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Journal of Vascular Surgery Jan 2011Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology,...
PURPOSE
Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival.
METHODS
From 2002 to 2009, 1768 patients underwent elective and emergent EVAR. At a mean follow-up of 29 months, 27 (1.5%) patients presented with delayed AAA rupture and required repair by either open surgical conversion or endovascular means. All data were prospectively collected in a vascular registry, and outcomes analyzed.
RESULTS
Over a mean follow-up of 29 months, the incidence of delayed AAA rupture after elective EVAR was 1.4% (24 of 1615 patients), and after emergent EVAR for ruptured AAA was 2.8% (3 of 106 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered "lost to follow-up," and, at presentation, 17 (63%) patients had Type 1 endoleak with stent graft migration, three (11%) had Type 1 endoleak without stent graft migration, five (19%) had Type 2 endoleak, and two (7%) had undetermined etiology for aneurysm rupture. Fifteen (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n = 8; 53%) or complete (n = 7; 47%) stent graft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and one (4%) patient refused treatment and died. Supraceliac aortic clamp was required in three (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in two (18%) patients with EVAR. There were three (11%) postoperative deaths; two following open surgical conversion and one following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size.
CONCLUSIONS
Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion or secondary EVAR. The approach to each patient should be individualized; complete stent graft explant is not necessary in most patients; a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR.
Topics: Aged; Aortic Aneurysm, Abdominal; Aortic Rupture; Balloon Occlusion; Blood Vessel Prosthesis Implantation; Female; Hemodynamics; Humans; Male; Reoperation; Stents; Time Factors; Treatment Outcome
PubMed: 20875712
DOI: 10.1016/j.jvs.2010.07.052 -
The Journal of Thoracic and... Jun 2021
Topics: Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Follow-Up Studies; Humans
PubMed: 31926691
DOI: 10.1016/j.jtcvs.2019.11.113 -
Journal of the Royal Society, Interface Dec 2015A rupture risk assessment is critical to the clinical treatment of abdominal aortic aneurysm (AAA) patients. The biomechanical AAA rupture risk assessment quantitatively...
A rupture risk assessment is critical to the clinical treatment of abdominal aortic aneurysm (AAA) patients. The biomechanical AAA rupture risk assessment quantitatively integrates many known AAA rupture risk factors but the variability of risk predictions due to model input uncertainties remains a challenging limitation. This study derives a probabilistic rupture risk index (PRRI). Specifically, the uncertainties in AAA wall thickness and wall strength were considered, and wall stress was predicted with a state-of-the-art deterministic biomechanical model. The discriminative power of PRRI was tested in a diameter-matched cohort of ruptured (n = 7) and intact (n = 7) AAAs and compared to alternative risk assessment methods. Computed PRRI at 1.5 mean arterial pressure was significantly (p = 0.041) higher in ruptured AAAs (20.21(s.d. 14.15%)) than in intact AAAs (3.71(s.d. 5.77)%). PRRI showed a high sensitivity and specificity (discriminative power of 0.837) to discriminate between ruptured and intact AAA cases. The underlying statistical representation of stochastic data of wall thickness, wall strength and peak wall stress had only negligible effects on PRRI computations. Uncertainties in AAA wall stress predictions, the wide range of reported wall strength and the stochastic nature of failure motivate a probabilistic rupture risk assessment. Advanced AAA biomechanical modelling paired with a probabilistic rupture index definition as known from engineering risk assessment seems to be superior to a purely deterministic approach.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Biomechanical Phenomena; Female; Humans; Male; Models, Cardiovascular; Risk Assessment
PubMed: 26631334
DOI: 10.1098/rsif.2015.0852 -
BMJ Case Reports Feb 2014Isolated acute abdominal aortic dissection is a rare condition, accounting for 1.3% of all aortic dissections. It may be classified as iatrogenic, traumatic or...
Isolated acute abdominal aortic dissection is a rare condition, accounting for 1.3% of all aortic dissections. It may be classified as iatrogenic, traumatic or spontaneous. To date, only 92 patients have been reported in western literature. All the reports were based on the Caucasian population, and the mean age according to the International Registry of Acute abdominal aortic dissection (IRAD) was 67.7 ± 13.3 years. We report a case of an isolated infrarenal abdominal aortic dissection in a middle age Asian man, and our subsequent management.
Topics: Adult; Aorta, Abdominal; Aortic Rupture; Humans; Male; Tomography, X-Ray Computed
PubMed: 24532236
DOI: 10.1136/bcr-2013-203097 -
Biomedical Engineering Online Jan 2013An aortic aneurysm is a local dilation of the aorta, which tends to expand and often results in a fatal rupture. Although larger aneurysms have a greater risk of...
BACKGROUND
An aortic aneurysm is a local dilation of the aorta, which tends to expand and often results in a fatal rupture. Although larger aneurysms have a greater risk of rupture, some small aneurysms also rupture. Since the mechanism of aortic rupture is not well understood, clarification of the microstructure influencing the failure to rupture is important. Since aortic tissues are stretched biaxially in vivo, we developed a technique to microscopically observe the failure of an aortic rupture during biaxial stretch.
METHODS
A thinly sliced porcine thoracic aortic specimen was adhered to a circular frame and pushed onto a cylinder with a smaller diameter to stretch the specimen biaxially. To induce failure to rupture at the center, the specimen was thinned at the center of the hole as follows: the specimen was frozen while being compressed with metal plates having holes, which were 3 mm in diameter at their centers; the specimen was then sliced at 50-μm intervals and thawed.
RESULTS
The ratio of the thickness at the center to the peripheral area was 99.5% for uncompressed specimens. The ratio decreased with an increase in the compression ratio εc and was 47.3% for specimens with εc = 40%. All specimens could be stretched until failure to rupture. The probability for crack initiation within the cylinder was <30% and 100% for specimens with εc <10% and εc >30%, respectively. Among specimens ruptured within the cylinder, 93% of those obtained from the mid-media showed crack initiation at the thin center area.
CONCLUSIONS
Aortic tissues were successfully stretched biaxially until failure, and their crack initiation points were successfully observed under a microscope. This could be a very useful and powerful method for clarifying the mechanism of aortic rupture. We are planning to use this technique for a detailed investigation of events occurring at the point of failure when the crack initiates in the aortic aneurysm wall.
Topics: Animals; Aorta, Thoracic; Aortic Aneurysm; Aortic Rupture; Dimethylpolysiloxanes; In Vitro Techniques; Models, Cardiovascular; Specimen Handling; Stress, Mechanical; Swine; Tensile Strength
PubMed: 23305508
DOI: 10.1186/1475-925X-12-3 -
PloS One 2014To systematically review studies comparing peri-operative mortality and length of hospital stay in patients with ruptured abdominal aortic aneurysms (rAAAs) who... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVES
To systematically review studies comparing peri-operative mortality and length of hospital stay in patients with ruptured abdominal aortic aneurysms (rAAAs) who underwent endovascular aneurysm repair (EVAR) to patients who underwent open surgical repair (OSR).
METHODS
The Medline, Cochrane, EMBASE, and Google Scholar databases were searched until Apr 30, 2013 using keywords such as abdominal aortic aneurysm, emergent, emergency, rupture, leaking, acute, endovascular, stent, graft, and endoscopic. The primary outcome was peri-operative mortality and the secondary outcome was length of hospital stay.
RESULTS
A total of 18 studies (2 randomized controlled trials, 5 prospective studies, and 11 retrospective studies) with a total of 135,734 rAAA patients were included. rAAA patients who underwent EVAR had significantly lower peri-operative mortality compared to those who underwent OSR (overall OR = 0.62, 95% CI = 0.58 to 0.67, P<0.001). rAAA patients with EVAR also had a significantly shorter mean length of hospital stay compared to those with OSR (difference in mean length of stay ranged from -2.00 to -19.10 days, with the overall estimate being -5.25 days (95% CI = -9.23 to -1.26, P = 0.010). There was no publication bias and sensitivity analysis showed good reliability.
CONCLUSIONS
EVAR confers significant benefits in terms of peri-operative mortality and length of hospital stay. There is a need for more randomized controlled trials to compare outcomes of EVAR and OSR for rAAA.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Female; Humans; Length of Stay; Male; Randomized Controlled Trials as Topic
PubMed: 24498112
DOI: 10.1371/journal.pone.0087465 -
Journal of Vascular Surgery Dec 2022We sought to compare immediate and early mortality among patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair. Evaluation of RAAA has focused on 30-day...
BACKGROUND
We sought to compare immediate and early mortality among patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair. Evaluation of RAAA has focused on 30-day postoperative mortality. Other emergency conditions such as trauma have demonstrated a multimodal mortality distribution within the 30-day window, expanding the pathophysiologic understanding and allowing for intervention investigations with practice changing and lifesaving results. However, the temporal distribution and risk factors of postoperative morbidity and mortality in RAAA have yet to be investigated.
METHODS
We evaluated factors associated with RAAA postoperative mortality in immediate (<1 day) and early (1-30 days) postoperative periods in a landmarked retrospective cohort study using data from the Vascular Quality Initiative (2010-2020).
RESULTS
We identified 5157 RAAA repairs (mean age, 72 ± 10 years; 77% male; 88% White; 61% endovascular). The mortality rate in the immediate period was 10.2% (528/5157) and the early mortality rate was 22.1% (918/4163). In multivariable regression analyses, signs of hemorrhagic shock (ie, hemoglobin <7 g/dL: adjusted odds ratio [aOR], 1.87 [95% confidence interval [CI], 1.14-3.06]; any preoperative systolic blood pressure <70 mm Hg: aOR, 1.40 [95% CI, 1.04-1.89]; and estimated blood loss >40%: aOR, 3.65 [95% CI, 2.29-5.83]) were associated with an increased risk of immediate mortality. Comorbid conditions (heart failure: aOR, 1.38 [95% CI, 1.00-1.92]; pulmonary disease: aOR, 1.29 [95% CI, 1.05-1.58]; elevated creatinine: aOR 1.26 [95% CI, 1.31-1.41]) were associated with increased risk of early mortality.
CONCLUSIONS
Immediate deaths were associated predominantly with shock from massive hemorrhage, whereas early deaths were associated with comorbid conditions predisposing patients to multisystem organ failure despite successful repair. These temporal distinctions should guide future mechanistic and intervention evaluations to improve RAAA mortality.
Topics: Humans; Male; Middle Aged; Aged; Aged, 80 and over; Female; Aortic Aneurysm, Abdominal; Retrospective Studies; Endovascular Procedures; Aortic Rupture; Odds Ratio; Risk Factors; Treatment Outcome; Blood Vessel Prosthesis Implantation
PubMed: 35803483
DOI: 10.1016/j.jvs.2022.06.090 -
JACC. Cardiovascular Interventions Sep 2022
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Stents; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 36057536
DOI: 10.1016/j.jcin.2022.07.016 -
Journal of Vascular Surgery Jun 2016Aortic diameter as the primary criterion in the decision to repair abdominal aortic aneurysms (AAAs) has drawbacks as some rupture below size thresholds, whereas others...
OBJECTIVE
Aortic diameter as the primary criterion in the decision to repair abdominal aortic aneurysms (AAAs) has drawbacks as some rupture below size thresholds, whereas others reach extreme size without rupture. Predictions of static aortic wall stress have also failed to reliably predict rupture potential. The objective of this study was to computationally assess blood flow characteristics at the site of infrarenal AAA rupture. On the basis of the finite element literature correlating rupture location with high static local wall stress, we hypothesized that a computational fluid dynamics approach would also demonstrate rupture at regions of high pressure and wall shear stress (WSS).
METHODS
Three-dimensional AAA geometry was generated from computed tomography angiography images of seven ruptured AAAs. Aortic blood flow velocity, pressure, and WSS were computationally determined. Flow characteristics at the site of rupture were determined and compared across all cases.
RESULTS
AAA size at the time of rupture was 8.3 ± 0.9 cm. Only three of the seven AAAs ruptured at the site of maximal diameter. Blood flow velocity in the aneurysmal aorta showed dominant flow channels with zones of recirculation, where low WSS predominated. Regardless of aneurysm size or configuration, rupture occurred in or near these flow recirculation zones in all cases. WSS was significantly lower and thrombus deposition was more abundant at the site of rupture.
CONCLUSIONS
This computational study was the first to assess blood flow characteristics at the site of infrarenal AAA rupture in realistic aortic geometries. In contradiction to our initial hypothesis, rupture occurred not at sites of high pressure and WSS but rather at regions of predicted flow recirculation, where low WSS and thrombus deposition predominated. These findings raise the possibility that this flow pattern may lead to thrombus deposition, which may elaborate adventitial degeneration and eventual AAA rupture.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Aortography; Arterial Pressure; Blood Flow Velocity; Computed Tomography Angiography; Disease Progression; Female; Finite Element Analysis; Hemodynamics; Humans; Imaging, Three-Dimensional; Male; Models, Cardiovascular; Patient-Specific Modeling; Radiographic Image Interpretation, Computer-Assisted; Regional Blood Flow; Stress, Mechanical
PubMed: 25752691
DOI: 10.1016/j.jvs.2015.01.040 -
Journal of Vascular Surgery Oct 2003Penetrating atheromatous ulceration of the infrarenal aorta is a rare entity. There are few reported cases of this lesion, and most of the published data is in regards... (Review)
Review
Penetrating atheromatous ulceration of the infrarenal aorta is a rare entity. There are few reported cases of this lesion, and most of the published data is in regards to the thoracic aorta. Spontaneous rupture of a nonaneurysmal noninfected atherosclerotic infrarenal aorta is a rare event. We report the eleventh case of this occurrence and present the first reported case of endovascular stent-graft placement in treating this entity. We review the literature regarding ulcerative disease of the aorta and specifically discuss the published data on spontaneous rupture of the nondilated, noninfected infrarenal aorta secondary to penetrating atheromatous ulceration.
Topics: Aged; Aged, 80 and over; Aorta, Abdominal; Aortic Rupture; Arteriosclerosis; Blood Vessel Prosthesis Implantation; Humans; Male; Radiography; Rupture, Spontaneous; Stents; Ulcer
PubMed: 14560239
DOI: 10.1016/s0741-5214(03)00557-3