Effects of Chemotherapy in Patients with Concomitant Aortic Aneurysm and Malignant Disease

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Cancer, cancer treatment and aneurysmatic ascending aorta growth within a retrospective single center study

Background: Multi-morbidity poses a substantial challenge for health care in an aging population. Recent studies did not provide evidence for general side effects of anti-cancer therapy regarding the growth rate of coincident abdominal aortic aneurysms, although it was suggested that specific therapeutic substances might accelerate growth. Aneurysm pathology, however, differs with respect to localization. Hence, we present the first ever analysis on the association of cancer and cancer therapy with growth alteration of aneurysms of the ascending aorta (AscAA). Patients and methods: A retrospective single-center identification of AscAA+cancer patients was performed in the institutional picture archiving and communication system (PACS). Included were all patients with ≥2 CT angiograms over ≥6 months and additional malignancy. Clinical data and aneurysm diameters were retrieved and analyzed for an association of cancer (stratified by tumor entity) or cancer therapy (stratified by several classes of chemotherapeutic agents and radiation therapy) with annual growth rate, respectively. Statistics included t-test, Wilcoxon test, and a linear regression model accounting for initial AscAA diameter and type of treatment. Results: From 2003 to 2021, 151 patients (median age 70 years; 85% male) with AscAA and coincident 163 malignancies were identified. Prostate (37%) and hematologic cancer (17%) were most frequent. One-hundred-eleven patients (74%) received chemotherapy and 75 patients (50%) had radiation. After exclusion of six patients with an initial AscAA diameter >55 mm, the average annual AscAA growth rate was 0.18±0.64 mm/year, with only 12 patients experiencing a growth rate >1mm/year. Neither tumor entity nor radiation or chemotherapy - alone or in combination - were significantly associated with an alteration of the annual AscAA growth rate. Likewise, a subanalysis for singular chemotherapeutic agents did not reveal a specific association with AscAA growth alteration. Conclusions: Growth rates of AscAA are low in this cohort with coincident malignancy. Cancer and/or chemotherapy or radiation are not associated with an alteration of the annual growth rate. Additional control examinations seem unnecessary.

Immunosuppressive Agents and Thoracic Aortic Aneurysm: Real Correlation or Mere Coincidence?

BACKGROUND

Atherosclerosis, hypertension, age, and fibrillopathies are well-known risk factors for the development of aortic aneurysm. We discovered that a significant proportion of our patients were previously on chemotherapy treatment or long-term treatment with cytostatic agents or immunosuppressive drugs. Thus, we examined this phenomenon.

METHODS

A total of 224 patients with thoracic aorta aneurysm were retrospectively analyzed after aortic surgery from 2006 to 2016. Seventy-three patients received aortic wrapping and 151 patients underwent aortic replacement of which 89 had a valve-carrying conduit and 62 a supracoronary ascending replacement. Aortic morphology was assessed by means of compute tomography scan before and after surgery. Demographic data, risk profile, and postoperative complications were collected. Short- and long-term survival analysis was performed. Statistical analysis was performed with SPSS 19.0.

RESULTS

Eighty-eight of 224 patients undergoing aortic surgery because of aortic aneurysm had previously or currently been treated with immunosuppressive agents. Dilatation of the ascending aorta was more pronounced in patients without such therapy. Demographic profile, intraoperative, as well as short- and long-term postoperative results did not differ significantly between both groups.

CONCLUSION

The potential effect of immunosuppressant and cytostatic therapies on the development of an aortic aneurysm needs further study. Because of the astoundingly high proportion of these patients being found in an unselected aortic aneurysm cohort with immunosuppressive therapy in the past should be monitored for potential development of aortic aneurysm. If it occurs and requires treatment these patients can fortunately be operated upon with the same short- and long-term outcome than patients without such previous therapy.

Contained abdominal aortic rupture secondary to follicular lymphoma invasion

An 87-year-old woman with grade IIIb follicular lymphoma treated with rituximab had presented with nausea, emesis, and chest pain of 1 day duration. She was found to have a contained abdominal aortic rupture secondary to follicular lymphoma invasion. She safely and successfully underwent emergent endovascular aortic repair. We have described a rare case of extranodal disease in follicular lymphoma associated with abdominal aortic pseudoaneurysms, likely due to a combination of malignancy-induced chronic inflammation and radiation therapy and chemotherapy side effects.

Management of Concomitant Abdominal Aortic Aneurysm and Intra-abdominal, Retroperitoneal Malignancy

BACKGROUND/AIM

As the population ages, there are increasing findings of coincidental diseases such as abdominal aortic aneurysm (AAA) and intra-abdominal, retroperitoneal malignancy. The aim of this study was to propose an optimal treatment procedure for these patients.

PATIENTS AND METHODS

Over a twenty-year-period, surgery was performed on a total of 1,098 patients with AAA and 32 (2.9%) patients with AAA and intra-abdominal, retroperitoneal malignancy: 18 renal, 6 colorectal carcinomas, 3 carcinomas of the small intestine, 3 primary liver tumours, 1 stomach carcinoma and 1 teratoma. The median age of patients was 72.5 years, there were 20 men (62.5%) and 12 women (37.5%). A one-stage procedure was performed on 19 patients (59.4%), and a two-stage procedure on 13 (40.6%) patients.

RESULTS

The average time of hospitalization was 12.4±6.9 days (median=11.0 days) for one-stage procedure, for a two-stage procedure 21.3±9.3 days (median=20.0 days), p=0.0045. Seven patients (21.9%) died within 30 days after the operation. All the deaths were in the group of one-stage procedures (p=0.0252). The 1-, 3- and 5-year overall survival for patients following one-stage and twostage procedures was 61.0/56.3/51.5% and 89.0/79.9/53.0% respectively (p=0.1199).

CONCLUSION

Symptomatic disease must be resolved first. Two-stage procedures are the method of choice and offer better short-term results compared to one-stage procedures.

Acute aortobiliac graft thrombosis

Introduction and Importance

Acute limb ischemia after infrarenal aortic repair is a rare complication, which in mainly described to appear in a short time after surgery.The aim of this paper is to describe a case of a 66-year-old woman who presented at out attention with acute right limb ischemia, one year later an aortic repair for acute abdominal aortic aneurysm rupture. In the best of our knowledge there are no cases of sudden graft occlusion after such long time, described in literature.

Case presentation

Patient presented with sudden pain and pallor in the right lower limb and subsequently same symptoms to the left lower limb. One year before she underwent an emergency repair for abdominal aortic aneurysm rupture with an aortobiliac graft. Computed Tomography Angiography (CTA) scan showed a complete occlusion of the infrarenal aorta, including aortoiliac graft, to the common bilateral iliac arteries. On the right side was also found a complete occlusion of the popliteal artery.Emergent embolectomy of the right popliteal artery via the femoral artery was performed.

Clinical discussion

CTA scan performed on third post-operative day showed the patency of infrarenal aorta and aortic portion of the grafts in presence of floating thrombus, right iliac branch patency and chronic occlusion of left iliac branch. A kinking of both graft iliac branches was evident after this CTA scan. CTA scan at one month demonstrated resolution of the thrombosis of the infrarenal aorta, complete patency of aortic portion of the graft and right iliac branch and chronic obstruction of the left common iliac artery.

Conclusion

Acute limb ischemia caused by sudden graft occlusion one year later an aortic repair for acute abdominal aortic aneurysm rupture is a very rare event. Graft limbs kinking could explain acute thrombosis of the graft.

Aortic Aneurysm Natural Progression is Not Influenced by Concomitant Malignancy and Chemotherapy

BACKGROUND

Aortic aneurysms occur concomitantly with malignancy in approximately 1.0-17.0% of patients. There is little published information regarding the effects of subsequent oncological therapies on aortic aneurysm growth. The aim of this study was to determine the effects of chemoradiation therapies on the natural progression of small abdominal aortic aneurysm (AAA), thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm.

METHODS

Patients with aortic aneurysms with and without malignancy between 2005 and 2017 were identified within institutional databases using Current Procedural Terminology and International Classification of Disease codes. Inclusion criteria included complete chemotherapy documentation, a minimum of 3 multiplanar axial/coronal imaging or ultrasonography before, during, and after receiving therapy or 2 studies for patients without malignancy. Propensity matching, Cox and linear regression, and Kaplan-Meier survival analyses were performed.

RESULTS

A total of 159 (172 aneurysms) patients with malignancy and 127 (149 aneurysms) patients without malignancy were included. Average patient demographics were 74.4 ± 9.8-years-old, Caucasian (66.8%), male (70.3%), with hypertension (71.1%), current smoking (24.5%), coronary atherosclerotic disease (26.2%), and AAA (71.0%). The most common malignancy was lung cancer (48.4%) with most chemotherapy regimens including a platinum-based alkylating agent and concurrent antimetabolite (56.0%). The overall median follow-up time was 28.2 (range 3.1-174.4) months. Aortic aneurysms in patients without malignancy grew to larger sizes (4.43 ± 0.96 vs. 4.14 ± 1.00, P = 0.008) with similar median growth rates (0.12 vs. 0.12 cm/year, P = 0.090), had more atypical morphologic features (14.1% vs. 0.6%, P < 0.001), more frequently underwent repair (22.1% vs. 8.7%, P = 0.001), and more frequently required emergency repair for rupture (5.4% vs. 0.0%, P = 0.087). Cox regression identified initial aortic size ≥4.0 cm (hazard ratio [HR] 3.028), AAA (HR 2.146), chronic aortic findings (3.589), and the use of topoisomerase inhibitors (HR 2.694). Linear regression demonstrated increased growth rates predicted by antimetabolite chemotherapy (β 0.170), initial aortic size (β 0.086), and abdominal aortic location (β 0.139, all P < 0.002).

CONCLUSIONS

Small aortic aneurysms with concomitant malignancies are discovered at smaller initial sizes, grow at similar rates, require fewer interventions, and have fewer ruptures and acute dissections than patients without malignancy. Antimetabolite therapies modestly accelerate aneurysmal growth, and patients receiving topoisomerase inhibitors may require earlier repair. Patients with concomitant disease can be confidently treated according to standard institutional aneurysm surveillance protocols. Overall, we recommend treatment of the malignancy before small aortic aneurysm repair as these aneurysms behave similarly to those in patients without malignancy.

Vascular Toxicity in Patients with Cancer: Is There a Recipe to Clarify Treatment? CME

The acknowledgement of cardiovascular disease as one of the leading causes of mortality and morbidity among cancer survivors is the cornerstone of the growing field of cardio-oncology. Although standardizing treatment for any given disease is often considered ideal, it is important to recognize the value of pursuing a practical and personalized approach when caring for an oncology patient to minimize the risk of treatment-related cardiotoxicity. We hereby discuss a series of cases that illustrate the ways vascular toxicity can manifest in patients with cancer and, when appropriate, provide scientific evidence that supports clinical decision making. We also raise questions about the complex management of these patients while shedding light on future research in this growing field.

Management of abdominal aortic aneurysm and concomitant malignant disease

INTRODUCTION

Concomitant malignant disease and abdominal aortic aneurysms (AAA) represent a challenging issue in terms of treatment priority, timing and perspectives. This systematic review provides an overview of the available literature about AAA and concomitant malignant disease.

EVIDENCE ACQUISITION

We conducted a literature search of all the English-language medical literature in Medline (through PubMed), Embase, Clinical Trial databases and the Cochrane Library up to December 31st, 2018.

EVIDENCE SYNTHESIS

The literature about AAA and concomitant malignant disease is mostly based on retrospective small case series. Two recently published meta-analyses focusing on the management of AAA and concomitant abdominal neoplasms came to the same conclusion "treat what is most threatening or symptomatic first." The threshold to treat asymptomatic AAA should not be altered in patients with AAA and concomitant cancer including cases under chemotherapy. An asymptomatic AAA of at least 55 mm anatomically suitable for EVAR, should only be treated first in patients with at least a life expectancy of two years followed by staged cancer surgery two weeks later.

CONCLUSIONS

Decisions about management of AAA and concomitant malignant disease should be based on clinical judgment applied individually in a multidisciplinary setting ("treat first what kills first"). The indication for treatment is not different than in patients with AAA without cancer. A staged approach is preferable and ideally the AAA should be excluded by endovascular means if anatomically suitable. An international registry should be initiated to gather more evidence about the management and outcomes of patients with AAA and concomitant carcinoma.

Pharmacologic Management of Aneurysms

Current management of aortic aneurysms relies exclusively on prophylactic operative repair of larger aneurysms. Great potential exists for successful medical therapy that halts or reduces aneurysm progression and hence alleviates or postpones the need for surgical repair. Preclinical studies in the context of abdominal aortic aneurysm identified hundreds of candidate strategies for stabilization, and data from preoperative clinical intervention studies show that interventions in the pathways of the activated inflammatory and proteolytic cascades in enlarging abdominal aortic aneurysm are feasible. Similarly, the concept of pharmaceutical aorta stabilization in Marfan syndrome is supported by a wealth of promising studies in the murine models of Marfan syndrome-related aortapathy. Although some clinical studies report successful medical stabilization of growing aortic aneurysms and aortic root stabilization in Marfan syndrome, these claims are not consistently confirmed in larger and controlled studies. Consequently, no medical therapy can be recommended for the stabilization of aortic aneurysms. The discrepancy between preclinical successes and clinical trial failures implies shortcomings in the available models of aneurysm disease and perhaps incomplete understanding of the pathological processes involved in later stages of aortic aneurysm progression. Preclinical models more reflective of human pathophysiology, identification of biomarkers to predict severity of disease progression, and improved design of clinical trials may more rapidly advance the opportunities in this important field.