic aneurysm progression by enhancing SLC44A2 expression. These findings reveal SLC44A2/NRP1/ITGB3 complex is a major regulator of VSMCs phenotypic switching and provide potential therapeutic approach (LEN) for aortic aneurysm treatment.
PubMed: 38916960
DOI: 10.1172/JCI173690 -
Journal of Cardiothoracic Surgery Jun 2024Acute type A aortic dissection is a dangerous disease that threatens public health. In recent years, with the progress of medical technology, the mortality rate of...
BACKGROUND
Acute type A aortic dissection is a dangerous disease that threatens public health. In recent years, with the progress of medical technology, the mortality rate of patients after surgery has been gradually reduced, leading that previous prediction models may not be suitable for nowadays. Therefore, the present study aims to find new independent risk factors for predicting in-hospital mortality and construct a nomogram prediction model.
METHODS
The clinical data of 341 consecutive patients in our center from 2019 to 2023 were collected, and they were divided into two groups according to the death during hospitalization. The independent risk factors were analyzed by univariate and multivariate logistic regression, and the nomogram was constructed and verified based on these factors.
RESULTS
age, preoperative lower limb ischemia, preoperative activated partial thromboplastin time (APTT), preoperative platelet count, Cardiopulmonary bypass (CPB) time and postoperative acute kidney injury (AKI) independently predicted in-hospital mortality of patients with acute type A aortic dissection after surgery. The area under the receiver operating characteristic curve (AUC) for the nomogram was 0.844. The calibration curve and decision curve analysis verified that the model had good quality.
CONCLUSION
The new nomogram model has a good ability to predict the in-hospital mortality of patients with acute type A aortic dissection after surgery.
Topics: Humans; Nomograms; Aortic Dissection; Male; Hospital Mortality; Female; Middle Aged; Risk Factors; Retrospective Studies; Aged; Postoperative Complications; Acute Disease; ROC Curve; Aortic Aneurysm, Thoracic; Aortic Aneurysm; Risk Assessment
PubMed: 38915077
DOI: 10.1186/s13019-024-02921-6 -
Journal of Cardiothoracic Surgery Jun 2024The operative outcomes of thoracoabdominal aortic aneurysms (TAAAs) are challenged by high operative mortality and disabling complications. This study aimed to explore... (Observational Study)
Observational Study
Differential impacts of clinical, anatomical, and procedural factors on early and late mortality following open thoracoabdominal aortic repair: a retrospective observational study.
BACKGROUND
The operative outcomes of thoracoabdominal aortic aneurysms (TAAAs) are challenged by high operative mortality and disabling complications. This study aimed to explore the baseline clinical, anatomical, and procedural risk factors that impact early and late outcomes following open repair of TAAAs.
METHODS
We reviewed the medical records of 290 patients who underwent open repair of TAAAs between 1992 and 2020 at a tertiary referral center. Determinants of early mortality (within 30 days or in hospital) were analyzed using multivariable logistic regression models, while those of overall follow-up mortality were explored using multivariable Cox proportional hazards models and landmark analyses.
RESULTS
The rates of early mortality and spinal cord deficits were 13.1% and 11.0%, respectively, with Crawford extent II showing the highest rates. In the logistic regression models, older age (P < 0.001), high cardiopulmonary bypass (CPB) time (P < 0.001), and low surgical volume of the surgeon (P < 0.001) emerged as independent factors significantly associated with early mortality. During follow-up (median, 5.0 years; interquartile range, 1.1-7.6 years), 82 late deaths occurred (5.7%/patient-year). Cox proportional hazards models demonstrated that older age (P < 0.001) and low hemoglobin level (P = 0.032) were significant risk factors of overall mortality, while the landmark analyses revealed that the significant impacts of low surgical volume (P = 0.017), high CPB time (P = 0.002), and Crawford extent II (P = 0.017) on mortality only remained in the early postoperative period, without significant late impacts (all P > 0.05).
CONCLUSION
There were differential temporal impacts of perioperative risk variables on mortality in open repair of TAAAs, with older age and low hemoglobin level having significant impacts throughout the postoperative period, and low surgical volume, high CPB time, and Crawford extent II having impacts in the early postoperative phase.
Topics: Humans; Male; Female; Retrospective Studies; Aortic Aneurysm, Thoracic; Middle Aged; Risk Factors; Aged; Postoperative Complications; Blood Vessel Prosthesis Implantation; Time Factors; Hospital Mortality; Aorta, Thoracic
PubMed: 38915060
DOI: 10.1186/s13019-024-02933-2 -
Interdisciplinary Cardiovascular and... Jun 2024Diameter-based risk stratification for elective repair of ascending aortic aneurysm fails to prevent type A dissection in many patients. Aneurysm wall stresses may...
OBJECTIVES
Diameter-based risk stratification for elective repair of ascending aortic aneurysm fails to prevent type A dissection in many patients. Aneurysm wall stresses may contribute to risk prediction; however, rates of wall stress change over time are poorly understood. Our objective was to examine aneurysm wall stress changes over three to five years and subsequent all-cause mortality.
METHODS
Male veterans with <5.5-cm ascending aortic aneurysms and computed tomography at baseline and 3 to 5-years follow-up underwent three-dimensional aneurysm model construction. Peak circumferential and longitudinal wall stresses at systole were calculated using finite element analysis. Temporal trends were assessed by mixed-effects modelling. Changes in aortic wall stresses, diameter, and length over time were evaluated as predictors of subsequent 3-year all-cause mortality by Cox proportional hazards modelling.
RESULTS
Sixty-two male veterans were included in the study. Yearly changes in geometric and biomechanical measures were 0.12 mm/yr (95% CI, 0.04-0.20) for aortic diameter, 0.41 mm/yr (0.12-0.71) for aortic length, 1.19 kPa/yr (-5.94-8.33) for peak circumferential stress, and 0.48 kPa/yr (-3.89-4.84) for peak longitudinal stress. Yearly change in peak circumferential stress was significantly associated with hazard of death-hazard ratio for peak circumferential stress growth per 10 kPa/yr, 1.27 (95% CI, 1.02-1.60; p = 0.037); hazard ratio for peak circumferential stress growth ≥ 32 kPa/yr, 8.47 (95% CI, 2.42-30; p < 0.001).
CONCLUSIONS
In this population of nonsurgical aneurysm patients, large temporal changes in peak circumferential stress, but not aortic diameter or length, was associated with all-cause mortality. Biomechanical stress and stress changes over time may be beneficial as additional risk factors for elective surgery in small aneurysms.
PubMed: 38913870
DOI: 10.1093/icvts/ivae116 -
Cureus May 2024This case report revolves around a 73-year-old male patient who initially sought medical attention due to left lower extremity weakness. Suspicions of a potential...
This case report revolves around a 73-year-old male patient who initially sought medical attention due to left lower extremity weakness. Suspicions of a potential vascular etiology arose during the initial clinical examination, prompting further investigation. Unexpectedly, computed tomography (CT) imaging of the abdomen and pelvis revealed the presence of three giant aneurysms. Concurrently, positive syphilis titers were identified. The patient's presentation, marked by focal neurological deficits, unveiled the incidental discovery of a triad of aneurysms involving the distal abdominal aorta, right common iliac, and left common iliac. The neurological symptoms observed in the patient were attributed to the compression within the left common iliac artery, leading to compromised blood flow to the lower extremity. Alternatively, the neurological deficits could be linked to neurosyphilis or a combination of both factors. This case underscores the critical role of considering syphilis in patients presenting with neurological symptoms. The unique discovery of extensive aortic abnormalities through imaging studies, specifically CT angiography, emphasized the importance of such diagnostic tools in unraveling complex and potentially life-threatening vascular pathologies. Recognizing the diverse manifestations of syphilis in patients with vast neurological symptoms is crucial for timely diagnosis and multidisciplinary management. This case emphasizes the need to keep a high index of suspicion for syphilis in individuals who have widespread aortic anomalies together with neurological symptoms, to sum up. The triad of aneurysms discovered incidentally in this 73-year-old patient underscores the intricate interplay between vascular and neurological manifestations. The timely diagnosis and multidisciplinary management of both the neurological and vascular aspects of this unique presentation are essential for ensuring optimal patient outcomes.
PubMed: 38910719
DOI: 10.7759/cureus.60944 -
Journal of Vascular Surgery Jun 2024To report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside, Artivion - Kennesaw,...
OBJECTIVES
To report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside, Artivion - Kennesaw, GA - USA).
METHODS
Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months.
RESULTS
Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 (48.4%) patients, a contained rupture in 8 (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I-III in 32 patients (50% and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two-hundred-forty-nine (97.2%) target vessels were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9±28.4 min per target vessel. Thirty-days cumulative MAE rate was 28% and mortality occurred in 5 patients (9.1%). There were 1 postoperative stroke (1.6%) and SCI rate was 8% (n=5). For the 249 target vessels successfully incorporated through an inner branch, one-year freedom from target vessel instability was 93±3% after 1 year.
CONCLUSION
The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings, and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.
PubMed: 38908806
DOI: 10.1016/j.jvs.2024.05.056 -
Journal of Cardiothoracic Surgery Jun 2024Aneurysms of the pulmonary arteries and the ascending aorta are rare, and both bear a high mortality risk if left untreated. In general, these entities are primarily...
BACKGROUND
Aneurysms of the pulmonary arteries and the ascending aorta are rare, and both bear a high mortality risk if left untreated. In general, these entities are primarily caused by etiologies such as hypertension, pulmonary arterial hypertension, infection or congenital disorders. Treatment requires a rapid diagnostic work-up or even immediate surgical intervention in acute cases. Nevertheless, surgery entails serious perioperative risks, in particular in patients with multiple comorbidities.
CASE PRESENTATION
We discuss a 70-year-old woman presented with decompensated heart failure based on severe pulmonary artery hypertension, coincided by a massive pulmonary artery aneurysm with secondary embolism. Additional diagnostic imaging also showed a chronic post-dissection, saccular aneurysm of the ascending aorta. To our knowledge, this simultaneous diagnosis of a saccular aneurysm of the ascending aorta and a large aneurysm of the pulmonary artery with secondary embolism has not yet been described. Nonetheless, conservative treatment was chosen due to extensive pulmonal and cardiovascular comorbidities and the high-risk profile of surgery.
CONCLUSIONS
Extensive aneurysmatic disease of the pulmonary arteries and ascending aorta come with a serious burden of disease, especially if coincided by severe pulmonal and cardiovascular comorbidities. Both conditions can be curatively treated by surgical intervention. However, in every case the risk of surgery and the patient's vitality, comorbidities and wishes should be taken into account to formulate an adequate treatment plan. Therefore, shared decision making is of utter importance.
Topics: Humans; Female; Pulmonary Artery; Aged; Aortic Dissection; Aorta; Aortic Aneurysm; Aneurysm
PubMed: 38907334
DOI: 10.1186/s13019-024-02865-x -
Journal of Cardiothoracic Surgery Jun 2024Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare complication of infective endocarditis or aortic valve surgery. Surgical treatment is... (Review)
Review
BACKGROUND
Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare complication of infective endocarditis or aortic valve surgery. Surgical treatment is suggested, but the long-term follow-up of conservative management remains unclear.
CASE PRESENTATION
A 33-year follow-up of a patient who developed PMAIF six years after aortic valve replacement is reported. The patient presented to our center with dyspnea, and the echocardiography revealed an ejection fraction of 20% and a PMAIF measuring 7 × 10 mm. Despite being advised to undergo surgery, the patient declined due to fear of surgical outcomes. Consequently, conservative treatment with close observation but without surgery was initiated. During the 33-year follow-up period, the patient did not experience any adverse health effects.
CONCLUSION
Surgical intervention should be considered whenever the PMAIF is diagnosed. However, in any case that the surgery was not applicable, conservative management might lead to long-term survival, based on this and similar case reports in the literature.
Topics: Humans; Aneurysm, False; Mitral Valve; Aortic Valve; Male; Follow-Up Studies; Heart Aneurysm; Echocardiography; Heart Valve Prosthesis Implantation; Middle Aged
PubMed: 38907323
DOI: 10.1186/s13019-024-02885-7