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Annals of Cardiac Anaesthesia 2015Intraoperative aortic dissection is a rare but fatal complication of open heart surgery. By recognizing the population at risk and by using a gentle operative technique... (Review)
Review
Intraoperative aortic dissection is a rare but fatal complication of open heart surgery. By recognizing the population at risk and by using a gentle operative technique in such patients, the surgeon can usually avoid iatrogenic injury to the aorta. Intraoperative transesophageal echocardiography and epiaortic scanning are invaluable for prompt diagnosis and determination of the extent of the injury. Prevention lies in the strict control of blood pressure during cannulation/decannulation, construction of proximal anastomosis, or in avoiding manipulation of the aorta in high-risk patients. Immediate repair using interposition graft or Dacron patch graft is warranted to reduce the high mortality associated with this complication.
Topics: Aorta; Aortic Rupture; Cardiac Surgical Procedures; Echocardiography, Transesophageal; Humans; Intraoperative Complications; Risk Factors
PubMed: 26440240
DOI: 10.4103/0971-9784.166463 -
Diabetes & Vascular Disease Research Sep 2016To summarize the association of diabetes with abdominal aortic aneurysm rupture, we reviewed currently available studies with a systematic literature search and... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To summarize the association of diabetes with abdominal aortic aneurysm rupture, we reviewed currently available studies with a systematic literature search and meta-analytic evaluation.
METHODS
To identify all studies reporting the association of diabetes with abdominal aortic aneurysm rupture, MEDLINE and EMBASE were searched through July 2015. For each study, data regarding diabetes prevalence in both the ruptured and non-ruptured groups were used to generate an unadjusted odds ratio for abdominal aortic aneurysm rupture and 95% confidence intervals. Alternatively, an unadjusted or adjusted odds ratio, or hazard ratio for abdominal aortic aneurysm rupture with 95% confidence interval was directly abstracted (as available) from each individual study.
RESULTS
Our search identified 11 eligible studies. A primary meta-analysis of nine studies reporting data on ruptured (not including non-ruptured symptomatic) abdominal aortic aneurysm demonstrated that diabetes was associated with significantly lower prevalence/incidence of abdominal aortic aneurysm rupture (odds ratio/hazard ratio, 0.71; 95% confidence interval, 0.56 to 0.89; p = 0.003). A secondary meta-analysis of all 11 studies (adding two studies in which non-ruptured symptomatic abdominal aortic aneurysm was included in the rupture group) also demonstrated that diabetes was associated with significantly lower prevalence/incidence of abdominal aortic aneurysm rupture (odds ratio/hazard ratio, 0.77; 95% confidence interval, 0.63 to 0.95; p = 0.01).
CONCLUSION
Diabetes is negatively associated with abdominal aortic aneurysm rupture.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Chi-Square Distribution; Diabetes Mellitus; Humans; Incidence; Odds Ratio; Prevalence; Protective Factors; Risk Assessment; Risk Factors
PubMed: 27334484
DOI: 10.1177/1479164116651389 -
Journal of Vascular Surgery Mar 2016Abdominal aortic aneurysm (AAA) has long been recognized as a condition predominantly affecting males, with sex-associated differences described for almost every aspect... (Review)
Review
Abdominal aortic aneurysm (AAA) has long been recognized as a condition predominantly affecting males, with sex-associated differences described for almost every aspect of the disease from pathophysiology and epidemiology to morbidity and mortality. Women are generally spared from AAA formation by the immunomodulating effects of estrogen, but once they develop, the natural history of AAAs in women appears to be more aggressive, with more rapid expansion, a higher tendency to rupture at smaller diameters, and higher mortality following rupture. However, simply repairing AAAs at smaller diameters in women is a debatable solution, as even elective endovascular AAA repair is fraught with higher morbidity and mortality in women compared to men. The goal of this review is to summarize what is currently known about the effect of gender on AAA presentation, treatment, and outcomes. Additionally, we aim to review current controversies over screening recommendations and threshold for repair in women.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Diagnostic Imaging; Disease Progression; Endovascular Procedures; Female; Health Status Disparities; Healthcare Disparities; Humans; Male; Patient Selection; Predictive Value of Tests; Risk Factors; Sex Distribution; Treatment Outcome
PubMed: 26747679
DOI: 10.1016/j.jvs.2015.10.087 -
Australian Family Physician Jun 2013Aortic aneurysms are a common finding in elderly patients. Rupture of an aortic aneurysm is a catastrophic event associated with a very high mortality. (Review)
Review
BACKGROUND
Aortic aneurysms are a common finding in elderly patients. Rupture of an aortic aneurysm is a catastrophic event associated with a very high mortality.
OBJECTIVE
To review the current literature on aortic aneurysmal disease, including the recommended referral threshold, surveillance guidelines and treatment options.
DISCUSSION
Screening of men aged 65 years and over has been shown to reduce aneurysm related mortality, however, no formal screening guidelines exist in Australia. In addition to the risk of aneurysm expansion and rupture, patients are at increased risk of cardiovascular morbidity and mortality. Small aneurysms should be managed with surveillance and cardiovascular risk factor modification. Large aneurysms should be referred promptly to a vascular surgeon for assessment and repair. Symptomatic and ruptured aneurysms require emergency assessment and treatment. Advances in endovascular techniques enable most patients with aortic aneurysms to be treated with minimally invasive stent grafts, which have lower perioperative complication rates than open repair.
Topics: Aortic Dissection; Aortic Aneurysm, Abdominal; Aortic Rupture; Australia; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Combined Modality Therapy; Endovascular Procedures; Humans; Mass Screening; Population Surveillance; Practice Guidelines as Topic; Referral and Consultation; Risk Factors
PubMed: 23781541
DOI: No ID Found -
European Journal of Vascular and... May 2022Brucellosis is the most common zoonosis worldwide. Although cardiovascular complications in human brucellosis comprise only 3% of morbidity, they are the principal cause... (Review)
Review
OBJECTIVE
Brucellosis is the most common zoonosis worldwide. Although cardiovascular complications in human brucellosis comprise only 3% of morbidity, they are the principal cause of death. Endocarditis covers the majority of these cases. Infected aneurysms and ulcerative processes of the aorta are rare but can be life threatening as well. Currently, limited information is available about aortic and iliac involvement in brucellosis.
METHODS
A PubMed, Web of Science, and AccessMedicine search (without restriction on language or year of publication) was performed to identify relevant articles on aortic and iliac involvement in brucellosis. Case reports were eligible for inclusion if they reported on thoracic, abdominal, or iliac aortic pathology caused by Brucella.
RESULTS
Seventy-one cases were identified over the last 70 years, with an overall mortality rate of 22%. Most of the patients were male (86%) and had a history of Brucella exposure (66%). Approximately one quarter (23%) contracted Brucella while travelling in a (hyper)endemic region. Almost half of the infections were located in the abdominal aorta (49%), followed by the ascending (37%) and descending (13%) thoracic aorta. Infected aneurysms (61%) and ulcerative processes (16%) were seen most frequently. Aortic rupture was present in 31% of cases and occurred mainly in the abdominal (49%) and descending thoracic aorta (44%). The majority of all patients (59%) underwent open surgery combined with long term antibiotics. Over the past 15 years, a trend towards endovascular treatment was observed.
CONCLUSION
Although aortic and iliac involvement in brucellosis is rare, it can be a life threatening manifestation. Due to low awareness, this infection may represent an under reported disease. The therapeutic cornerstone in these cases remains open surgery combined with antibiotics. The role of endovascular treatment is yet to be decided, in which the condition of the patient and the risks of long term complications need to be considered.
Topics: Aneurysm, Infected; Anti-Bacterial Agents; Aorta, Abdominal; Aortic Rupture; Brucellosis; Female; Humans; Male
PubMed: 35282998
DOI: 10.1016/j.ejvs.2022.02.004 -
Journal of Vascular Surgery Feb 2023The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm... (Review)
Review
OBJECTIVE
The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR).
METHODS
We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II).
RESULTS
Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta.
CONCLUSIONS
LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.
Topics: Male; Humans; Aged; Aged, 80 and over; Blood Vessel Prosthesis Implantation; Retrospective Studies; Aortic Rupture; Endovascular Procedures; Postoperative Complications; Aortic Aneurysm, Abdominal; Treatment Outcome; Risk Factors
PubMed: 36272507
DOI: 10.1016/j.jvs.2022.08.005 -
Anaesthesia Feb 2023In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at... (Review)
Review
In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.
Topics: Humans; Aortic Rupture; Mesenteric Ischemia; Emergencies; Postoperative Complications; Treatment Outcome; COVID-19; Anesthesia; Aortic Dissection; Endovascular Procedures; Stents; Ischemia
PubMed: 36308289
DOI: 10.1111/anae.15899 -
Journal of Vascular Surgery Nov 2022The maximal aortic diameter has been used as a key indication for whether to repair abdominal aortic aneurysms (AAAs). Aortic tortuosity has been proposed as another...
OBJECTIVE
The maximal aortic diameter has been used as a key indication for whether to repair abdominal aortic aneurysms (AAAs). Aortic tortuosity has been proposed as another factor to consider. In the present study, we compared the degree of aortic tortuosity in ruptured AAAs with that of unruptured AAAs using computed tomography.
METHODS
We performed a retrospective review of a prospectively maintained database of patients who had undergone AAA repair from December 2014 to December 2019. Patients with a ruptured aneurysm (rAAA) were matched with patients with a nonruptured AAA (nrAAA) with the same maximal aneurysm diameter and age. The degree of aortic tortuosity, defined as the maximum lateral deviation from the aortic centerline, was measured on preoperative coronal computed tomography scans.
RESULTS
During a 5-year period, 572 AAA cases were identified. The aortic tortuosity of the 25 rAAA cases was compared with that of a matched control group of 31 nrAAAs, selected by the same mean maximum diameter of 8.4 cm and similar patient age. In the rAAA group, the mean age was 74.8 years (84% men). In the nrAAA group, the mean age was 76.3 years (88% men). The mean aortic tortuosity for the rAAA and nrAAA groups was 9.3 ± 7.9 mm and 18.0 ± 11.2 mm, respectively (P < .01).
CONCLUSIONS
Greater aortic tortuosity was seen in the nrAAA cases compared with the rAAA cases at the same matched aneurysm size. Thus, aortic tortuosity might confer a reduced rupture risk. Further studies with larger cohorts are needed to verify this observation.
Topics: Male; Humans; Aged; Female; Aortic Aneurysm, Abdominal; Risk Factors; Aortic Rupture; Tomography, X-Ray Computed; Aorta; Retrospective Studies
PubMed: 35489553
DOI: 10.1016/j.jvs.2022.03.879 -
Journal of the American College of... Mar 2023
Topics: Humans; Aortic Aneurysm, Abdominal; Aortic Rupture; Air Pollution; Aorta, Abdominal
PubMed: 36948742
DOI: 10.1016/j.jacc.2022.12.029 -
Journal of Vascular Surgery Aug 2010It is difficult to reliably predict abdominal aortic aneurysm (AAA) expansion and rupture in individuals. There is increasing interest in the role of patient-specific... (Review)
Review
INTRODUCTION
It is difficult to reliably predict abdominal aortic aneurysm (AAA) expansion and rupture in individuals. There is increasing interest in the role of patient-specific biomechanical profiling of AAA development and rupture. This review examines evidence to support the use of biomechanical profiling in AAA.
METHODS
The literature was systematically reviewed to examine the evidence to support the role of patient-specific biomechanical profiles in the management of patients with AAA. A search of Medline, Medline in process and other nonindexed citations, and EMBASE was performed for articles published from January 1980 to December 2008. The search strategy retrieved 2410 titles. After exclusions, 83 articles were reviewed in full and form the basis of this review.
RESULTS
There is increasing evidence that patient-specific biomechanical factors may be more reliable in predicting AAA rupture than currently available clinical and biochemical parameters. Wall stress determination using finite element analysis is consistently higher in symptomatic and ruptured AAA. Recent improvements in computational methodology and advances in imaging and processing technology have increased the power of these biomechanical factors in predicting AAA expansion and rupture.
CONCLUSIONS
Major progress has been made in the development of biomechanical profiles for AAA. Large population-based studies for validation of patient-specific biomechanical profiles with rupture risk assessment and tailored decision making are now indicated, particularly with the introduction of AAA screening programs.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Biomechanical Phenomena; Disease Progression; Finite Element Analysis; Hemodynamics; Humans; Mass Screening; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors; Stress, Mechanical
PubMed: 20395107
DOI: 10.1016/j.jvs.2010.01.029