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European Journal of Vascular and... Dec 2016Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a... (Review)
Review
OBJECTIVE
Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a challenge. In situ fenestration (ISF) of standard endografts represents another endovascular means to maintain perfusion to such branches. This study aimed to review current indications, technical descriptions, and results of ISF.
METHOD
A review of the English language literature was performed in Medline databases, Cochrane Database, Web of Science, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Sixty-seven relevant papers were selected. Thirty-three papers were excluded, leaving 34 articles as the basis of the present review.
RESULTS
Most experimental papers evaluated ISF feasibility and assessed the consequences of ISF on graft fabric. Regarding clinical papers, 73 ISF procedures have been attempted in 58 patients, including 26 (45%) emergent and three (5%) bailout cases. Sixty-five (89%) ISF were located at the level of the arch, and eight (11%) in the abdominal aorta. Graft perforation was performed by physical, mechanical, or unspecified means in 33 (45%), 38 (52%), and two vessels (3%), respectively. ISF was technically successful in 68/73 (93%) arteries. At 30 days, two (3.4%) patients died in the setting of an aorto-bronchial fistula and an aorto-oesophageal fistula, respectively. No post-operative death, major complication, or endoleak was described as secondary to the ISF procedure. With follow-up between 0 and 72 months, four (6.9%) late deaths were noted, unrelated to the aorta. One (1.7%) LSA stent was stenosed without symptoms.
CONCLUSIONS
Although there may be publication bias, multiple techniques were described to perform ISF with satisfactory short-term results. Long-term data remain scarce. Aortic endograft ISF is an off-label procedure that should not be used outside emergent bailout techniques or investigational studies. A comparison with alternative techniques of preserving aortic side branches is needed.
Topics: Animals; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Postoperative Complications; Prosthesis Design; Risk Factors; Stents; Time Factors; Treatment Outcome
PubMed: 27843111
DOI: 10.1016/j.ejvs.2016.10.001 -
Journal of Vascular Surgery Dec 2019Isolated abdominal aortic dissection (IAAD) has remained poorly understood because of its rarity. We explored the prevalence, clinical characteristics, risk factors,... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Isolated abdominal aortic dissection (IAAD) has remained poorly understood because of its rarity. We explored the prevalence, clinical characteristics, risk factors, imaging characteristics, and treatment strategy of IAAD to facilitate its diagnosis and treatment.
METHODS
We performed a meta-analysis of 17 studies, with single-arm-based and network meta-analysis as the main data synthesis method. The Medline, Embase, and Cochrane library were searched from their inception to July 2018. A total of 9163 patients with aortic disease were enrolled, with IAAD identified in 491 patients.
RESULTS
The pooled prevalence of IAAD among cases of aortic dissection overall, type B aortic dissection, and type A aortic dissection was 1.7% (95% confidence interval [CI], 0.9%-3.4%), 4.1% (95% CI, 2.5%-6.6%), and 2.0% (95% CI, 0.7%-3.9%), respectively. Abdominal pain was the most common symptom (50.8%), followed by back pain (30.5%), and chest pain (21.7%). Up to 41.0% of the patients with IAAD did not present with any clinical symptoms, and up to 71.0% of these patients had negative findings on physical examination. The top three most prevalent risk factors for IAAD were hypertension, hyperlipidemia, and smoking. Most cases of IAAD were limited to the aorta inferior to the renal arteries (81.7%), and the average aortic diameter was 4 cm. No statistically significant difference was observed between open surgery, endovascular aortic repair, and conservative management for both early and late mortality.
CONCLUSIONS
The results from the present meta-analysis regarding IAAD support the following conclusions and recommendations. First, IAAD is rare and predominantly affects males. Second, symptoms (pain) might or might not be present, and physical findings will rarely be found on abdominal examination. Third, hypertension is the most prevalent risk factor. Fourth, most cases IAAD will be infrarenal. Finally, a complication-specific approach, similar to that for type B aortic dissection, would be appropriate.
Topics: Aortic Dissection; Aortic Aneurysm, Abdominal; Humans; Prevalence; Risk Factors
PubMed: 31204217
DOI: 10.1016/j.jvs.2019.04.467 -
Journal of Vascular Surgery Feb 2014The purpose of this study was to summarize the current evidence of the association between markers of hemostasis and both the presence and size of abdominal aortic... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The purpose of this study was to summarize the current evidence of the association between markers of hemostasis and both the presence and size of abdominal aortic aneurysms (AAAs).
METHODS
A systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines by use of the search terms "aneurysm AND abdominal AND aortic AND coagulation" NOT "thoracic." Outcome data including concentration of hemostatic marker, number of patients, and significance level were recorded.
RESULTS
A total of 22 nonrandomized studies were included in the analysis, with a total of 9862 patients. Fibrinogen mean difference (MD) (0.43 g/L; 95% confidence interval [CI], 0.28-0.58 g/L; P ≤ .00001), D-dimer MD (325.82 ng/mL; 95% CI, 199.74-451.89 ng/mL; P ≤ .00001), and thrombin-antithrombin III complex MD (5.58 g/L; 95% CI, 3.34-7.83 g/L; P ≤ .0001) were significantly elevated in the presence of AAAs. Tissue plasminogen activator, prothrombin fragments F1+F2, and platelet count were not shown to be significantly different between patients with and those without AAAs. Meta-regression of studies reporting plasma D-dimer concentration and aneurysm diameter suggests a strong and significant association (r(2) = 0.94; P ≤ .0001).
CONCLUSIONS
This study suggests that the presence of AAAs is associated with increased fibrin turnover, fibrinolysis, and thrombin generation, as shown by increased levels of fibrinogen, D-dimer, and thrombin-antithrombin III complex. This is clinically relevant because markers of hemostasis are independent risk factors for cardiovascular events, highlighting the necessity of addressing all modifiable cardiovascular risk factors in patients with AAAs. Furthermore, the finding that plasma D-dimer concentration appears to have a linear relationship with aneurysm diameter may be useful as a future biomarker of AAAs.
Topics: Antithrombin III; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Biomarkers; Dilatation, Pathologic; Fibrin Fibrinogen Degradation Products; Fibrinogen; Hemostasis; Humans; Peptide Hydrolases; Prognosis; Risk Factors
PubMed: 24461868
DOI: 10.1016/j.jvs.2013.10.088 -
Journal of Vascular Surgery Jan 2018The objective of this systematic review and meta-analysis was to evaluate the optimal modality and frequency of surveillance after endovascular aortic repair (EVAR) in... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The objective of this systematic review and meta-analysis was to evaluate the optimal modality and frequency of surveillance after endovascular aortic repair (EVAR) in adult patients with abdominal aortic aneurysms.
METHODS
We searched for studies of post-EVAR surveillance in MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Scopus through May 10, 2016. The outcomes of interest were endoleaks, mortality, limb ischemia, renal complications, late rupture, and aneurysm-related mortality. Outcomes were pooled using a random-effects model and were reported as incidence rate and 95% confidence interval.
RESULTS
Of 1099 candidate references, we included 6 meta-analyses and 52 observational studies. Complication rates were common after EVAR, particularly in the first year. Magnetic resonance imaging had a higher detection rate of endoleaks than computed tomography angiography. Doppler ultrasound had lower diagnostic accuracy, whereas contrast-enhanced ultrasound was likely to be as sensitive as computed tomography angiography. The highest endoleak detection rates were in surveillance approaches that used combined tests. There were no studies that compared different surveillance intervals to determine optimal intervals; however, most studies reported detection rates of patient-important outcomes at 1, 6, 12, 24, 36, 48, and 60 months. Data were insufficient to provide comparative inferences about the best strategy to reduce the risk of patient-important outcomes, such as mortality, limb ischemia, rupture, and renal complications.
CONCLUSIONS
Several tests with reasonable diagnostic accuracy are available for surveillance after EVAR. The available evidence suggests a high complication rate, particularly in the first year, and provides a rationale for surveillance.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Computed Tomography Angiography; Contrast Media; Endovascular Procedures; Extremities; Humans; Incidence; Ischemia; Kidney Diseases; Magnetic Resonance Angiography; Postoperative Complications; Risk Factors; Sensitivity and Specificity; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex
PubMed: 28662928
DOI: 10.1016/j.jvs.2017.04.058 -
Journal of Vascular Surgery Aug 2022Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic wall can rapidly lead to aneurysm induction through bacterial seeding into atheromatous lesions with consecutive life-threatening rupture. We summarize all published data on this rare and lethal disease to evaluate therapeutic approaches and give valid treatment recommendations because there are no guidelines.
METHODS
A systematic review of the literature was conducted screening EMBASE and MEDLINE databases following the PRISMA guidelines with search period from first description to August 25, 2021.
RESULTS
There were 72 cases of C septicum aortitis reported in 64 publications. Endovascular aortic repair (EVAR) was performed in a minority of patients (n = 6) unfit for surgery but lacked long-term survivors. Antibiotic treatment was beneficial in a bridge to surgery concept, but up to now harbored a 6-month mortality rate of 100% (median overall survival, 0.5 months) when no additional aortic repair was performed. Open aortic repair was the only potential curative approach but was accompanied with a 90-day-mortality of 26.7% (4/15).
CONCLUSIONS
Open aortic repair combined with perioperative antibiotic treatment should be offered to all patients as the only potentially curative approach. If applicable, resection of a coexisting colonic tumor should be performed after successful aortic repair. Alternatively, long-term antibiotic treatment can be offered to patients unfit for surgery in a palliative setting. Endovascular aortic repair has been performed on a minority of patients with a high risk for stent graft infection and should remain a salvage strategy when therapeutic pressure demands acute intervention in patients unfit for surgery.
Topics: Anti-Bacterial Agents; Aorta; Aortic Aneurysm, Abdominal; Aortitis; Blood Vessel Prosthesis Implantation; Clostridium septicum; Endovascular Procedures; Humans; Stents; Treatment Outcome
PubMed: 35358668
DOI: 10.1016/j.jvs.2022.02.029 -
European Journal of Vascular and... Jun 2017The aim of this study was to report on the natural history of a population based cohort of 70 year old women with screening detected dilated aortas, and to... (Review)
Review
OBJECTIVE
The aim of this study was to report on the natural history of a population based cohort of 70 year old women with screening detected dilated aortas, and to systematically review publications reporting the rate of intact infrarenal aneurysm repair in women.
MATERIAL AND METHODS
In a previous study, 5140 (74%) of 6925 invited women attended an ultrasound (US) examination of the abdominal aorta at age 70 years. All 52 women with screening detected sub-aneurysms (SA, diameter 25-29 mm) and abdominal aortic aneurysms (AAA, diameter ≥30 mm), were followed for 5 years with US. Infrarenal aortic diameters, AAA repair, all-cause and AAA specific mortality, and risk factors were recorded. In addition, a systematic review was conducted of the rate of intact infrarenal aneurysm repair in women.
RESULTS
A total of 33 (0.6%) women had a SA at the age of 70; two (6%) declined follow-up, five (15%) had died, and 26 were re-examined after 5 years follow-up at age 75. Twelve of 26 (46%) had progressed to AAAs, where one was directly qualified for surgery. Smoking (p = .010) and aortic diameter (p = .040) were associated with progression to AAA. A total of 19 (0.4%) women had an AAA at age 70; two (11%) had died, six (32%) had been electively repaired with no 30 day mortality, and 11 (58%) had an AAA still under surveillance after 5 years follow-up at age 75 years. In the systematic search four studies with heterogeneous cohorts were identified and data on natural history were extracted and reviewed.
CONCLUSION
Screening detected AAAs and sub-aneurysms are clinically relevant in women. Within 5 years of detection a high proportion of AAAs require elective surgery, and a high proportion of sub-aneurysms progress to AAAs. Consequently, surveillance of sub-aneurysms in women with reasonable life expectancy can be considered. Publications on repair rate in women with intact AAAs are scarce and heterogeneous.
Topics: Age Factors; Aged; Aortic Aneurysm, Abdominal; Disease Progression; Elective Surgical Procedures; Female; Humans; Mass Screening; Predictive Value of Tests; Risk Factors; Sex Factors; Smoking; Time Factors
PubMed: 28389251
DOI: 10.1016/j.ejvs.2017.02.024 -
Journal of the American Heart... Jan 2021Background The prognostic importance of abdominal aortic calcification (AAC) viewed on noninvasive imaging modalities remains uncertain. Methods and Results We searched... (Meta-Analysis)
Meta-Analysis
Background The prognostic importance of abdominal aortic calcification (AAC) viewed on noninvasive imaging modalities remains uncertain. Methods and Results We searched electronic databases (MEDLINE and Embase) until March 2018. Multiple reviewers identified prospective studies reporting AAC and incident cardiovascular events or all-cause mortality. Two independent reviewers assessed eligibility and risk of bias and extracted data. Summary risk ratios (RRs) were estimated using random-effects models comparing the higher AAC groups combined (any or more advanced AAC) to the lowest reported AAC group. We identified 52 studies (46 cohorts, 36 092 participants); only studies of patients with chronic kidney disease (57%) and the general older-elderly (median, 68 years; range, 60-80 years) populations (26%) had sufficient data to meta-analyze. People with any or more advanced AAC had higher risk of cardiovascular events (RR, 1.83; 95% CI, 1.40-2.39), fatal cardiovascular events (RR, 1.85; 95% CI, 1.44-2.39), and all-cause mortality (RR, 1.98; 95% CI, 1.55-2.53). Patients with chronic kidney disease with any or more advanced AAC had a higher risk of cardiovascular events (RR, 3.47; 95% CI, 2.21-5.45), fatal cardiovascular events (RR, 3.68; 95% CI, 2.32-5.84), and all-cause mortality (RR, 2.40; 95% CI, 1.95-2.97). Conclusions Higher-risk populations, such as the elderly and those with chronic kidney disease with AAC have substantially greater risk of future cardiovascular events and poorer prognosis. Providing information on AAC may help clinicians understand and manage patients' cardiovascular risk better.
Topics: Aorta, Abdominal; Aortic Diseases; Cardiovascular Diseases; Humans; Mortality; Prognosis; Risk Assessment; Vascular Calcification
PubMed: 33439672
DOI: 10.1161/JAHA.120.017205 -
Journal of Vascular Surgery Jan 2018Endovascular repair of the ascending aorta is currently limited to patients at high surgical risk with aortic diseases originating above the sinotubular junction. A... (Review)
Review
OBJECTIVE
Endovascular repair of the ascending aorta is currently limited to patients at high surgical risk with aortic diseases originating above the sinotubular junction. A number of different endovascular technologies and approaches have been used, although no consensus exists regarding a standardized technique. To better understand real-world endovascular approaches to the ascending aorta, we performed a comprehensive review of the types of endovascular aortic stents and associated vascular access used in repair of the ascending aorta.
METHODS
A search of the MEDLINE database was conducted from January 1, 1995, through January 31, 2017, with the search term "ascending aortic stent." Studies involving endovascular stenting in which the primary therapy was confined exclusively to the ascending aorta were included. Studies involving hybrid arch procedures and surgical replacement of the ascending aorta associated with aortic stenting were excluded. The type of aortic stent, underlying aortic disease, and surgical approach were recorded along with outcomes, need for reinterventions, and follow-up.
RESULTS
A total of 46 publications that focused on primary endovascular repair of the ascending aorta were identified. Thirteen different aortic stent grafts of various designs were used in 118 total patients. The most commonly used device types were thoracic stents (n = 84 [71.2%]) along with abdominal cuffs (n = 13 [11%]) and custom-made grafts (n = 12 [10.2%]). The most commonly treated aortic disease was type A aortic dissection (n = 59 [50%]), followed by aortic pseudoaneurysm (n = 35 [29.7%]), aortic aneurysm (n = 6 [5.1%]), penetrating atherosclerotic ulcer (n = 5 [4.2%]), and acute aortic rupture (n = 3 [2.5%]). Femoral arterial access was used in 62.7% of patients (n = 74); transapical (n = 17 [14.4%]), carotid (n = 15 [12.7%]), and axillary (n = 8 [6.8%]) approaches were also used. The overall type I endoleak rate was 18.6% (n = 22), with 11 patients (9.3%) requiring reintervention. Other complications included all-cause mortality (n = 18 [15.2%]), conversions to open surgery (n = 4 [3.4%]), and cerebrovascular complications (n = 4 [3.4%]). Aorta-related mortality was 5% (n = 6), and average follow-up was 17.2 months.
CONCLUSIONS
Despite the absence of a dedicated aortic stent graft for the ascending aorta, patients with a range of ascending aortic diseases are being successfully treated by endovascular technologies. For optimal outcomes, patient selection is critical to align aortic anatomy with the limited device sizing options, and it should be reserved for patients at high surgical risk.
Topics: Aorta; Aortic Diseases; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Patient Selection; Postoperative Complications; Reoperation; Stents; Treatment Outcome
PubMed: 28844469
DOI: 10.1016/j.jvs.2017.06.099 -
European Journal of Vascular and... Oct 2016Experimental animal models have been used to investigate the formation, development, and progression of abdominal aortic aneurysms (AAAs) for decades. New models are... (Review)
Review
OBJECTIVE
Experimental animal models have been used to investigate the formation, development, and progression of abdominal aortic aneurysms (AAAs) for decades. New models are constantly being developed to imitate the mechanisms of human AAAs and to identify treatments that are less risky than those used today. However, to the authors' knowledge, there is no model identical to the human AAA. The objective of this systematic review was to assess the different types of animal models used to investigate the development, progression, and treatment of AAA and to highlight their advantages and limitations.
METHODS
A search protocol was used to perform a systematic literature search of PubMed and Embase. A total of 2,830 records were identified. After selection of the relevant articles, 564 papers on animal AAA models were included.
RESULTS
The most common models in rodents, including elastase, calcium chloride, angiotensin II, xenograft, and transgenic models, and the most common models in non-rodents, including chemically induced, graft models, and patch models, all have limitations with regard to the pathological interpretation of human AAA.
CONCLUSION
Although findings from animal models of AAAs cannot be directly translated to human AAAs, the identification and awareness of animal models of AAA will provide knowledge for further investigation and insight into human AAA disease.
Topics: Animals; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Disease Models, Animal; Feasibility Studies; Humans; Species Specificity
PubMed: 27543385
DOI: 10.1016/j.ejvs.2016.07.004 -
European Journal of Vascular and... Aug 2012A recent GWAS demonstrated an association between low density lipoprotein receptor related protein 1 (LRP1) and abdominal aortic aneurysm (AAA). This review aims to... (Review)
Review
OBJECTIVES
A recent GWAS demonstrated an association between low density lipoprotein receptor related protein 1 (LRP1) and abdominal aortic aneurysm (AAA). This review aims to identify how LRP1 may be involved in the pathogenesis of abdominal aortic aneurysm.
DESIGN AND MATERIALS
A systematic review of the English language literature was undertaken in order to determine whether LRP1 and associated pathways were plausible candidates for contributing to the development and/or progression of AAA.
METHODS AND RESULTS
A comprehensive literature search of MEDLINE (since 1948), Embase (since 1980) and Health and Psychological Instruments (since 1985) was conducted in January 2012 identified 50 relevant articles. These studies demonstrate that LRP1 has a diverse range of biological functions and is a plausible candidate for playing a central role in aneurysmogenesis. Importantly, LRP1 downregulates MMP (matrix metalloproteinase) activity in vascular smooth muscle cells and regulates other key pathways involved in extracellular matrix remodelling and vascular smooth muscle migration and proliferation. Crucially animal studies have shown that LRP1 depletion leads to progressive destruction of the vascular architecture and aneurysm formation.
CONCLUSIONS
Published evidence suggests that LRP1 may play a key role in the development of AAA.
Topics: Animals; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Disease Progression; Genetic Predisposition to Disease; Humans; Low Density Lipoprotein Receptor-Related Protein-1; Phenotype; Polymorphism, Single Nucleotide; Protein Conformation
PubMed: 22658609
DOI: 10.1016/j.ejvs.2012.05.009