Increasing incidence of ruptured abdominal aortic aneurysm: A population-based study

Effect of stress-induced hyperglycemia on long-term mortality in non-diabetic patients with acute type A aortic dissection: a retrospective analysis

BACKGROUND

Acute Type A Aortic Dissection (AAAD) is one of the most life-threatening diseases, often associated with transient hyperglycemia induced by acute physiological stress. The impact of stress-induced hyperglycemia on the prognosis of ST-segment elevation myocardial infarction has been reported. However, the relationship between stress-induced hyperglycemia and the prognosis of AAAD patients remains uncertain.

METHODS

The clinical data of 456 patients with acute type A aortic dissection were retrospectively reviewed. Patients were divided into two groups based on their admission blood glucose. Cox model regression analysis was performed to assess the relationship between stress-induced hyperglycemia and the 30-day and 1-year mortality rates of these patients.

RESULTS

Among the 456 patients, 149 cases (32.7%) had AAAD combined with stress-induced hyperglycemia (SIH). The results of the multifactor regression analysis of the Cox model indicated that hyperglycemia (RR = 1.505, 95% CI: 1.046-2.165, p = 0.028), aortic coarctation involving renal arteries (RR = 3.330, 95% CI: 2.237-4.957, p < 0.001), aortic coarctation involving superior mesenteric arteries (RR = 1.611, 95% CI: 1.056-2.455, p = 0.027), and aortic coarctation involving iliac arteries (RR = 2.034, 95% CI: 1.364-3.035, p = 0.001) were independent influences on 1-year postoperative mortality in AAAD patients.

CONCLUSION

The current findings indicate that stress-induced hyperglycemia measured on admission is strongly associated with 1-year mortality in patients with AAAD. Furthermore, stress-induced hyperglycemia may be related to the severity of the condition in patients with AAAD.

Implantable Pressure-Sensing Devices for Monitoring Abdominal Aortic Aneurysms in Post-Endovascular Aneurysm Repair

Over the past two decades, there has been extensive research into surveillance methods for the post-endovascular repair of abdominal aortic aneurysms, highlighting the importance of these technologies in supplementing or even replacing conventional image-screening modalities. This review aims to provide an overview of the current status of alternative surveillance solutions for endovascular aneurysm repair, while also identifying potential aneurysm features that could be used to develop novel monitoring technologies. It offers a comprehensive review of these recent clinical advances, comparing new and standard clinical practices. After introducing the clinical understanding of abdominal aortic aneurysms and exploring current treatment procedures, the paper discusses the current surveillance methods for endovascular repair, contrasting them with recent pressure-sensing technologies. The literature on three commercial pressure-sensing devices for post-endovascular repair surveillance is analyzed. Various pre-clinical and clinical studies assessing the safety and efficacy of these devices are reviewed, providing a comparative summary of their outcomes. The review of the results from pre-clinical and clinical studies suggests a consistent trend of decreased blood pressure in the excluded aneurysm sac post-repair. However, despite successful pressure readings from the aneurysm sac, no strong link has been established to translate these measurements into the presence or absence of endoleaks. Furthermore, the results do not allow for a conclusive determination of ongoing aneurysm sac growth. Consequently, a strong clinical need persists for monitoring endoleaks and aneurysm growth following endovascular repair.

Prehospital point-of-care ultrasound in ruptured abdominal aortic aneurysms-a retrospective cohort study

BACKGROUND

Patients with ruptured abdominal aortic aneurysm (rAAA) require immediate vascular treatment to survive. The use of prehospital point-of-care ultrasound (POCUS) may support clinical assessment, correct diagnosis, appropriate triage and reduce system delay. The aim was to study the process of care and outcome in patients receiving prehospital POCUS versus patients not receiving prehospital POCUS in patients with rAAA, ruptured iliac aneurysm or impending aortic rupture.

METHODS

We performed a retrospective cohort study in patients diagnosed with rAAA in the Central Denmark Region treated by a prehospital critical care physician from 1 January 2017 to 31 December 2021. Performance of prehospital POCUS was extracted from the prehospital electronic health records. System delay was defined as the time from the emergency phone call to the emergency medical service dispatch centre until the start of surgery. Data on patients primary hospital admission to a centre with/without vascular treatment expertise, treatments and complications including death were extracted from electronic health records.

RESULTS

We included 169 patients; prehospital POCUS was performed in 124 patients (73%). Emergency surgical treatment was performed in 71 patients. The overall survival in the POCUS group was 39% versus 16% in the NO POCUS group (hazard ratio (HR) (95% 0.60, 95% CI: 0.41-0.89, p = .011). In the POCUS group 99/124 (80%) were directly admitted to a vascular surgical centre versus 25/45 (56%) in the NO POCUS, RD 24% (95% CI: 8-40)), (p = .002). In the POCUS group, system delay was a median of 142 minutes (interquartile range (IQR) 121-189) and a median of 232 minutes (IQR 166-305) in the NO POCUS group (p = .006). In a multivariable analysis incorporating age, sex, previously known rAAA, and typical clinical symptoms of rAAA, the HR for death was 0.57, 95% CI 0.38-0.86 (p = .008) favouring prehospital POCUS.

CONCLUSIONS

Prehospital POCUS was associated with reduced time to treatment, higher chance of operability and significantly higher 30-day survival in patients with rAAA, ruptured iliac aneurysm or impending rupture of an AAA in this retrospective study. Residual confounding cannot be excluded. This study supports the clinical relevance of prehospital POCUS of the abdominal aorta.

Modified Harborview Risk Score accurately predicts mortality for patients with ruptured abdominal aortic aneurysm

OBJECTIVE

The modified Harborview Risk Score (HRS) is a simple measure initially derived from a single institutional dataset used to predict ruptured abdominal aortic aneurysm (rAAA) repair survival preoperatively using basic labs and vital signs collected upon presentation. However, validation of this widely applicable scoring system has not been performed. This study aims to validate this scoring system using a large multi-institutional database.

METHODS

All patients who underwent repair of an rAAA from 2011 to 2018 in the National Surgical Quality Improvement Program (NSQIP) and at a single academic medical center were included. The modified HRS was calculated by assigning 1 point for each of the following: age >76 years, creatinine >2 mg/dL, international normalized ratio >1.8, and any systolic blood pressure less than 70 mmHg. Assessment of the prediction model was then completed. Using a primary outcome measure of 30-day mortality, the receiver operating characteristic area under the curve was calculated. The discrimination between datasets was compared using a Delong test. Mortality rates for each score were compared between datasets using the Pearson χ2 test. Comparative analysis for patients with a score of 4 was limited due to a small sample size.

RESULTS

A total of 1536 patients were identified using NSQIP, and 163 patients were assessed in the institutional dataset. There were 518 patients with a score of 0 (455 NSQIP, 63 institutional), 676 patients with a score of 1 (617 NSQIP, 59 institutional), 391 patients with a score of 2 (364 NSQIP, 27 institutional), 106 with a score of 3 (93 NSQIP, 13 institutional), and 8 patients with a score of 4 (7 NSQIP, 1 institutional). No difference was found in the receiver operating characteristic area under the curves between datasets (P = .78). Thirty-day mortality was 10% NSQIP vs 22% institutional for a score of 0; 28% NSQIP vs 36% institutional for a score of 1; 41% NSQIP vs 44% institutional for a score of 2; 45% NSQIP vs 69% institutional for a score of 3; and 57% NSQIP vs 100% institutional for a score of 4. Score 0 was the only score with a significant mortality rate difference between datasets (P = .01).

CONCLUSIONS

The modified HRS is confirmed to be broadly applicable as a clinical decision-making tool for patients presenting with rAAAs. Therefore, this easily applicable model should be applied for all patients presenting with rAAAs to assist with provider and patient decision-making prior to proceeding with repair.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

The prognosis of patients with postoperative hyperglycemia after Stanford type A aortic dissection surgery and construction of prediction model for postoperative hyperglycemia

Objective

The mortality of type A aortic dissection (TAAD) is extremely high. The effect of postoperative hyperglycemia (PHG) on the prognosis of TAAD surgery is unclear. This study aims to investigate the prognosis of patients with PHG after TAAD surgery and construct prediction model for PHG.

Methods

Patients underwent TAAD surgery from January 2016 to December 2020 in Xiangya Hospital were collected. A total of 203 patients were included and patients were divided into non PHG group and PHG group. The occurrence of postoperative delirium, cardiac complications, spinal cord complication, cerebral complications, acute kidney injury (AKI), hepatic dysfunction, hypoxemia, and in-hospital mortality were compared between two groups. Data from MIMIC-IV database were further applied to validate the relationship between PHG and clinical outcomes. The prediction model for PHG was then constructed using Extreme Gradient Boosting (XGBoost) analysis. The predictive value of selected features was further validated using patient data from MIMIC-IV database. Finally, the 28-days survival rate of patient with PHG was analyzed using data from MIMIC-IV database.

Results

There were 86 patients developed PHG. The incidences of postoperative AKI, hepatic dysfunction, and in-hospital mortality were significant higher in PHG group. The ventilation time after surgery was significant longer in PHG group. Data from MIMIC-IV database validated these results. Neutrophil, platelet, lactic acid, weight, and lymphocyte were selected as features for prediction model. The values of AUC in training and testing set were 0.8697 and 0.8286 respectively. Then, five features were applied to construct another prediction model using data from MIMIC-IV database and the value of AUC in the new model was 0.8185. Finally, 28-days survival rate of patients with PHG was significantly lower and PHG was an independent risk factor for 28-days mortality after TAAD surgery.

Conclusion

PHG was significantly associated with the occurrence of AKI, hepatic dysfunction, increased ventilation time, and in-hospital mortality after TAAD surgery. The feature combination of neutrophil, platelet, lactic acid, weight, and lymphocyte could effectively predict PHG. The 28-days survival rate of patients with PHG was significantly lower. Moreover, PHG was an independent risk factor for 28-days mortality after TAAD surgery.

Abdominal Aortic Aneurysm Detection in Bioelectrical Impedance Cardiovascular Screenings-A Pilot Study

Screening and diagnosing abdominal aortic aneurysms (AAA) are currently dependent on imaging studies such as ultrasound or computed tomography angiography. All imaging studies offer distinct advantages but also suffer from inherent limitations such as examiner dependency or ionizing radiation. Bioelectrical impedance analysis has previously been investigated with respect to its use in the detection of several cardiovascular and renal pathologies. The present pilot study assessed the feasibility of AAA detection based on bioimpedance analysis. In this single-center exploratory pilot study, measurements were conducted among three different cohorts: patients with AAA, end-stage renal disease patients without AAA, and healthy controls. The device used in the study, CombynECG, is an open-market accessible device for segmental bioelectrical impedance analysis. The data was preprocessed and used to train four different machine learning models on a randomized training sample (80% of the full dataset). Each model was then evaluated on a test set (20% of the full dataset). The total sample included 22 patients with AAA, 16 chronic kidney disease patients, and 23 healthy controls. All four models showed strong predictive performance in the test partitions. Specificity ranged from 71.4 to 100%, while sensitivity ranged from 66.7 to 100%. The best-performing model had 100% accuracy for classification when applied to the test sample. Additionally, an exploratory analysis to approximate the maximum AAA diameter was conducted. An association analysis revealed several impedance parameters that might possess predictive ability with respect to aneurysm size. AAA detection via bioelectrical impedance analysis is technically feasible and appears to be a promising technology for large-scale clinical studies and routine clinical screening assessments.

Abdominal Aortic Thrombus Segmentation in Postoperative Computed Tomography Angiography Images Using Bi-Directional Convolutional Long Short-Term Memory Architecture

Abdominal aortic aneurysm (AAA) is a fatal clinical condition with high mortality. Computed tomography angiography (CTA) imaging is the preferred minimally invasive modality for the long-term postoperative observation of AAA. Accurate segmentation of the thrombus region of interest (ROI) in a postoperative CTA image volume is essential for quantitative assessment and rapid clinical decision making by clinicians. Few investigators have proposed the adoption of convolutional neural networks (CNN). Although these methods demonstrated the potential of CNN architectures by automating the thrombus ROI segmentation, the segmentation performance can be further improved. The existing methods performed the segmentation process independently per 2D image and were incapable of using adjacent images, which could be useful for the robust segmentation of thrombus ROIs. In this work, we propose a thrombus ROI segmentation method to utilize not only the spatial features of a target image, but also the volumetric coherence available from adjacent images. We newly adopted a recurrent neural network, bi-directional convolutional long short-term memory (Bi-CLSTM) architecture, which can learn coherence between a sequence of data. This coherence learning capability can be useful for challenging situations, for example, when the target image exhibits inherent postoperative artifacts and noises, the inclusion of adjacent images would facilitate learning more robust features for thrombus ROI segmentation. We demonstrate the segmentation capability of our Bi-CLSTM-based method with a comparison of the existing 2D-based thrombus ROI segmentation counterpart as well as other established 2D- and 3D-based alternatives. Our comparison is based on a large-scale clinical dataset of 60 patient studies (i.e., 60 CTA image volumes). The results suggest the superior segmentation performance of our Bi-CLSTM-based method by achieving the highest scores of the evaluation metrics, e.g., our Bi-CLSTM results were 0.0331 higher on total overlap and 0.0331 lower on false negative when compared to 2D U-net++ as the second-best.

Hemostatic Biomarkers and Volumetry Help to Identify High-Risk Abdominal Aortic Aneurysms

Predicting the progression of small aneurysms is a main challenge in abdominal aortic aneurysm (AAA) management. The combination of circulating biomarkers and image techniques might provide an alternative for risk stratification. We evaluated the association of plasma TAT complexes (TAT) and D-dimer with AAA severity in 3 groups of patients: group 1, without AAA (n = 52), group 2, AAA 40−50 mm (n = 51) and group 3, AAA > 50 mm (n = 50). TAT (p < 0.001) and D-dimer (p < 0.001) were increased in patients with AAA (groups 2 and 3) vs. group 1. To assess the association between baseline TAT and D-dimer concentrations, and AAA growth, aortic diameter and volume (volumetry) were measured by computed tomography angiography (CTA) in group 2 at recruitment (baseline) and 1-year after inclusion. Baseline D-dimer and TAT levels were associated with AAA diameter and volume variations at 1-year independently of confounding factors (p ≤ 0.044). Additionally, surgery incidence, recorded during a 4-year follow-up in group 2, was associated with larger aneurysms, assessed by aortic diameter and volumetry (p ≤ 0.036), and with elevated TAT levels (sub-hazard ratio 1.3, p ≤ 0.029), while no association was found for D-dimer. The combination of hemostatic parameters and image techniques might provide valuable tools to evaluate AAA growth and worse evolution.

Automatic Detection and Segmentation of Thrombi in Abdominal Aortic Aneurysms Using a Mask Region-Based Convolutional Neural Network with Optimized Loss Functions

The detection and segmentation of thrombi are essential for monitoring the disease progression of abdominal aortic aneurysms (AAAs) and for patient care and management. As they have inherent capabilities to learn complex features, deep convolutional neural networks (CNNs) have been recently introduced to improve thrombus detection and segmentation. However, investigations into the use of CNN methods is in the early stages and most of the existing methods are heavily concerned with the segmentation of thrombi, which only works after they have been detected. In this work, we propose a fully automated method for the whole process of the detection and segmentation of thrombi, which is based on a well-established mask region-based convolutional neural network (Mask R-CNN) framework that we improve with optimized loss functions. The combined use of complete intersection over union (CIoU) and smooth L1 loss was designed for accurate thrombus detection and then thrombus segmentation was improved with a modified focal loss. We evaluated our method against 60 clinically approved patient studies (i.e., computed tomography angiography (CTA) image volume data) by conducting 4-fold cross-validation. The results of comparisons to multiple other state-of-the-art methods suggested the superior performance of our method, which achieved the highest F1 score for thrombus detection (0.9197) and outperformed most metrics for thrombus segmentation.

Role of Extracellular Vesicles as Potential Diagnostic and/or Therapeutic Biomarkers in Chronic Cardiovascular Diseases

Cardiovascular diseases (CVDs) are the first cause of death worldwide. In recent years, there has been great interest in the analysis of extracellular vesicles (EVs), including exosomes and microparticles, as potential mediators of biological communication between circulating cells/plasma and cells of the vasculature. Besides their activity as biological effectors, EVs have been also investigated as circulating/systemic biomarkers in different acute and chronic CVDs. In this review, the role of EVs as potential diagnostic and prognostic biomarkers in chronic cardiovascular diseases, including atherosclerosis (mainly, peripheral arterial disease, PAD), aortic stenosis (AS) and aortic aneurysms (AAs), will be described. Mechanistically, we will analyze the implication of EVs in pathological processes associated to cardiovascular remodeling, with special emphasis in their role in vascular and valvular calcification. Specifically, we will focus on the participation of EVs in calcium accumulation in the pathological vascular wall and aortic valves, involving the phenotypic change of vascular smooth muscle cells (SMCs) or valvular interstitial cells (IC) to osteoblast-like cells. The knowledge of the implication of EVs in the pathogenic mechanisms of cardiovascular remodeling is still to be completely deciphered but there are promising results supporting their potential translational application to the diagnosis and therapy of different CVDs.

Incidence and Outcome of Acute Myocardial Infarction in Patients With Aortic Dissection and Risk Factor Control

Background and Aims: The contradiction of management modality between acute myocardial infarction(AMI) and aortic dissection(AD) may result in clinical catastrophe. Data on risk factors, incidence, and outcome of AD and AMI are limited, and there have been no studies on the long-term outcomes of AMI in patients with AD. So we aimed to investigate long-term outcomes after AMI in patients with AD, and propose a useful diagnostic paradigm.

Methods: Consecutively enrolled patients with AD and AMI who were referred to our center from 2010 to 2017. Baseline patient characteristics, risk factors, all medical treatments, echocardiographic parameters, laboratory data, and treatment were recorded. All patients were followed up from the first hospitalization until a first heart event, death, or 17 March, 2018.

Results: 0.13% in AMI and 7.49% in AD patients had a concomitant diagnosis of AD and AMI. The average patient age was 53.3 ± 12.1 years and 84.6% were male. The most prevalent vascular risk factors were hypertension (69.2%) and current smoker (64.1%). Of all the 39 patients, 66.7% were managed surgically. Overall in-hospital mortality was 10.3%. The 30-day and 5-year fatality rates were 23.1% and 35.9%, but were higher for female than for male (66.7 vs. 30.3%, log-rank P = 0.045) on 5-year mortality. The overall survival of females was inferior to the males (log-rank P = 0.045).

Conclusions: Patients with AMI and AD exhibit high 5-year fatality rates. For these patients, surgical management tends to have lower mortality. Improved management of hypertension and smoking, may reduce future incidence rates.

Impact of solitons on the progression of initial lesion in aortic dissection

Aortic dissection (AD) is the most common catastrophic disease reported at cardiovascular emergency in hospitals. Herein, a tear in the tunica intima results into separation of layers of aortic wall leading to rupture and torrential bleed. Hypoxia and oxidative stress are associated with AD. The release of hypoxia inducible factor (HIF)-1[Formula: see text] from the initial flap lesion in the tunica intima is the basis for aneurysmal prone factors. We framed a boundary value problem (BVP) to evaluate homeostatic saturation for oxygen dynamics using steady-state analysis. We prove uniqueness and existence of the solution of the BVP for gas exchange at capillary–tissue interface as a normal physiological function. Failure of homeostatic mechanism establishes hypoxia, a new quasi-steady-state in AD. We model permeation of two-layer fluid comprised of blood and HIF-1[Formula: see text] through tunica media as a generalized [Formula: see text]-dimensional nonlinear evolution equation and solve it using Lie group of transformations method. We note that the two-layer fluid permeates the tunica media as solitary wave including solitons such as bright soliton, dark soliton, peregrine soliton, topological soliton, kink soliton, breather soliton and multi-soliton complex. Also, we introduce the main result and discuss the implications of soliton solution, using graphic interpretation, to describe the early stage of progression of AD.

Reassessing the operative threshold for abdominal aortic aneurysm repair in the context of COVID-19

OBJECTIVE

The worldwide pandemic involving the novel respiratory syndrome (COVID-19) has forced health care systems to delay elective operations, including abdominal aortic aneurysm (AAA) repair, to conserve resources. This study provides a structured analysis of the decision to delay AAA repair and quantify the potential for harm.

METHODS

A decision tree was constructed modeling immediate repair of AAA relative to an initial nonoperative (delayed repair) approach. Risks of COVID-19 contraction and mortality, aneurysm rupture, and operative mortality were considered. A deterministic sensitivity analysis for a range of patient ages (50 to >80), probability of COVID-19 infection (0.01%-30%), aneurysm size (5.5 to >7 cm), and time horizons (3-9 months) was performed. Probabilistic sensitivity analyses were conducted for three representative ages (60, 70, and 80). Analyses were conducted for endovascular aortic aneurysm repair (EVAR) and open surgical repair (OSR).

RESULTS

Patients with aneurysms 7 cm or greater demonstrated a higher probability of survival when treated with immediate EVAR or OSR, compared with delayed repair, for patients under 80 years of age. When considering EVAR for aneurysms 5.5 to 6.9 cm, immediate repair had a higher probability of survival except in settings with a high probability of COVID-19 infection (10%-30%) and advanced age (70-85+ years). A nonoperative strategy maximized the probability of survival as patient age or operative risk increased. Probabilistic sensitivity analyses demonstrated that patients with large aneurysms (>7 cm) faced a 5.4% to 7.7% absolute increase in the probability of mortality with a delay of repair of 3 months. Young patients (60-70 years) with aneurysms 6 to 6.9 cm demonstrated an elevated risk of mortality (1.5%-1.9%) with a delay of 3 months. Those with aneurysms 5 to 5.9 cm demonstrated an increased survival with immediate repair in young patients (60); however, this was small in magnitude (0.2%-0.8%). The potential for harm increased as the length of surgical delay increased. For elderly patients requiring OSR, in the context of endemic COVID-19, delay of repair improves the probability of survival.

CONCLUSIONS

The decision to delay operative repair of AAA should consider both patient age and local COVID-19 prevalence in addition to aneurysm size. EVAR should be considered when possible due to a reduced risk of harm and lower resource utilization.

The Effect of Blood Transfusion during Air Medical Transport on Transport Times in Patients with Ruptured Abdominal Aortic Aneurysm

Background: Patients presenting with a diagnosis of ruptured abdominal aortic aneurysm (RAAA) to community hospitals must be transported to tertiary care centers, where necessary resources are available. Unfortunately, guidelines for treatment of RAAA lack high-level evidence on the optimal resuscitation of RAAA patients during transport. We hypothesized that transfusion of packed red blood cells (PRBCs) during transport would not delay transport times in patients with RAAA. Methods: We performed a retrospective analysis of a prospective registry including prehospital data of patients with RAAA presenting to a single academic hospital in Western Pennsylvania between 2001 and 2019. Our primary outcomes were prehospital transport times: "transport interval" and "total interval." "Transport interval" is the duration from patient pickup at the outside hospital (OSH) to arrival at the receiving facility. "Total interval" is the duration from dispatch of the air medical transport to arrival of the patient to the receiving facility. We then compared two groups of patients, stratified by the receipt of PRBCs in transit, by reporting mean difference (95% confidence interval: CI) for continuous variables and percent difference (95% CI) for categorical variables. We performed two multivariate linear regression models to test if there was any effect of the receipt of PRBCs in transit on transport times. Results: We included 271 patients with RAAA transported by our air ambulance system who underwent an operation at the receiving facility, 99 (37%) of whom received PRBCs in transit. Mean ± standard deviation (SD) of the total intervals were 67 ± 28 and 71 ± 42 minutes, among patients who received or did not receive PRBCs in transit respectively, with no significant difference (p = 0.437). Following adjusted analysis, the receipt of PRBCs during transport was not associated with increased transport times, after accounting for age, hypotension, endovascular aneurysm repair (EVAR), and PRBC transfusion at the OSH. Conclusion: PRBC transfusion during air medical transport in patients with RAAA did not delay transport times.

Aortic Aneurysms, Chronic Kidney Disease and Metalloproteinases

Metalloproteinases (MPs) are proteolytic enzymes involved in extracellular matrix deposition, regulation of cellular signals of inflammation, proliferation, and apoptosis. Metalloproteinases are classified into three families: Matrix-MPs (MMPs), A-Disintegrin-and-Metalloprotease (ADAMs), and the A-Disintegrin-and-Metalloproteinase-with-Thrombospondin-1-like-Domains (ADAMTS). Previous studies showed that MPs are involved in the development of aortic aneurysms (AA) and, concomitantly, in the onset of chronic kidney disease (CKD). CKD has been, per se, associated with an increased risk for AA. The aim of this review is to examine the pathways that may associate MPs with CKD and AA. Several MMPs, such as MMP-2, -8, -9, and TIMP-1 have been shown to damage the AA wall and to have a toxic effect on renal tubular cells, leading to fibrosis. Similarly, ADAM10 and 17 have been shown to degrade collagen in the AA wall and to worsen kidney function via pro-inflammatory stimuli, the impairment of the Renin-Angiotensin-Aldosterone System, and the degradation of structural proteins. Moreover, MMP-2 and -9 inhibitors reduced aneurysm growth and albuminuria in experimental and human studies. It would be important, in the future, to expand research on MPs from both a prognostic, namely, to refine risk stratification in CKD patients, and a predictive perspective, likely to improve prognosis in response to targeted treatments.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES

This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients.

METHODS

This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping.

RESULTS

From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter.

CONCLUSIONS

The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Thoracic aortic size in Brazilian smokers: measures using low-dose chest computed tomography anatomical and epidemiological assessment

OBJECTIVES

Thoracic aortic aneurysms (TAAs) represent one-third of the hospitalizations for aortic diseases. The prevalence rate depends on the definition of the normal size of the aorta, which is quite variable, depending on the population studied. The aim of this study was to evaluate the characteristics of the thoracic aorta of Brazilian smokers, identifying the normal size of the aorta, presence of anatomical variations, and prevalence of TAA.

MATERIALS AND METHODS

A total of 711 patients underwent radiological evaluation with low-dose computed tomography (CT) from January 2013 to July 2014 with the initial objective of lung nodule tracking. Two examiners evaluated these images, and measurements of maximum and serial diameters were performed manually in true orthogonal planes. Serial diameter measurements were taken every 2 cm in the ascending aorta and 5 cm in the descending segment. We searched for anatomical variations, aortic arch type, and correlations between anatomical characteristics, sex, body mass index, and body surface area (BSA).

RESULTS

The maximum diameters were 33.61 (standard deviation [SD] 3.88), 28.66 (SD 2.89), and 28.36 mm (SD 3.09) for the ascending segment, aortic arch, and descending segment, respectively. A positive correlation was found between male sex, age, and BSA and aorta diameter. The bovine arch was the most common variation of the aortic arch type, and we found one (0.14%) case of TAA.

CONCLUSIONS

This study with low-dose CT allowed the determination of the mean diameters of the ascending aorta, aortic arch, and descending aorta in Brazilian smokers and TAA prevalence.

Association of Infections and Use of Fluoroquinolones With the Risk of Aortic Aneurysm or Aortic Dissection

IMPORTANCE

Prior observational studies have suggested that fluoroquinolone use may be associated with more than 2-fold increased risk of aortic aneurysm or aortic dissection (AA/AD). These studies, however, did not fully consider the role of coexisting infections and the risk of fluoroquinolones relative to other antibiotics.

OBJECTIVE

To estimate the risk of AA/AD associated with infections and to assess the comparative risk of AA/AD associated with fluoroquinolones vs other antibiotics with similar indication profiles among patients with the same types of infections.

DESIGNS, SETTINGS, AND PARTICIPANTS

This nested case-control study identified 21 651 176 adult patients from a nationwide population-based health insurance claims database from January 1, 2009, to November 30, 2015. Each incident case of AA/AD was matched with 10 control individuals by age, sex, and follow-up duration in the database using risk-set sampling. Analysis of the data was conducted from April 2019 to March 2020.

EXPOSURES

Infections and antibiotic use within a 60-day risk window before the occurrence of AA/AD.

MAIN OUTCOMES AND MEASURES

Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% CIs comparing infections for which fluoroquinolones are commonly used with no infection within a 60-day risk window before outcome occurrence, adjusting for baseline confounders and concomitant antibiotic use. The adjusted ORs comparing fluoroquinolones with antibiotics with similar indication profiles within patients with indicated infections were also estimated.

RESULTS

A total of 28 948 cases and 289 480 matched controls were included (71.37% male; mean [SD] age, 67.41 [15.03] years). Among these, the adjusted OR of AA/AD for any indicated infections was 1.73 (95% CI, 1.66-1.81). Septicemia (OR, 3.16; 95% CI, 2.63-3.78) and intra-abdominal infection (OR, 2.99; 95% CI, 2.45-3.65) had the highest increased risk. Fluoroquinolones were not associated with an increased AA/AD risk when compared with combined amoxicillin-clavulanate or combined ampicillin-sulbactam (OR, 1.01; 95% CI, 0.82-1.24) or with extended-spectrum cephalosporins (OR, 0.88; 95% CI, 0.70-1.11) among patients with indicated infections. The null findings for fluoroquinolone use remained robust in different subgroup and sensitivity analyses.

CONCLUSIONS AND RELEVANCE

These results highlight the importance of accounting for coexisting infections while examining the safety of antibiotics using real-world data; the findings suggest that concerns about AA/AD risk should not deter fluoroquinolone use for patients with indicated infections.

Systematic review of plasma/packed red blood cell ratio on survival in ruptured abdominal aortic aneurysms

BACKGROUND

The ideal perioperative fluid resuscitation for patients with ruptured abdominal aortic aneurysms (rAAAs) is unknown. It has been shown in trauma studies that a higher ratio of plasma and platelets to packed red blood cells confers a mortality benefit. Controversy remains whether this is true also in the rAAA population. The objective of the present study was to investigate the benefit of a greater ratio of plasma/packed red blood cells in patients with rAAAs.

METHODS

A health sciences librarian searched four electronic databases, including PubMed, Embase, Cochrane, and ClinicalTrials.gov, using concepts for the terms "fluid resuscitation," "survival," and "ruptured abdominal aortic aneurysm." Two reviewers independently screened the studies that were identified through the search strategy and read in full any study that was potentially relevant. Studies were included if they had compared the mortality of patients with rAAAs who had received a greater ratio of plasma to other component therapy with that of patients who had received a lower ratio. The risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions) validated tool, and evidence quality was rated using the GRADE (grades of recommendation assessment, development, and evaluation) profile. No data synthesis or meta-analysis was planned or performed, given the anticipated paucity of research on this topic and the high degree of heterogeneity of available studies.

RESULTS

Our search identified seven observational studies for inclusion in the present review. Of these seven studies, three found an associated decrease in mortality with a greater ratio of plasma to packed red blood cells. The remaining four found no significant differences. The overall risk of bias was serious, and the evidence quality was very low.

CONCLUSIONS

Overall, the findings from the available studies would suggest that for patients who have undergone open surgery for a rAAA, mortality tends to be decreased when the amount of plasma transfused perioperatively is similar to the amount of packed red blood cells. However, the included studies reported very low-quality evidence based solely on highly heterogeneous observational studies, and further research is warranted.

Analysis of Endovascular Aneurysm Repair for Small Abdominal Aortic Aneurysms in Males

BACKGROUND

Current guidelines recommend repair of abdominal aortic aneurysms (AAAs) when ≥5.5 cm. This study sought to evaluate the incidence of male patients undergoing endovascular aneurysm repair (EVAR) for AAAs of various diameters (small <4 cm; intermediate 4-5.4 cm; standard ≥5.5 cm). We analyzed predictors of mortality, hypothesizing that smaller AAAs (<5.5 cm) have no differences in associated risk of mortality compared to standard AAAs (≥5.5 cm).

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for male patients undergoing elective EVAR. Patients were stratified by aneurysm diameter. A multivariable logistic regression analysis for clinical outcomes, adjusting for age, clinical characteristics, and comorbidities, was performed.

RESULTS

A total of 8037 male patients underwent EVAR with 3926 (48.9%) performed for AAAs <5.5 cm. There was no difference in mortality, readmission, major complications, myocardial infarction, stroke, or ischemic complications among the 3 groups (P > 0.05). In AAAs <5.5 cm, predictors of mortality included prior abdominal surgery (odds ratio [OR], 5.77; confidence interval [CI], 1.38-24.13; P = 0.016), weight loss (OR, 43.4; CI, 3.78-498.7; P = 0.002), disseminated cancer (OR, 17.9; CI, 1.30-245.97; P = 0.031), and diabetes (OR, 6.09; CI, 1.52-24.36; P = 0.011).

CONCLUSIONS

Nearly 50% of male patients undergoing elective EVAR were treated for AAAs <5.5 cm. There was no difference in associated risk of mortality for smaller AAAs compared to standard AAAs. The strongest predictors of mortality for patients with smaller AAAs were prior abdominal surgery, weight loss, disseminated cancer, and diabetes.

Feasibility and accuracy of a novel automated three-dimensional ultrasonographic analysis system for abdominal aortic aneurysm: comparison with two-dimensional ultrasonography and computed tomography

Background

Accurate measurement of the maximum aortic diameter (Dmax) is crucial for patients with abdominal aortic aneurysm (AAA). Aortic computed tomography (CT) provides accurate Dmax values by three-dimensional (3-D) reconstruction but may cause nephrotoxicity because of contrast use and radiation hazard. We aimed to evaluate the accuracy of a novel semi-automated 3-D ultrasonography (3-D US) system compared with that of CT as a reference.

Methods

Patients with AAA (n = 59) or individuals with normal aorta (n = 18) were prospectively recruited in an outpatient setting. Two-dimensional ultrasonography (2-D US) and 3-D US images were acquired with a single-sweep volumetric transducer. The analysis was performed offline with a software. Dmax and the vessel area of the Dmax slice were measured with 2-D US, 3-D US, and CT. The lumen and thrombus areas of the Dmax slice were also measured in 40 patients with intraluminal thrombus. Vessel and thrombus volumes were measured using 3-D US and CT.

Results

The Dmax values from 3-D US demonstrated better agreement (R² = 0.984) with the CT values than with the 2-D US values (R² = 0.938). Overall, 2-D US underestimated Dmax compared with 3-D US (32.3 ± 12.1 mm vs. 35.1 ± 12.0 mm). The Bland-Altman analysis of the 3-D US values, revealed better agreement with the CT values (2 standard deviations [SD], 2.9 mm) than with the 2-D US values (2 SD, 5.4 mm). The vessel, lumen, and thrombus areas all demonstrated better agreement with CT than with 2-D US (R² = 0.986 vs. 0.960 for the vessel, R² = 0.891 vs. 0.837 for the lumen, and R² = 0.977 vs. 0.872 for the thrombus). The thrombus volume assessed with 3-D US showed good correlation with the CT value (R² = 0.981 and 2 SD in the Bland-Altman analysis: 13.6 cm³).

Conclusions

Our novel semi-automated 3-D US analysis system provides more accurate Dmax values than 2-D US and provides precise volumetric data, which were not evaluable with 2-D US. The application of the semi-automated 3-D US analysis system in abdominal aorta assessment is easy and accurate.

Association of simple renal cysts and chronic kidney disease with large abdominal aortic aneurysm

Background

Abdominal aortic aneurysms (AAA) primarily affect men over 65 years old who often have many other diseases, with similar risk factors and pathobiological mechanisms to AAA. The aim of this study was to assess the prevalence of simple renal cysts (SRC), chronic kidney disease (CKD), and other kidney diseases (e.g. nephrolithiasis) among patients presenting with AAA.

Methods

Two groups of patients (97 AAA and 100 controls), with and without AAA, from the Surgical Clinic Charité, Berlin, Germany, were selected for the study. The control group consisted of patients who were evaluated for a kidney donation (n = 14) and patients who were evaluated for an early detection of a melanoma recurrence (n = 86). The AAA and control groups were matched for age and sex. Medical records were analyzed and computed tomography scans were reviewed for the presence of SRC and nephrolithiasis.

Results

SRC (74% vs. 57%; p<0.016) and CKD (30% vs. 8%; p<0.001) were both more common among AAA than control group patients. On multivariate analysis, CKD, but not SRC, showed a strong association with AAA.

Conclusions

Knowledge about pathobiological mechanisms and association between CKD and AAA could provide better diagnostic and therapeutic approaches for these patients.

Management of Uncomplicated Type B Aortic Dissection

Acute aortic dissection has an incidence of approximately half that of symptomatic abdominal and thoracic aneurysm of the aorta and more than twice the mortality of population-based controls. While urgent undelayed open surgery is the strategy of choice in proximal dissection, medical management has been the mainstay of treatment for uncomplicated distal or type B aortic dissection, but endovascular intervention is now considered a potential treatment option for all type B dissection due to its success in complicated cases. Endovascular repair can be technically demanding in aortic dissection, and timing of the repair can have a significant influence on anatomical and clinical outcome. Observational reports of feasibility and reasonable safety are flanked by only two randomised trials; the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) trial demonstrated improved remodelling in acute dissection and the INvestigation of STEnt grafts in patients with type B Aortic Dissections (INSTEAD) trial showed better long-term survival in patients treated endovascularly in the subacute phase. Meta-analyses and other large clinical studies have demonstrated mixed results. Due to some risks associated endovascular repair and the requirement of specialist aortic care (which is not always available), a pragmatic approach for current management could involve high intensity serial imaging in the acute phase of a type B aortic dissection, thereby identifying complicated cases for early intervention and selection of patients at high risk of disease progression for deferred endovascular management in the subacute phase within 90 days.

Anti-inflammatory diet and risk of abdominal aortic aneurysm in two Swedish cohorts

Objective

The relationship between dietary patterns and development of abdominal aortic aneurysm (AAA) is not well understood. Thus, we prospectively evaluated the association between the anti-inflammatory potential of diet and risk of AAA.

Methods

The study population included the Cohort of Swedish Men (45 072 men) and the Swedish Mammography Cohort (36 633 women), aged 45–83 years at baseline. The anti-inflammatory potential of diet was estimated using Anti-inflammatory Diet Index (AIDI) based on 11 foods with anti-inflammatory potential and 5 with proinflammatory potential (maximum 16 points) that was validated againsthigh sensitivity C reactive protein (hsCRP). Cox proportional hazard regression models were used to estimate HRs and 95% CIs. During the 14.9 years of follow-up (1 217 263 person-years), 1528 AAA cases (277 (18%) ruptured, 1251 non-ruptured) were ascertained via the Swedish Inpatient Register, the National Cause of Death Register and the Register for Vascular Surgery (Swedvasc).

Results

We observed an inverse association between the AIDI and AAA risk in women and men; HRs between extreme quartiles of the AIDI (≥8 vs ≤5 points) were 0.55 (95% CI 0.36 to 0.83) in women and 0.81 (95% CI 0.68 to 0.98) in men. The AIDI was inversely associated with both ruptured and non-ruptured AAA incidence; the HR of participants in the highest quartile of AIDI compared with those in the lowest quartile was 0.61 (95% CI 0.41 to 0.90) for ruptured AAA and 0.79 (95% CI 0.65 to 0.95) for non-ruptured AAA.

Conclusion

Adherence to diet with a high anti-inflammatory potential was associated with a reduced AAA risk, an association that was even more pronounced for AAA rupture.

Health literacy and abdominal aortic aneurysms

OBJECTIVE

Little is known about the public's knowledge of abdominal aortic aneurysms (AAA). Although preventive screening is available, millions of Americans remain unaware of their risk. Improved health literacy has been associated with increased screening and improvement in health outcomes. This study assessed the level of AAA literacy among respondents who participated in a free AAA screening event.

METHODS

Thirteen key words used by vascular surgeons to describe the risk, diagnosis, and treatment options for AAA were extracted from the screening tool used by the nation's largest provider of free AAA diagnostic services, AAAneurysm Outreach. The National Institutes of Health recommends readability of patient education materials to be at the sixth-grade level, but a readability analysis of these words placed them at a grade level of 14.6. A self-administrated questionnaire was developed that allowed respondents to compare each of the extracted words with a definitionally correct or incorrect word that reflected a sixth-grade readability score. These scores were then compared with the available demographics.

RESULTS

There were 570 completed questionnaires. Of the participants, 57.6% were female, 61.4% were 60 and above, and 32.6% were veterans. The average number of correct answers was 9.31 out of 13 (72% correct). Only 4.7% answered all questions correctly, with 29.1% missing five or more answers. The most frequently missed words were asymptomatic, screening, and cholesterol (56.5%, 44%, and 41.4% incorrect, respectively). The most frequently known terms were abdominal, diagnosis, and genetic (96%, 95.3%, and 91.9% correct, respectively). The remaining words fell between these extremes. Those aged 60 and above scored significantly lower than younger respondents (P < .0001). A post hoc power analysis indicated that the power to detect the obtained effects of age at the .05 level was greater than 0.95. Gender and veteran status did not produce any significant differences.

CONCLUSIONS

These data suggest an important communication gap between the words used by clinicians to describe the risks, diagnostic results, and treatment options of AAA and the targeted at-risk population, especially those 60 years and older.

Endovascular management of ruptured abdominal aortic aneurysms and acute aortic dissections

The management of vascular emergencies is dependent on rapid identification and confirmation of the diagnosis with concurrent patient stabilization prior to immediate transfer to the operating suite. A variety of technological advances in diagnostic imaging as well as the advent of minimally invasive endovascular interventions have shifted the contemporary treatment algorithms of such pathologies. This review provides a comprehensive discussion on the current state and future trends in the management of ruptured abdominal aortic aneurysms as well as acute aortic dissections.

Educational Case: Symptomatic but Unruptured Abdominal Aortic Aneurysm

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.

Tobacco smoking and the risk of abdominal aortic aneurysm: a systematic review and meta-analysis of prospective studies

Several studies have found that smoking increases the risk of abdominal aortic aneurysm, however, the strength of the association has differed between studies and data from cohort studies have not yet been summarized. A systematic review and meta-analysis was therefore conducted to clarify this association. We searched PubMed and Embase databases up to May 2nd 2018. A random effects model was used to estimate summary relative risks (RRs) and 95% confidence intervals (CIs). Twenty three prospective studies were included. Comparing current, former and ever smokers with never smokers the summary RRs were 4.87 (95% CI: 3.93-6.02, I2 = 92%, n = 20), 2.10 (95% CI: 1.76-2.50, I2 = 71%, n = 15) and 3.28 (95% CI: 2.60-4.15, I2 = 96%, n = 18), respectively. The summary RR was 1.87 (95% CI: 1.45-2.40, I2 = 97%) per 10 cigarettes per day, 1.78 (95% CI: 1.54-2.06, I2 = 83%) per 10 pack-years was and 0.45 (95% CI: 0.32-0.63, I2 = 92.3%) per 10 years of smoking cessation. There was evidence of nonlinearity for cigarettes per day and pack-years (pnonlinearity < 0.0001 and pnonlinearity = 0.02, respectively), but not for smoking cessation, pnonlinearity = 0.85. Among smokers who quit, the RR was similar to that of never smokers by 25 years of smoking cessation. These findings confirm a strong association between smoking and the risk of developing abdominal aortic aneurysms.

Understanding abdominal aortic aneurysm epidemiology: socioeconomic position affects outcome

Background

Low socioeconomic position (SEP) has been demonstrated to negatively influence outcome in several cardiovascular patient groups. The aim of this study was to analyse time trends of incidence of intact abdominal aortic aneurysm (iAAA) and ruptured AAA (rAAA), respectively, and to investigate whether SEP had any influence on the probability to present with rupture and, finally, to determine the impact of SEP on outcome.

Methods

Nationwide population-based study including all individuals with iAAA or rAAA in Sweden during 2001–2015.

Results

The number of individuals with an AAA was 41 222; the majority were identified as iAAA 33 254 (80.7%) and 7968 (19.3%) as rAAA. Time trends showed decreasing incidence of rAAA but increase in iAAA during the study period. Individuals with low income or low educational level were more likely to present with a rAAA rather than iAAA: OR 2.16 (95 % CI 1.98 to 2.36, p<0.001) and OR 1.33 (95 % CI 1.21 to 1.46, p<0.001), respectively. Low income was also associated with increased 90-day mortality and 1-year mortality after treatment for rAAA, OR 1.42 (95% CI 1.07 to 1.89, p=0.014) and OR 1.39 (95% CI 1.13 to 1.97, p=0.005).

Conclusion

This large nationwide study showed a decreasing incidence of rAAA. Individuals with low SEP were found to have an augmented risk of presenting with rAAA rather than iAAA and, in addition, to fare worse after repair. Consequently, SEP should be regarded as a relevant risk factor that should be included in considerations for improved care flow of patients with AAA.

Preoperative risk score for the prediction of mortality after repair of ruptured abdominal aortic aneurysms

OBJECTIVE

Even in the ruptured endovascular aneurysm repair first era, there are still patients who will not survive their ruptured abdominal aortic aneurysm (rAAA). All previously published mortality risk scores include intraoperative variables and are not helpful with the decision to operate or in providing preoperative patient and family counseling. The purpose of this study was to develop a practical preoperative risk score to predict mortality after repair of rAAA.

METHODS

Data of all patients with rAAA presenting between January 1, 2002, and October 31, 2013, were collected. Logistic regression was used to evaluate predictive variables both univariately and jointly, and the results of multivariate models guided the definition of the final simplified scoring algorithm.

RESULTS

There were 303 patients who presented during the study period. Sixteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Preoperative variables most predictive of mortality were age >76 years (odds ratio [OR], 2.11; confidence interval [CI], 1.47-4.97; P = .011), creatinine concentration >2.0 mg/dL (OR, 3.66; CI, 1.85-7.24; P < .001), pH <7.2 (OR, 2.58; CI, 1.27-5.24; P = .009), and systolic blood pressure ever <70 mm Hg (OR, 2.70; CI, 1.46-4.97; P = .002). Assigning 1 point for each variable, patients were stratified according to the preoperative rAAA mortality risk score (range, 0-4). For all repairs, at 30 days, patients with 1 point suffered 22% mortality; 2 points, 69% mortality; and 3 points, 80% mortality. All patients with 4 points died. There was a mortality benefit for ruptured endovascular aneurysm repair across all categories.

CONCLUSIONS

Our rAAA mortality risk score is based on four variables readily assessed in the emergency department and allows accurate prediction of 30-day mortality after repair of rAAAs. It also has a direct impact on clinical decision-making by adding prognostic information to the decision to transfer patients to tertiary care centers and aiding in preoperative discussions with patients and their families.

Endovascular management of acute aortic dissection

Acute dissection of the thoracic aorta is a potentially life-threatening condition which requires collaborative treatment from multiple specialties for optimal patient outcomes. Dissections involving the ascending aorta and aortic arch have traditionally been managed entirely by surgery, while dissections beyond the arch vessels have most commonly been relegated to medical management. This algorithm has been undergoing a paradigm shift over the past two decades due to improvements in stent graft technology, better understanding of the hemodynamic interactions of the true and false lumen and their influence on organ and limb perfusion, and improvements in medical management and long term surveillance for dissection-related complications. This manuscript includes a brief discussion of the pathogenesis and etiology of dissection, followed by an in-depth review of the medical and endovascular techniques utilized to treat patients afflicted by this condition.

Two-Year Outcomes of the Nellix EndoVascular Aneurysm Sealing System for Treatment of Abdominal Aortic Aneurysms

Purpose: To analyze the 2-year outcomes of endovascular aneurysm sealing (EVAS) according to 2 versions of the instructions for use (IFU). Methods: A retrospective study was conducted involving 355 consecutive patients treated with the first-generation EVAS device from April 2013 to December 31, 2015, at 3 high-volume centers. Out of 355 patients treated with EVAS, 264 were elective asymptomatic infrarenal EVAS procedures suitable for analysis. In this cohort, 168 (63.3%) patients were treated within the IFU 2013 criteria; of these 48 (18.2%) were in compliance with the revised IFU 2016 version. Results: Overall technical success was 98.2% (165/168) in the IFU 2013 group and 97.9% (47/48) in the IFU 2016 subgroup (p=0.428). The 2-year freedom from reintervention estimates were 89.7% (IFU 2013) and 95.7% (IFU 2016), with significantly more reinterventions in the first 45 cases (p=0.005). The stenosis/occlusion estimates were 6.5% (IFU 2013) and 4.2% (IFU 2016; p=0.705). Nine (5.4%) endoleaks (8 type Ia and 1 type Ib) were observed within the IFU 2013 cohort; 3 (2.1%) were in the IFU 2016 subgroup (p=0.583). Migration ≥10 mm or ≥5 mm requiring intervention was reported in 12 (7.1%) patients in the IFU 2013 cohort but none within the IFU 2016 subgroup. Ten (6.0%) patients demonstrated aneurysm growth in the IFU 2013 cohort, of which 2 (4.2%) were in the IFU 2016 subgroup. Overall survival and freedom from aneurysm-related death estimates at 2 years were 90.9% and 97.6% in the IFU 2013 cohort (IFU 2016: 95.5% and 100.0%). The prevalence of complications seemed lower within IFU 2016 without significant differences. Conclusion: This study shows acceptable 2-year results of EVAS used within the IFU, without significant differences between the 2 IFU versions, though longer follow-up is indicated. The refined IFU significantly reduced the applicability of the technique.

Fatal thoracic aortic aneurysm and dissection in a large family with a novel MYLK gene mutation: delineation of the clinical phenotype

Background

Thoracic and abdominal aortic aneurysms and dissection often develop in hypertensive elderly patients. At higher risk are smokers and those who have a family history of aortic aneurysms. In most affected families, the aortic aneurysms and dissection is inherited in an autosomal dominant manner with decreased penetrance and variable expressivity. Mutations at two chromosomal loci, TAA1 at 11q23 and the TAA2 at 5q13–14, and eight genes, MYLK, MYH11, TGFBR2, TGFBR1, ACTA2, SMAD3, TGFB2, and MAT2A, have been identified as being responsible for the disease in 23% of affected families.

Results

Herein, we inform on the clinical, genetic and pathological characteristics of nine living and deceased members of a large consanguineous Arab family with thoracic aortic aneurysm and dissection who carry a missense mutation c.4471G > T (Ala1491Ser), in exon 27 of MYLK gene. We show a reduced kinase activity of the Ala1491Ser protein compared to wildtype protein. This mutation is expressed as aortic aneurysm and dissection in one of two distinct phenotypes. A severe fatal and early onset symptom in homozygous or mild late onset in heterozygous genotypes.

Conclusions

We found that MYLK gene Ala1491Ser mutation affect the kinase activity and clinically, it presents with vascular aneurysms and dissection. We describe a distinct genotype phenotype correlation where; heterozygous patients have mild late onset and incomplete penetrance disease compared with the early onset severe and generally fatal outcome in homozygous patients.

Epidemiology of abdominal aortic aneurysms in a Chinese population during introduction of endovascular repair, 1994 to 2013: A retrospective observational study

The aim of this study was to examine changes in abdominal aortic aneurysm repair and mortality during a period when endovascular aneurysm repair (EVAR) was introduced.Open repair surgery was the mainstay of treatment for abdominal aortic aneurysm (AAA), but EVAR is increasingly utilized. Studies in the Western population have reported improved short-term or postoperative mortality and shorter length of hospital stay with EVAR. However, scant data are available in the Chinese population.We conducted a retrospective observational study using the database of the Hospital Authority, which provides public health care to most of the Hong Kong population. AAA patients admitted to public hospitals for intact repair or rupture from 1994 to 2013 were included in this study. We calculated the incidence of ruptured AAA, annual repair rates according to type of AAA and surgery, as well as death rates (operative and overall short-term). We calculated whether there were significant changes over time and compared short-term mortality between open surgery and EVAR.One thousand eight hundred eighty-five patients were admitted for intact repair and 1306 patients were admitted for AAA rupture, of whom 795 underwent rupture repair. Intact repair rates significantly increased in all age groups (7.3-37.8%, P < .001) over the study period.The incidence of ruptured AAA increased, in all age groups, except in < 64 years old. By 2013, 85% of intact repairs and 55.4% of rupture repair were done by EVAR. Over time, there was a significant decrease in operative mortality for intact repair (16.5 in 1994 to 7.1 in 2013, P = .01) and rupture repair (59.7 in 1994 to 30.8 in 2013, P = .003). Over the same time period, short-term AAA-related deaths decreased by more than half (73% in 1994 to 24% in 2013, P < .001), with a significant decline in all age groups, except < 64 years old. Short-term mortality was significantly lower for EVAR than for open repair (17.2% vs 40.3%, P < .01).Short-term AAA-related deaths have declined likely due to decreased operative mortality and rupture deaths during the period of EVAR introduction and expansion.

B-type natriuretic peptide for prediction of incident clinically significant abdominal aortic aneurysm: A population-based prospective study

Pathogenesis of abdominal aortic aneurysm (AAA) is unclear. The aim of this study was to evaluate inflammatory and hemodynamic plasma biomarkers as predictors for AAA in the prospective longitudinal cohort of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer Study ( n=5551; 1991–94). C-reactive protein, cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional pro-atrial natriuretic peptide (MR-proANP) and conventional risk factors at baseline were measured in patients with incident AAA during follow-up and compared to individuals without a diagnosis of AAA. Subjects were followed until 31 December 2013. Multivariable analyses were expressed in terms of hazard ratios (HR) per 1 standard deviation increment of each respective log-transformed plasma biomarker in the Cox proportional hazard models. Mean follow-up time was 20.7 years. Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%). Mean age of individuals with incident AAA was 59.7 years at study entry and AAA was diagnosed on average 14 years later. Adjusting for age, sex, smoking, body mass index, hypertension and diabetes mellitus, N-BNP (HR 1.29; 95% CI 1.03–1.62), but not MR-proANP (HR 1.20; 95% CI 0.95–1.50), was independently associated with incident AAA. In conclusion, the plasma biomarker N-BNP was associated with future development of AAA, which implies that this marker is a sensitive indicator of early subclinical cardiovascular disease.

MicroRNAs and Current Concepts on the Pathogenesis of Abdominal Aortic Aneurysm

OBJECTIVE

Abdominal aortic aneurysm is an important cause of morbidity and mortality in the elderly. Currently, the only way to prevent rupture and death related to abdominal aortic aneurysms is through surgical intervention. Endovascular treatment is associated with less morbidity than conventional treatment. The formation of an aneurysm is a complex multifactorial process, involving destructive remodeling of the connective tissue around the affected segment of the aorta wall. MicroRNAs are small sequences of non-coding RNAs that control diverse cellular functions by promoting degradation or inhibition of translation of specific mRNAs. A profile aberrant expression of miRNAs has been linked to human diseases, including cardiovascular dysfunction.

Circulating Midregional Proadrenomedullin and Risk of Incident Abdominal Aortic Aneurysm: A Prospective Longitudinal Cohort Study

Prospective clinical plasma biomarker studies in abdominal aortic aneurysm (AAA) pathogenesis have been hampered by the need for very large cohorts and long follow-up time. The main aim of the present study was to evaluate the association of adrenomedullin, a cardiovascular (CV) stress marker, and incident AAA risk. Prospective longitudinal cohort of middle-aged individuals from the CV cohort of the Malmö Diet and Cancer Study (n = 5551; 1991-1994) was assessed. Plasma concentrations of midregional proadrenomedullin (MR-proADM), C-reactive protein (CRP), and conventional risk factors were measured at baseline. Incidence of AAA was studied up to December 31, 2013. Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%). Mean age of individuals with incident AAA was 59.7 years at study entry, and AAA was diagnosed on average 14 years later. Adjusting for age, gender, smoking, body mass index, hypertension, diabetes mellitus, and CRP, MR-proADM (hazard ratio: 1.28; 95% confidence interval: 1.01-1.62) was independently associated with incident AAA. The plasma biomarker MR-proADM seems to be a marker of AAA risk, implying that AAA development may be driven by long-standing CV stress on the aortic wall.

Multi-modality molecular imaging of aortic aneurysms

Aneurysms of the thoracic and abdominal aorta are common and can be associated with significant morbidity and mortality when complications, including dissection, rupture, or thrombosis, occur. Current approaches to diagnosis and risk stratification rely on measurements of aneurysm size and rate of growth, often using various imaging modalities, which may be suboptimal in identifying patients at the highest and lowest risk of complications. Targeting the biological processes underlying aneurysm formation and expansion with molecular imaging offers an exciting opportunity to characterize aortic aneurysms beyond size and address current gaps in our approach to diagnosis and treatment. In this review, we summarize the epidemiology and biology of aortic aneurysms and highlight the role of molecular imaging in furthering our understanding of aneurysm pathogenesis and its potential future role in guiding management.

Time trends in hospital admissions and mortality due to abdominal aortic aneurysms in France, 2002-2013

BACKGROUND

Abdominal aortic aneurysms (AAA) are serious disease with a high fatality rate but recent epidemiologic data showed a decrease of AAA mortality. Our objective was to estimate, in France, the hospitalization, inhospital mortality and mortality rates due to AAA and to analyze their trends over time.

METHODS

Hospitalization data were extracted from the hospital discharge summaries in the national database between 2002 and 2013. The analysis covered all patients hospitalized for AAA as a principal diagnosis. During the same period, all death certificates mentioning AAA as an initial cause of death were included in the study. Crude and standardized rates were calculated according to age and sex. Poisson regression was used to analyze the average annual percent change.

RESULTS

In 2013, there were 8853 patients hospitalized for AAA in France (7986 unruptured and 867 ruptured). Between 2002 and 2013, the rate of patients hospitalized for unruptured AAA decreased slightly in men (-5.0%) but increased in women (+5.2%). By contrast, the rate of patients hospitalized for ruptured AAA has decreased by >20% in men and women. The proportion of endovascular treatment of unruptured AAA rose from <10% in 2005 to 35% in women and 40% in men in 2013. In 2013, 939 deaths from AAA were recorded. Mortality for this disease declined significantly from 2002 to 2013 in men and women.

CONCLUSION

The unfavorable epidemiological trends in women and important evolution of the management of AAA call for an epidemiological surveillance of this disease.