Inflammatory Abdominal Aortic Aneurysms

Endovascular repair of an inflammatory abdominal aortic aneurysm causing bilateral ureteric obstruction

BACKGROUND

Conventional open repair of inflammatory abdominal aortic aneurysms (IAAA) remains challenging through the presence of extensive peri-aortic inflammation and fibrosis which makes dissection and vascular control difficult with a risk of inadvertent injury to adjacent visceral structures such as the ureters, duodenum, inferior vena cava, left renal vein and sigmoid colon.

METHODS

We describe a case of a 69-year-old gentleman who presented with acute renal failure due to bilateral ureteric obstruction in association with an IAAA and discuss the various management options available.

CONCLUSION

IAAAs and the associated peri-aortic inflammation and fibrosis can be successfully treated using endovascular abdominal aortic aneurysm repair with concurrent ureteric stenting.

Giant pararenal abdominal aortic aneurysm

Inflammatory aortic aneurysms are unusual vascular lesions and most commonly involve the infrarenal segment of the abdominal aorta. These complex aneurysms represent a challenge to the vascular surgeon and become even more difficult as the extent of the aneurysm and size of the inflammatory mass increase. Although well described, few cases of giant inflammatory aneurysms are reported. In this case, we review the clinical presentation and surgical management of a patient with a giant pararenal abdominal aortic aneurysm and highlight an uncommon morphologic pattern of aortic disease and provide a review of relevant literature.

Retroaortic left renal vein and inflammatory abdominal aortic aneurysm

The aim of this study was to report successful surgical management of an inflammatory abdominal aortic aneurysm associated with a retroaortic left renal vein. The patient, a 78-year-old man, presented with diffuse abdominal pain, fever, and constipation. Contrast-enhanced computed tomography showed soft tissue surrounding the aneurysm and a left renal vein behind the aorta. Intraoperative findings confirmed the CT images. The patient is alive and well 6 months postoperatively.

[Ultrasound imaging of the abdominal aorta]

Abnormalities of the abdominal aorta and the visceral vessels can represent a diagnostic challenge in patients with both acute and chronic clinical symptoms. In addition to the primary conventional examination using color-coded duplex ultrasound, contrast-enhanced ultrasound (CEUS) with low mechanical index (low MI) may contribute to achieving a precise diagnosis. CEUS is a new and promising method in the diagnosis and follow-up of aortic and visceral artery lesions. Color-coded duplex ultrasound and CEUS with SonoVue(R) allow a rapid and non-invasive diagnosis especially in critically ill patients as these methods can readily be applied at the bedside. In this article the contribution of color-coded duplex ultrasound and CEUS as compared to multi-slice computed tomography angiography (MS-CTA) in various pathologies of the abdominal aorta and the visceral arteries will be addressed.

Tender Inflammatory Infrarenal Aortic Aneurysm Simulating Acute Rupture

Even with multislice computed tomography, it may be difficult to differentiate contained ruptured or leaking atherosclerotic aneurysm from a tender inflammatory aneurysm. The decision for early intervention is based on clinical judgment. We describe successful open graft repair of a tender inflammatory infrarenal abdominal aortic aneurysm simulating acute rupture in a 63-year-old man.

Endovascular repair of sealed rupture of a thoracic inflammatory aneurysm that developed after corticosteroid therapy

A 53-year-old man was admitted to our hospital with thoracic back pain and weight loss. Computed tomography revealed inflammatory aortic aneurysm (IAA) of the descending aorta. Sealed rupture of the aneurysm occurred while the patient was under corticosteroid therapy. Endovascular aneurysm repair (EAR) was performed without postoperative complications. Periaortic fibrosis was remarkably decreased three months later while the patient was under prednisolone (20 mg) administration. We believe that EAR could become a practical alternative to open surgical repair. The possibility of an aneurysm rupturing during corticosteroid therapy for IAA should be considered.

Inflammatory Abdominal Aortic Aneurysms (IAAA): Past and Present

Aim: The aim of the study is to determine whether presentation and outcomes of inflammatory abdominal aortic aneurysms (IAAA) have changed over the last five decades. Methods: Comparison of current outcomes (January 2001 to December 2007) with results of the earliest report from our unit in 1972. Results: In contemporary series, 421 patients underwent AAA repair; 38 (9%) were IAAA. In 58% patients, IAAA was an incidental finding, whereas 42% patients were symptomatic with abdominal or back pain. Of those, 32% were ruptured IAAA. Male-to-female ratio was 12:1. Thirty-day mortality was 13%; elective 11.5%; emergency 17%. Comparison with 1972 study showed no change in the incidence and gender predilection. Presentation as an incidental finding and rupture increased 4- and 2-folds, respectively. Conclusion: The incidence and gender predilection of IAAA have remained unchanged. The 4-fold increase in the presentation as an incidental finding reflects current trends in patient evaluation.

Persistent chronic peri-aortitis (‘inflammatory aneurysm’) after abdominal aortic aneurysm repair: systematic review of the literature

Abstract

Data on the outcome of aneurysmal chronic peri-aortitis (‘inflammatory aneurysm’) after open surgical aneurysm repair are few and contradictory. To what extent this inflammatory process is reversed after endovascular aneurysm repair (EVAR) is even more unclear. The objective of this review was to study the outcome of peri-aortic fibrosis (PAF) and ureteral obstruction in patients with aneurysmal chronic peri-aortitis treated with open surgery or EVAR. Medical literature was searched for pertinent articles on the outcome of PAF and ureteral obstruction after open surgery or EVAR from 1970 through October 2007. Studies were included if specific follow-up data were available on outcomes of interest. A total of 19 studies were included comprising 478 patients (open surgical, n = 426; EVAR, n = 52). Age, sex and percentage of patients with ureteral obstruction (31% vs 37%) did not differ between groups. Regression of PAF occurred more frequently after open surgery compared to EVAR (86% vs 60%; p < 0.0001). Complete regression of PAF was more frequent after open surgery compared to EVAR (52% vs 14%; p < 0.0001). After excluding patients in whom concurrent ureterolysis was performed, the frequency of persistent ureteral obstruction remained lower in patients treated surgically compared to patients treated with EVAR, albeit not statistically significant (32% vs 56%; p = 0.09). In conclusion, although open surgery is superior to EVAR in achieving regression of chronic peri-aortitis, the frequency of persistent PAF and/or ureteral obstruction is not negligible. Additional medical and/or urological treatment should be considered in selected cases of aneurysmal chronic peri-aortitis.

Distal graft anastomosis using a tapered elephant trunk in an inflammatory aneurysm

Graft replacement of an inflammatory abdominal aortic aneurysm is rather troublesome due to the marked adhesion to surrounding organs and thickened wall, which is mostly too hard and inflexible to allow the artery to be fitted to a prosthetic graft. For one such case, we developed a novel and unique technique for a distal anastomosis using a tapered elephant trunk. This technique was designed on the assumption of further aneurysmal changes and enabled us to create a secure anastomosis at the enlarged inflammatory part of the common iliac artery. The distal flow to both the external and internal iliac arteries was well maintained without any complications.

Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 38-year-old man with a history of chronic episodic low back pain (LBP) was referred to physical therapy by his physician.

DIAGNOSIS

Concerns ascertained from the patient's history included an insidious onset of unrelenting, deep, boring pain that was constant, irrespective of movements or posture changes, or time of day. In addition, the patient reported night pain and the inability to find relief in recumbent positions. The primary warning signs associated with the physical examination were unremarkable examination of the lumbar spine, pelvis, and hip regions (symptoms not altered and minimal impairments detected), and a strong nontender, palpable pulse noted over the left lateral lumbar region, with the patient prone, and over the midline and left upper/lower abdominal quadrants, with the patient supine. Suspicion of the presence of an abdominal aortic aneurysm led the therapist to immediately refer the patient to an allopathic physician. The subsequent abdominal ultrasound and computed tomography scanning revealed a 10-cm-diameter abdominal aortic aneurysm. The patient was immediately hospitalized and underwent surgical repair within two days.

DISCUSSION

LBP is the most frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom LBP may be related to underlying pathological conditions. A prompt referral of patients presenting with suspicious findings to the appropriate physician may lead to a more timely diagnosis, with the goal of minimizing or preventing morbidity and mortality.

Inflammatory aneurysm of the common iliac artery mimicking appendicitis

Isolated inflammatory aneurysm of the common iliac artery is a rare condition. Previously reported cases presented with urologic complications owing to entrapment of the ureter in the perianeurysmal fibrosis. We report a case of a healthy young man who presented with acute abdominal pain in the right lower quadrant without urologic complications mimicking acute appendicitis. The pain was caused by an isolated inflammatory aneurysm of the right common iliac artery measuring 4 cm in diameter. Three years after open aneurysmal resection and graft interposition, the patient is doing well, with excellent peripheral circulation. The available literature on presentation, diagnosis, and treatment is reviewed.

Spontaneous perforation of a nonaneurysmal infrarenal aorta

Spontaneous perforation of a nonaneurysmal abdominal aorta due to a penetrating atherosclerotic ulcer (PAU) is exceedingly rare. We describe the case of a 57-year-old man with a perforating PAU of the infrarenal aortic wall and discuss the clinical presentation, diagnostic pathways, and therapeutic options based on a comprehensive review of the literature. Since a PAU of the aorta can give rise to chronic mild to moderate abdominal or back pain, a computed tomographic scan of the abdomen should be performed in patients with evidence of vascular disease and persistent abdominal or back discomfort. Surgical resection or stent-graft placement is indicated in symptomatic patients or in asymptomatic patients with radiographic signs of progressive PAU.

Increasing evidence for immune-mediated processes and new therapeutic approaches in abdominal aortic aneurysms--a review

Animal models for abdominal aortic aneurysms (AAAs), immunogenetical and pathophysiological studies support the importance of immune-mediated processes in the pathogenesis of AAA disease. Neutrophils, natural killer (NK) cells, monocytes/macrophages, and proinflammatory cytokines are involved in the complex and dynamic tissue remodeling of the AAA vessel wall. Our group showed an increased prevalence of circulating interferon-gamma (IFN-gamma) producing CD28(-) T cells especially in smaller AAAs, thus supporting the concept of a T cell-mediated pathophysiology of AAAs, especially during the early development of AAAs. Further research should now assess the possible benefit of anti-inflammatory therapeutic approaches in AAA patients, especially with small AAAs.

Abdominal aortic aneurysms: an underestimated type of immune-mediated large vessel arteritis?

PURPOSE OF REVIEW

To review recent studies on the immune-mediated pathogenesis of abdominal aortic aneurysms, opening a wide field for possible new therapeutic approaches.

RECENT FINDINGS

Immune-mediated processes including involvement of neutrophils, interferon-gamma producing T cells and proinflammatory cytokines play an important role especially in the initiation of abdominal aortic aneurysm disease. C-reactive protein was associated with aneurysm size and is possibly produced by the aneurysmal tissue itself. From the clinical perspective, both inflammatory and noninflammatory abdominal aortic aneurysms are associated with various autoimmune diseases. Preliminary data of F-FDG positron emission tomography imaging of abdominal aortic aneurysms suggest focal uptake of F-FDG within the aneurysm wall in patients with either large, rapidly expanding or symptomatic aneurysms that are prone to rupture. Thus basic research findings and clinical research focusing on the underlying immune-mediated mechanisms of abdominal aortic aneurysms will likely pave the way for new medical therapies in the future. In animal models the effects of rapamycin as an immunosuppressive agent, modulation of estrogen receptors by tamoxifen as well as gene therapy using decoy oligonucleotides binding to the transcription factor ets has already proved helpful in decreasing aneurysm expansion rates.

SUMMARY

Pathophysiological, immunogenetical and interventional studies support the concept of abdominal aortic aneurysm as an immune-mediated process, which will help to identify more laboratory and imaging signs of development in the future. Further research will now assess the possible benefit of antiinflammatory therapeutic approaches, especially in patients with small abdominal aortic aneurysms.

Inflammatory Aneurysm of the Descending Aorta: A Case Report

We report a rare case of an inflammatory descending aneurysm. At surgery, the patient had multiple aneurysms on the descending aorta. Histology of the specimen demonstrated an infiltration of chronic inflammatory cells in the aortic media.

Endovascular Therapy of Inflammatory Aortic Aneurysms:A Meta-Analysis

PURPOSE

To report a meta-analysis of results from endovascular aneurysm repair (EVAR) of inflammatory aortic aneurysms (IAA).

METHODS

A comprehensive literature review was performed to identify all studies reporting the results of EVAR in patients with IAA. To be included in the analysis, an article had to provide a minimum follow-up of 6 months, information about primary technical success, details of immediate and long-term complications, and evaluation of at least one of the basic outcome criteria: changes in aneurysm sac diameter, periaortic fibrosis (PAF), and/ or renal impairment. All studies were reviewed by 2 independent observers for the inclusion criteria. Data were retrieved on the technical and clinical success, outcome criteria, mortality in follow-up, and reinterventions from 14 articles selected from among 701 initially identified.

RESULTS

The 14 articles encompassed 46 patients (45 men [97.8%]; mean age 65 years, range 59-75) with a mean follow-up of 18 months after endovascular repair of IAAs located in the abdominal aorta. The primary technical success rate was 95.6% (44/46) and the 30-day clinical success rate was 93.4% (43/46). The median aneurysm sac diameter regression was 11 mm. Of 43 patients with PAF prior to the intervention, 22 (51.2%) patients showed complete regression, 18 (41.8%) remained unchanged, and 3 (7.0%) showed progression after EVAR. Renal impairment disappeared in 11 (45.8%) of 24 patients. Reinterventions were reported in 8 patients. The procedure-related and follow-up mortality rates were 0% and 13.0%, respectively.

CONCLUSIONS

EVAR of IAA is feasible, excludes the aneurysm effectively, and reduces PAF and renal impairment in most patients with very low periprocedural and midterm mortality and an acceptable reintervention rate.