Inflammatory Abdominal Aortic Aneurysm Endovascular Repair into the Long-Term Follow-Up

Infective native arterial aneurysms and inflammatory abdominal aortic aneurysms: An overview with a focus on emergency settings

Infective native arterial aneurysms and inflammatory aortic aneurysms are rare but morbid pathologies seen by vascular surgeons in the emergency setting. Presentation is not always clear, and a full workup must be obtained before adopting a management strategy. Treatment is multidisciplinary and is tailored to every case based on workup findings. Imaging with computed tomography, magnetic resonance, or with fluorodeoxyglucose-positron emission tomography aids in diagnosis and in monitoring response to treatment. Open surgery is traditionally performed for definitive management. Endovascular surgery may offer an alternative treatment in select cases with acceptable outcomes. Neither technique has been proven to be superior to the other. Physicians should consider patient's anatomy, comorbidities, life expectancy, and goals of care before selecting an approach. Long-term pharmacological treatment, with antibiotics in case of infective aneurysms and immunosuppressants in case of inflammatory aneurysms, is usually required and should be managed in collaboration with infectious disease specialists and rheumatologists.

Heterogeneous Characteristics of Patients with Inflammatory Abdominal Aortic Aneurysm. Systematic Review of Therapeutic Solutions

BACKGROUND

Endovascular repair of inflammatory abdominal aortic aneurysms (IAAAs) has emerged as an alternative to open surgery, but direct comparisons are limited. The aim of the study was to compare clinical outcomes of endovascular and open repair for IAAA according with specific clinical characteristics.

METHODS

We performed a literature review of reports describing patients who had open or endovascular repair for IAAA. A literature search was performed in June 2022 by 2 investigators who conducted a review of papers reported in PubMed, Embase, MEDLINE, and Cochrane Database. The strings "Inflammatory aneurysm" and "Abdominal Aortic Aneurysms" were used. There was no language restriction and screened reports were published from March 1972 to December 2021. We identified 2,062 patients who had open (1,586) or endovascular repair (476) for IAAA. Primary outcomes were operative mortality and morbidity. Secondary outcomes were complications during follow-up (mean follow-up: 48 months). Propensity score matching was performed between patients who had open or endovascular surgery.

RESULTS

In Western countries, propensity-weighted postoperative mortality (in-hospital) (1.5% endovascular vs. 6% open) and morbidity rates (6% vs. 18%) were significantly lower in patients who had endovascular repair (P < 0.0001); patients with larger aneurysm (more than 7 cm diameter), signs of active inflammation, and retroperitoneal rupture of the aneurysm had better outcomes after endovascular repair than after open surgery. Hydronephrosis was present in 20% of the patients. Hydronephrosis regressed in most patients when signs of active inflammation were present suggesting an acute onset of the hydronephrosis itself (fever, elevated serum C Reactive Protein) either after endovascular or open surgery. Long-standing hydronephrosis as suggested by the absence of signs of active inflammation rarely regressed after endovascular surgery despite associated steroid therapy. During a mean follow-up of 48 months, propensity-weighted graft-related complications were more common in patients who had endovascular repair (20% vs. 8%). For patients from Asia, short-term and medium-term results were similar after open and endovascular repair. IAAAs related with aortitis were more common in Asia. In Western countries, IAAAs were commonly associated with atherosclerosis.

CONCLUSIONS

Patients with IAAA represent a heterogeneous population, suggesting biological differences from continent to continent; conservative therapy and endovascular or open surgery should be chosen according to the patient clinical condition. Endovascular repair presents advantages in patients with signs of active inflammation and contained rupture of the IAAA and larger aneurysms. Hydronephrosis, without signs of active inflammation, rarely regresses after endovascular repair associated with steroid therapy. Further studies are needed to establish the long-term results of endovascular repair.

Multidisciplinary diagnosis and management of inflammatory aortic aneurysms

BACKGROUND

Inflammatory abdominal aortic aneurysms (IAAAs) are a variant involving a distinct immunoinflammatory process, with nearly one half believed to be associated with IgG4-related disease (IgG4-RD).

METHODS

MEDLINE and Google Scholar searches were conducted for English-language publications relevant to inflammatory aortic aneurysms from January 1970 onward. The search terms included inflammatory aortic aneurysms, aortitis, periaortitis, IgG4-related disease, and retroperitoneal fibrosis. Relevant studies were selected for review based on their relevance.

RESULTS

Morphologically, IAAAs are characterized by a thickened aneurysm wall often displaying contrast enhancement and elevated metabolic activity on fluorine-18 fluorodeoxyglucose-positron emission tomography imaging. A strong association exists with perianeurysmal and retroperitoneal fibrosis. Although the rupture risk appears lower with IAAAs than with noninflammatory abdominal aortic aneurysms (AAAs), the currently recommended diameter threshold for operative management is the same. Open repair has been associated with increased morbidity compared with noninflammatory AAAs, and a retroperitoneal approach or minimal dissection transperitoneal approach has been recommended to avoid duodenal and retroperitoneal structural injuries. Endovascular aneurysm repair has been increasingly used, especially for patients unfit for open surgery. It is important to exclude an infectious etiology before the initiation of immunosuppressive therapy or operative repair. Multimodality imaging follow-up is critical to monitor disease activity and secondary involvement of retroperitoneal structures by the associated fibrotic process. Maintenance of immunosuppressive therapy will be needed postoperatively for most patients with active systemic disease, especially those with IgG4-RD and those with persistent symptoms. Additional interventions aimed at ureteral decompression could also be required, and lifelong follow-up is mandatory.

CONCLUSIONS

Preoperative multimodality imaging is a diagnostic cornerstone for assessment of the disease extent and activity. IgG4-RD is an increasingly recognized category of IAAAs, with implications for tailoring adjunctive medical therapy. Open surgical repair remains the procedure of choice, although endovascular aneurysm repair is increasingly being offered. Maintenance immunosuppressive therapy can be offered according to the disease activity as assessed by follow-up imaging studies.

Extraabdominal Rupture of an Inflammatory Abdominal Aortic Aneurysm in a Patient With Aortodecubital Fistula: A Case Report

Aortodecubital fistula is a pathologic communication between aorta and a decubitus ulcer. It is very rarely encountered vascular condition in abdominal aortic aneurysms (AAA), with difficult diagnostics and high mortality. Patients often present with systemic and local infection and are at risk for hemorrhage. We present a paraplegic patient with fistulous communication between an inflamed abdominal aortic aneurysm and a sacral decubitus ulcer, leading to intermittent bleeding episodes and finally to exsanguination. While extremely rare, this case emphasizes the need for early, accurate diagnosis and salvage intervention when possible.

Endovascular Repair of Inflammatory Aortic Aneurysms: Experience in a Single Center

BACKGROUND

Inflammatory abdominal aortic aneurysm (IAAA) remained a rare cause of aneurysmal aortic disease, with incidences between 5% and 10%. The current treatment for IAAA consists of open surgical repair and endovascular aneurysm repair (EVAR). Avoiding an inflamed, fibrotic retroperitoneum is the driving force behind the desire to repair IAAA endovascularly. The latest published works confirm the promising results after EVAR for IAAA, but there is still a paucity of data regarding hydroureter and hydronephrosis. In this article, we describe our experience with 5 patients diagnosed with IAAA and treated by EVAR, of whom 3 presented with associated hydronephrosis.

METHODS

A retrospective review of our endovascular database identified five patients who underwent EVAR for IAAA. Unilateral ureteral involvement in the inflammatory process was seen in 3 patients, accompanied by secondary hydronephrosis. One patient presented retroperitoneal fibrosis with duodenal stenosis. Primary outcomes were primary technical success, aneurysm-related mortality, change in aneurysm size, perianeurysmal fibrosis (PAF), and hydronephrosis. Secondary outcomes were requirement for reintervention, progression/resolution of symptoms, and short-term clinical success.

RESULTS

Follow-up duration ranged from 3 to 61 months. No patients were lost to follow-up. Primary technical success was obtained in all patients. One patient died three months after the operation due to persistence of the duodenal stenosis in spite of subsequent endoscopic treatments and corticotherapy. The aneurysm sac progressively reduced in 4 patients and remained unchanged in one patient. PAF regressed in 2 patients, reduced in two, and remained unchanged in one patient. Hydronephrosis persisted in all three patients preoperatively diagnosed with this condition. No patient required subsequent intervention. Four patients had complete resolution of their symptoms at a follow-up visit at 1 month.

CONCLUSIONS

This series suggests that EVAR for IAAA is technically feasible, excludes the aneurysm effectively, and reduces PAF with an acceptable morbidity and mortality rate. EVAR does not seem to offer any benefits for hydronephrosis, and closer follow-up in patients presenting renal or ureter involvement treated by EVAR is necessary.

Endovascular Treatment of Inflammatory Infrarenal Aortic Aneurysms

Objectives:

The aim of this study was to evaluate short- and midterm outcomes of endovascular aneurysm repair in patients with inflammatory abdominal aortic aneurysm (IAAA) focusing on changes in perianeurysmal inflammation and hydronephrosis.

Methods:

A retrospective study was performed considering data prospectively gathered from 1998 to 2013 in 3 centers. Patient demographics, preoperative clinical characteristics, clinical presentation, preoperative imaging measurements, procedural, and postoperative data were collected. Main outcome was to define evolution of periaortic fibrosis and hydronephrosis at computed tomography angiography (CTA) during follow-up.

Results:

A total of 22 patients (male n = 20; mean age 70.9 years ± 9.3) were included (mean AAA diameter: 58 mm ± 11, symptomatic: 50%, ruptured: 9.1%). Hydroureteronephrosis was preoperatively diagnosed by CTA in 6 (27.3%) cases. Median clinical follow-up was 2.2 years (range 0.1-14.5). Nine patients died during follow-up. At 1, 2, 4, and 6 years, overall survival was 85.4%, 74.3%, 56.6%, and 49.5%, respectively. Among these 13 patients with CTA follow-up, the mean AAA diameter was 56.2 mm ± 15.5, and progression of sac diameter was detected in 1 (7.7%) patient. Median maximum thickness of perianeurysmal inflammation was 5 mm (range 2-11) and decreased/remained unchanged in 92.3% of patients. Regression of hydroureteronephrosis occurred in 3 of 5 patients available for follow-up. There were no cases of de novo hydroureteronephrosis.

Conclusion:

Endovascular treatment of IAAA has comparable short-term outcomes with non-IAAA. During midterm follow-up, aneurysm sac progression is rare, and perianeurysmal fibrosis decreases or remains unchanged in most cases. Hydronephrosis regression can occur in some but not all instances and thus warrants close surveillance.

Unstable abdominal aortic aneurysms: a review of MDCT imaging features

Abdominal aortic aneurysms are commonly encountered during abdominal CT imaging, and size-based parameters for surgical or endovascular repair are well established. Aneurysms greater than 5 cm in diameter are recognized as representing an increased rupture risk and meriting intervention. Increasingly, additional interest has been generated in recognizing imaging features which may herald instability and portend a higher chance for potentially catastrophic rupture. This article will review and illustrate such signs, including hyperattenuation of mural thrombus, rapid expansion, low thrombus to lumen ratio, intimal calcification disruption, posterior mural draping, and saccular outpouching. Other features of complicated abdominal aneurysms including perianeurysmal inflammation, aortocaval and aortoenteric fistula formation will also be addressed. Heightened awareness of these features and their prognostic implications, as well as timely communication with the clinical service, is critical for the interpreting radiologist.

Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms

Objectives:

Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature.

Methods:

Twenty-seven patients with an intact IAAA operated on during a 21-year period were included.

Results:

Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units ( P = .001), procedure duration ( P < .001), and postoperative hospitalization ( P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR ( P = 1.00).

Conclusions:

Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.

Mid-term clinical outcomes and morphological changes after endovascular aneurysm repair of inflammatory abdominal aortic aneurysms: a single-center experience

BACKGROUND

Endovascular aneurysm repair (EVAR) has been suggested as treatment for inflammatory abdominal aortic aneurysms (IAAA), but the actual clinical and radiological outcomes need to be evaluated.

PURPOSE

To report morphological changes in EVAR of IAAAs.

MATERIAL AND METHODS

Ten male patients (mean age, 67 years; range, 54-78 years) with IAAA were treated with EVAR using endovascular stent-grafts between March 2001 and January 2012. We retrospectively compared computed tomography angiography (CTA) images taken immediately (30 days after the EVAR), short-term (up to 1 year), and mid-term (beyond 1 year) to CTA images taken before the EVAR. Clinical success was defined as successful deployment of the stent-graft without a type I or III endoleak. Morphologic responses of IAAA to EVAR were reviewed by measuring the changes in aneurysm sac maximum diameter (mm), periaortic fibrosis (PAF) thickness (mm), and PAF enhancement (Hounsfield units [HU] on delayed CTA) on serial images.

RESULTS

Ten IAAA patients treated with EVAR were followed for a mean of 42 months (range, 7-129 months). No aneurysm-related deaths were observed during the follow-up of 10 patients. Primary clinical success was achieved in seven patients, assisted primary clinical success in one patient, and secondary clinical success in two patients. Aneurysm sac maximum diameter decreased in all patients (mean percentage reduction of 7.6%, 8.5%, and 17.3% in immediate, short-term, and mid-term follow-up CTA, respectively). PAF thickness decreased in eight patients (10.4%, 16.8%, and 27.2% regression upon follow-up). PAF enhancement decreased in nine patients and increased in one patient (mean percentage decrease of 13.0%, 27.3%, and 40.8% upon follow-up).

CONCLUSION

Treatment of IAAA with EVAR was effective and reduced aneurysmal sac diameter and the extent of PAF with acceptable morbidity.

Inflammatory Abdominal Aortic Aneurysm

We report a case of an abdominal aortic aneurysm (AAA) that underwent inflammatory transformation which we treated medically with corticosteroids. Medical therapy resulted in resolution of presenting symptoms and observed inflammatory changes. We review the clinical features, associated pathology, diagnostic, and therapeutic options in the management of inflammatory AAA.

Endovascular surgery for inflammatory abdominal aortic aneurysm with contrast allergy-usefulness of carbon dioxide angiography and intravascular ultrasound: a case report

We report a patient with inflammatory abdominal aortic aneurysm who underwent endovascular aneurysm repair, despite his having an allergy to iodinated contrast medium and anatomy unsuitable for the procedure. Intravascular ultrasound-guided and CO2-assisted aortic stent graft placement was performed, and the procedures resulted in the successful exclusion of the aneurysm with regression of the mantle sign and resolution of hydronephrosis.

Infected aortic aneurysm and inflammatory aortic aneurysm--in search of an optimal differential diagnosis

Infected aortic aneurysm and inflammatory aortic aneurysm each account for a minor fraction of the total incidence of aortic aneurysm and are associated with periaortic inflammation. Despite the similarity, infected aortic aneurysm generally shows a more rapid change in clinical condition, leading to a fatal outcome; in addition, delayed diagnosis and misuse of corticosteroid or immunosuppressing drugs may lead to uncontrolled growth of microorganisms. Therefore, it is mandatory that detection of aortic aneurysm is followed by accurate differential diagnosis. In general, infected aortic aneurysm appears usually as a saccular form aneurysm with nodularity, irregular configuration; however, the differential diagnosis may not be easy sometimes for the following reasons: (1) symptoms, such as abdominal and/or back pain and fever, and blood test abnormalities, such as elevated C-reactive protein and enhanced erythrocyte sedimentation rate, are common in infected aortic aneurysm, but they are not found infrequently in inflammatory aortic aneurysm; (2) some inflammatory aortic aneurysms are immunoglobulin (Ig) G4-related, but not all of them; (3) the prevalence of IgG4 positivity in infected aortic aneurysm has not been well investigated; (4) enhanced uptake of 18F-fluorodeoxyglucose (FDG) by 18F-FDG-positron emission tomography may not distinguish between inflammation mediated by autoimmunity and that mediated by microorganism infection. Here we discuss the characteristics of these two forms of aortic aneurysm and the points of which we have to be aware before reaching a final diagnosis.