SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: Executive summary

Complicated and Uncomplicated Isolated Abdominal Aortic Dissections Demonstrate Different Patient Characteristics and Outcomes

BACKGROUND

Isolated abdominal aortic dissection (IAAD) is a rare entity with poorly defined risk factors and wide variation in management. We set forth to compare patient characteristics, management, and outcomes of uncomplicated isolated abdominal aortic dissection (uIAAD) versus high risk and complicated isolated abdominal aortic dissection (hrcIAAD) to investigate whether these categories can be utilized to guide IAAD management and provide risk stratification for intervention.

METHODS

Retrospective chart review was performed to identify all patients with spontaneous IAAD at a tertiary health care system between 1996 and 2022. Demographics, comorbidities, factors relating to initial presentation including imaging findings, and dissection outcomes including long-term all-cause mortality and aortic-related mortality from time of dissection to final available record were abstracted. IAAD demonstrating rupture or malperfusion were designated as complicated, those with aortic diameter greater than 4 cm on presentation or refractory pain were designated as high risk, and the remainder was designated as uIAAD. All variables were compared between hrcIAAD and uIAAD using Fisher's exact test, unpaired t-test, and Mann-Whitney U-test as appropriate.

RESULTS

Over the study period, 74 patients presented with spontaneous IAAD (mean age 60 ± 16 years, 61% male) with postdissection follow-up records to an average of 6.8 ± 5.8 years. Of these, 76% presented with uIAAD versus 24% with hrcIAAD. hrcIAAD was diagnosed at a significantly younger age on average than uIAAD (52 ± 14 vs. 62 ± 16 years, P = 0.02), was less likely to present with concomitant hyperlipidemia (0% vs. 41%, P < 0.01), coronary artery disease (6% vs. 47%, P < 0.01), and prior smoking history (39% vs. 72%). hrcIAAD was more likely to present in patients with a genetic aortopathy (27% vs. 7%, P = 0.03). Hypertension was not significantly different between groups. Patients with hrcIAAD were significantly more likely to present with extension into iliac arteries compared to uIAAD (61% vs. 18%, P < 0.01). A much higher proportion of hrcIAAD required hospitalization compared to uIAAD (83% vs. 30%, P < 0.01) and operative intervention (67% vs. 7%, P < 0.01). While there was no significant difference in all-cause mortality between groups, there was a significant difference between aortic-related mortality which only occurred in those with hrcIAAD (28% vs. 0%, P < 0.01).

CONCLUSIONS

Comparison of long-term outcomes suggests that hrcIAAD is associated with increased hospitalization and need for operative intervention compared to uIAAD. Significant differences in atherosclerotic risk factors and proportions of connective tissue disease history between patients who present with hrcIAAD and uIAAD suggest that differences in underlying etiology are largely responsible for whether IAAD progresses towards rupture or has a more benign course and should be considered in risk stratification to guide more specific and targeted management of IAAD.

Predictors of overall mortality after endovascular abdominal aortic repair - A single centre study

OBJECTIVES

A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause mortality after EVAR.

METHODS

Data regarding the demographic characteristics, comorbidities, laboratory values, selected anatomical factors, post-EVAR treatment, surveillance and complications of patients who underwent elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and January 2021 were evaluated. Mortality was assessed until 10 October 2023. Multivariate analyses were performed after adjusting for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery (IMA), IMA diameter and reinterventions.

RESULTS

This study included 196 patients (183 men and 13 women) with a mean age of 72.4 ± 7.67 years. The overall mortality rate during a mean follow-up period of 5.75 ± 3.1 years was 50.0% (N = 98). The 2-, 5- and 10-year mortality rates were 9.7%, 32.0% and 66.6%, respectively. The mortality rates decreased by 59% in patients with reinterventions (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.23-0.73; p = .002) and by 59% in patients treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR: 0.41; 95% CI: 0.26-0.66; p < .001). Chronic anticoagulation was associated with 2.09-fold higher mortality (HR: 2.09; 95% CI: 1.19-3.67; p = .010), and coronary artery disease (CAD) was associated with 1.74-fold higher mortality (HR: 1.74; 95% CI: 1.09-2.78; p = .021). Pre-EVAR AAA diameter and 1-year post-EVAR sac diameter were positively associated with mortality (HR: 1.05; 95% CI: 1.03-1.08; p < .001, and HR: 1.05; 95% CI: 1.03-1.07; p < .001, respectively), that is, an increase of pre-EVAR and/or 1-year post-EVAR AAA diameter by 1 mm was associated with a 5% higher risk of all-cause mortality.

CONCLUSIONS

Reinterventions and treatment with ACE inhibitors or ARBs may be associated with decreased post-EVAR mortality. A greater pre-EVAR, a post-EVAR AAA diameter, CAD and chronic anticoagulation were associated with higher all-cause mortality post-EVAR.

Laser assisted trans-endograft coil embolization of a type II endoleak

A type II endoleak after endovascular aneurysm repair can be challenging to stop. Numerous methods have been described, including trans-arterial, trans-lumbar, trans-caval, trans-endograft, peri-endograft, and open and laparoscopic surgical techniques. We present our experience with a laser-assisted trans-endograft approach, including technical variations of previous descriptions that might improve efficacy. In select cases, the laser-assisted trans-endograft approach might provide the most direct method of accessing and occluding the vessels feeding type II endoleaks.

SIRT6-mediated vascular smooth muscle cells senescence participates in the pathogenesis of abdominal aortic aneurysm

BACKGROUND AND AIMS

In this study, we carried out a clinical sample study, and in vivo and in vitro studies to evaluate the effect of SIRT6 and SIRT6-mediated vascular smooth muscle senescence on the development of abdominal aortic aneurysm (AAA).

METHOD AND RESULTS

AAA specimen showed an increased P16, P21 level and a decreased SIRT6 level compared with control aorta. Time curve study of Ang II infusion AAA model showed similar P16, P21 and SIRT6 changes at the early phase of AAA induction. The in vivo overexpression of SIRT6 significantly prevented AAA formation in Ang II infusion model. The expression of P16 and P21 was significantly reduced after SIRT6 overexpression. SIRT6 overexpression also attenuated chronic inflammation and neo-angiogenesis in Ang II infusion model. The overexpression of SIRT6 could attenuate premature senescence, inflammatory response and neo-angiogenesis in human aortic smooth muscle cells (HASMC) under Ang II stimulation.

CONCLUSIONS

SIRT6 overexpression could limit AAA formation via attenuation of vascular smooth muscle senescence, chronic inflammation and neovascularity.

Narrative Review of Risk Assessment of Abdominal Aortic Aneurysm Rupture Based on Biomechanics-Related Morphology

CLINICAL IMPACT

Studies have shown that the biomechanical indicators based on multi-scale models are more effective in accurately assessing the rupture risk of AAA. To meet the need for clinical monitoring and rapid decision making, the typical morphological parameters associated with AAA rupture and their relationships with the mechanical environment have been summarized, which provide a reference for clinical preoperative risk assessment of AAA.

Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair

BACKGROUND

Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA.

METHODS

This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months.

RESULTS

The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions.

CONCLUSIONS

Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.

BCGitis with aortoiliac aneurysm involvement: Report of two cases and review of the literature

BCGitis is a rare complication after intravesical administration of Bacillus Calmette-Guérin for high-grade superficial bladder cancer and carcinoma in situ. May cause vascular involvement. We present 2 cases and a review of the literature of the case reports pubished on the 10 years prior to April of 2022, when this proyect was finished, which described a case of aortoiliac mycotic aneurysm after receiving this treatment. Of the 51 cases included (49 revised and 2 original), 100% were men, 82% were older than 65 years. The median latency period was 15 months (IQR 18). The most frequent location was the abdominal aorta, rupture occurred in 45,1% of patients. The most frequent symptom was abdominal or lumbar pain (61%), followed by general syndrome (49%). In 39,2% cases, it was associated with retroperitoneal abscesess. Attributable mortality was 13,6%. BCGitis should be included in the differential diagnosis in patients who have received BCG therapy and present vascular involvement, even years after being treated.

The effect of exercise training intervention for patients with abdominal aortic aneurysm on cardiovascular and cardiorespiratory variables: an updated meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this meta-analysis was to evaluate the effect of exercise training intervention in patients with abdominal aortic aneurysm (AAA).

METHODS

Eight randomized controlled trials (RCTs) that recruited 588 AAA patients were extracted using 4 databases (PubMed, Embase, Wanfang Data, and Cochrane Library). Physiological and biochemistry parameters that included in this study are high-sensitivity C-reactive protein (hs-CRP), respiratory peak oxygen uptake rate (VO2peak), triglyceride (TG), total cholesterol (TC), anaerobic threshold (AT), the diameter of AAA, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), and matrix metalloproteinase-9 (MMP-9). Standard mean difference (SMD) was used to assess the between group effect.

RESULTS

This meta-analysis was synthesized with findings from RCTs and found that hs-CRP (SMD, - 0.56 mg/dL; 95% CI: - 0.90 to 0.22; P = 0.001), VO2peak (SMD, 0.4 mL/kg/min; 95% CI, 0.21 to 0.60; P < 0.001), TG (SMD, - 0.39 mg/dL; 95% CI: - 0.02 to 0.77; P = 0.04), and AT (SMD, 0.75 mL/kg/min; 95% CI, 0.54 to 0.96; P < 0.001) were significantly improved in the exercise groups, while the size of AAA (SMD, - 0.15; 95% CI: - 0.36 to 0.06; P = 0.15), TC (SMD, 0.16 mg/dL; 95% CI: - 0.10 to 0.42; P = 0.23), HDL/LDL ratio (SMD, - 0.06; 95% CI: - 0.32 to 0.20; P = 0.64), HDL (SMD, - 0.09; 95% CI: - 0.39 to 0.20; P = 0.54), LDL (SMD, 0.08; 95% CI: - 0.21 to 0.38; P = 0.59), and MMP-9 (SMD, - 0.23 mg/dL; 95% CI: - 0.53 to 0.06; P = 0.12) did not differ in the exercise groups compared with the controls.

CONCLUSION

Exercise intervention improved some of the CVD risk factors but not all, hs-CRP, VO2peak and AT were significantly improved after exercise intervention, while, changes of MMP-9, the size of AAA, and the overall lipids profile were not. Exercise intervention provides an additional solution for improving cardiorespiratory capacity and health status among AAA patients, and might lead to a delay of AAA progression.

Rotational Mechanical Thrombectomy to Treat Iliac Limb Occlusion after Endovascular Aortic Aneurysm Repair: The Rotational Mechanical Thrombectomy Italian Study

PURPOSE

To assess the safety and effectiveness of a rotational mechanical atherothrombectomy device in patients with symptomatic iliac limb occlusion after abdominal endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

A retrospective analysis was conducted on patients who underwent rotational mechanical thrombectomy using the Rotarex S device for symptomatic acute, subacute, or chronic graft limb thrombosis at 5 vascular centers between 2017 and 2021. This study comprised 23 male patients with a mean age of 74.5 years (SD ± 7.2) at the time of the procedure. The clinical presentation of the patients varied, with 1 patient experiencing acute limb ischemia and 11 patients (47.8%) experiencing disabling intermittent claudication. The remaining patients developed chronic limb-threatening ischemia after iliac limb occlusion. Early outcomes included technical success, postprocedural complications, and periprocedural mortality. Follow-up evaluations encompassed primary patency, patient survival, freedom from reintervention, and the need for surgical conversion.

RESULTS

Technical success was achieved in all cases, with no occurrences of distal embolization during or after the procedure, and no periprocedural deaths were reported. Endograft relining was performed in 82.6% of patients to establish a new, nonthrombogenic surface within the graft. Over a median follow-up period of 8 months (interquartile range, 3-16 months), 2 patients experienced iliac limb reocclusion. No deaths or other reinterventions occurred during the observational follow-up period.

CONCLUSIONS

Rotational mechanical thrombectomy for iliac limb occlusion after EVAR appears to be both safe and effective. This technique may uncover intraluminal defects contributing to graft occlusion and enable their resolution within the same procedure.

Predictive Parameters of Type 1A Endoleak for Elective Endovascular Aortic Repair: A Single-Center Experience

BACKGROUND

One of the most important factors that affects the success of Endovascular Aortic Repair (EVAR) treatment is the morphology of the neck of the aneurysm. Today, EVAR can be performed even in patients who do not meet the Instruction For Use criteria with hostile neck risk factors; thanks to the developing experience and technology. Our aim in this study was to determine risk factors for Type 1a endoleaks in patients who underwent EVAR and predictive factors for Type 1a endoleaks in patients with combinations of these risk factors.

METHODS

Patients who underwent elective EVAR for infrarenal abdominal aortic aneurysm in our medical center between July 2016 and January 2021 were enrolled. Of these 244 patients, 180 patients with documented preoperative and postoperative computed tomographic angiography results and a follow-up of at least 1 year were included in the study. The Mann-Whitney U test and Student's t-test were used to assess the relationship between nominal data and numerical values, and the t-test and Wilcoxon test were used to compare dependent groups. Logistic regression analysis was performed to model risk factors associated with endoleaks.

RESULTS

The results showed that a neck length less than 15 mm increased the development of type 1a endoleak by 10.4 times (P < 0.001). Furthermore, a neck diameter more than 28 mm increased the development of type 1a endoleak by 21.9 times (P = 0.04). A conical neck structure (gradual neck dilation > 2 mm) increased the development of type 1a endoleaks 4.8 times (P = 0.04). The presence of calcification (> 150 Hounsfield Unit and > 2 mm) in the neck increased the risk of type 1a endoleaks fourfold (P = 0.04). Hostile neck parameters were analyzed and patients with only 1 parameter (n = 69) had a 7.2% type 1a endoleak rate, while patients with 2 parameters (n = 15) had 26.6% and patients with more than 2 parameters (n = 11) had 45.5% type 1a endoleak rate.

CONCLUSIONS

Morphologic features of the neck structure of the aneurysm are among the most important parameters that affect the success of EVAR treatment. Alternative treatments should be considered in patients with more than 1 unfavorable neck parameter.

Photon-Counting Detector CT Angiography for Endoleak Detection After Endovascular Aortic Repair: Triphasic CT With True Noncontrast Versus Biphasic CT With Virtual Noniodine Imaging

OBJECTIVES

The aim of this study was to compare image quality and endoleak detection after endovascular abdominal aortic aneurysm repair between a triphasic computed tomography (CT) with true noncontrast (TNC) and a biphasic CT with virtual noniodine (VNI) images on photon-counting detector CT (PCD-CT).

MATERIALS AND METHODS

Adult patients after endovascular abdominal aortic aneurysm repair who received a triphasic examination (TNC, arterial, venous phase) on a PCD-CT between August 2021 and July 2022 were retrospectively included. Endoleak detection was evaluated by 2 blinded radiologists on 2 different readout sets (triphasic CT with TNC-arterial-venous vs biphasic CT with VNI-arterial-venous). Virtual noniodine images were reconstructed from the venous phase. The radiologic report with additional confirmation by an expert reader served as reference standard for endoleak presence. Sensitivity, specificity, and interreader agreement (Krippendorf α) were calculated. Image noise was assessed subjectively in patients using a 5-point scale and objectively calculating the noise power spectrum in a phantom.

RESULTS

One hundred ten patients (7 women; age, 76 ± 8 years) with 41 endoleaks were included. Endoleak detection was comparable between both readout sets with a sensitivity and specificity of 0.95/0.84 (TNC) versus 0.95/0.86 (VNI) for reader 1 and 0.88/0.98 (TNC) versus 0.88/0.94 (VNI) for reader 2. Interreader agreement for endoleak detection was substantial (TNC: 0.716, VNI: 0.756). Subjective image noise was comparable between TNC and VNI (4; IQR [4, 5] vs 4; IQR [4, 5], P = 0.44). In the phantom, noise power spectrum peak spatial frequency was similar between TNC and VNI (both f peak = 0.16 mm -1 ). Objective image noise was higher in TNC (12.7 HU) as compared with VNI (11.5 HU).

CONCLUSIONS

Endoleak detection and image quality were comparable using VNI images in biphasic CT as compared with TNC images in triphasic CT offering the possibility to reduce scan phases and radiation exposure.

Infrarenal Abdominal Aortic Aneurysm

Abdominal aortic aneurysms are found in up to 6% of men and 1.7% of women over the age of 65 years and are usually asymptomatic. The natural history of aortic aneurysms is continued dilation leading to rupture, which is associated with an overall 80% mortality. Of the patients with ruptured aneurysms that undergo intervention, half will not survive their hospitalization. Reduction in aneurysm mortality is therefore achieved by prophylactic repair during the asymptomatic period. On a population-based level, this is supported by abdominal aortic aneurysm screening programs. Approximately 60% of abdominal aortic aneurysms are confined to the infrarenal portion of the aorta and are amenable to repair with off-the-shelf endovascular devices. Endovascular techniques have now replaced open surgery as the primary modality for aneurysm repair.

Asymptomatic Fusiform Aortic Aneurysms in a 37-Year-Old Male: A Case Report

Abdominal aortic aneurysm (AAA) is mostly present in patients aged ≥65 years. Here, we present an unusual case of a 37-year-old male with a pair of asymptomatic, fusiform abdominal aortic aneurysms above and below the origin of the renal arteries. The patient was diagnosed with AAA in 2016 and had undergone yearly follow-ups since then. He had no major risk factors for AAA other than hypertension, which was managed with medication, and had only a brief history of smoking. He was also negative for all genetic and connective tissue defects. His aneurysms progressed slowly, with proximal and distal aneurysms currently measuring 3.9 cm and 4.5 cm, respectively. The patient was asymptomatic and was closely examined for further management.

Establishment of a clinical nurse specialist-led, virtual aneurysm surveillance clinic

BACKGROUND

The COVID-19 pandemic has necessitated significant changes to the manner in which healthcare is delivered. Chief among these has been the need to rapidly adopt virtual, or telephone clinics as a means of reducing unnecessary patient exposure to hospitals and clinical care settings. We were greatly aided in our adoption of virtual clinics by our experience in the establishment and maintenance of a Clinical Nurse Specialist-led, virtual clinic for both abdominal aortic (AAA) and extra-aortic aneurysm (EAA) surveillance within our department since 2016. Patients undergoing surveillance for abdominal aortic aneurysm (AAA) require frequent and lifelong clinical review. Previous studies have shown that post-operative surveillance in particular is critical in prolonging survival in AAA patients and in the early detection of late complications particularly following endovascular repair (EVAR). Poor compliance with EVAR surveillance has been shown to result in worse outcomes.

AIM

The aim of this study was to evaluate the success of a nurse-led virtual clinic programme in terms of the safe management of patients undergoing AAA surveillance in a nurse-led virtual clinic.

RESULTS

Over the course of the 4-year period from 2016 to 2019, 1352 patients were enrolled in the virtual aneurysm surveillance clinic. The majority of patients each year were male, ranging from 78.2% in 2016 to 85.2% in 2017. The majority of patients encountered the service owing to pre-operative surveillance of an AAA, with this group comprising at least 65% of the total cohort of patients each year.Over the course of the 4-year period of the virtual clinic there were 1466 patient encounters. Each ambulatory day care centre (ADCC) attendance normally costs the hospital €149. Therefore, a total saving of €218,434 resulted from this initiative alone. No patient presented as an emergency with a ruptured aneurysm during the time period studied.

CONCLUSION

Patients with AAA can be safely kept under surveillance in a nurse-led virtual clinic. Our experience with this model of care proved to be particularly advantageous during the period of the early COVID-19 pandemic.

Outcome of different endovascular modalities to treat common iliac artery aneurysms, single center study

INTRODUCTION

Iliac aneurysms occur in 10% of patients with abdominal aortic aneurysms (AAA). There are three different endovascular approaches to their treatment in the context of infrarenal Endovascular Aortic Aneurysm Repair (EVAR): occlusion by coiling the internal iliac, incorporation using an iliac branch device, and delaying repair using a bell bottom limb. We sought to determine outcomes associated with these three strategies in our practice.

METHODOLOGY

The study was a combined prospective cohort study with a retrospective arm: prospective patient recruitment was done for 1 year from September 2019 and ended by September 2020, and retrospective data was collected from 2017 to 2019. Demographic, procedural, and imaging data was collected. SPSS was used to analyze data as patients were classified by limbs in four groups: iliac branched, bell bottom, coil and cover technique, and standard treated limbs.

RESULTS

There were 65 male and 4 female patients included in this study incorporating 137 limbs with a mean age of 78 years (SD ± 8 years). Two patients died after discharge (at 3 and 21 months postoperatively, without hospital admission) and five patients were lost to long-term follow-up. Three patients had operations that deviated from the plan: one was an IBD converted to bell bottom, one was an IBD that was converted to coil and cover, and one was a bell bottom that did not seal. Follow-up revealed late type IB endoleak in three bell bottom limbs and one limb treated with coil and cover. Common iliac occlusion occurred in one IBD, three bell bottom limbs, and two limbs treated with coil/cover technique. There were four additional ischemic events (buttock claudication in three and intestinal ischemia in one): all ischemic events occurred in the coil and cover group (p = .001).

CONCLUSIONS

Given the small population size examined in this study, there is no statistical difference between treatment groups; however, there was a trend toward bell bottom technique being associated with higher incidence of type IB endoleak. Coil and cover technique was associated with decreased IB endoleak; however, Buttock claudication and intestinal ischemia occurred more significantly in this group. Using IBD may be the best strategy to improve short- and long-term outcomes in patients with iliac aneurysms.

Dual-Source Photon-Counting Computed Tomography-Part III: Clinical Overview of Vascular Applications beyond Cardiac and Neuro Imaging

Photon-counting computed tomography (PCCT) is an emerging technology that is expected to radically change clinical CT imaging. PCCT offers several advantages over conventional CT, which can be combined to improve and expand the diagnostic possibilities of CT angiography. After a brief description of the PCCT technology and its main advantages we will discuss the new opportunities brought about by PCCT in the field of vascular imaging, while addressing promising future clinical scenarios.

Pulsatile Changes of the Aortic Diameter May Be Irrelevant Regarding Endograft Sizing in Patients With Aortic Disease

PURPOSE

Endovascular aortic repair has become the preferred elective treatment of infrarenal aortic aneurysms. Aortic pulsatility may pose problems regarding endograft sizing. The aims of this study are to determine the aortic pulsatility in patients with aortic disease and to evaluate the effect of pulsatility on the growth of aneurysms.

MATERIALS AND METHODS

In this retrospective study, analyses of computed tomography angiography (CTA) images of 31 patients under conservative treatment for small abdominal aortic aneurysms were performed. Reconstructions of the raw electrocardiography (ECG) gated dataset at 30% and 90% of the R-R cycle were used. After lumen segmentation, total aortic cross-sectional area was measured in diastole and systole in the following zones: Z0, Z3, Z5, Z6, Z8, and Z9. Effective diameters (EDs) were calculated from the systolic (ED_sys) and diastolic (ED_dia) cross-sectional areas to determine absolute (ED_sys - ED_dia, mm) and relative pulsatility [(ED_sys - ED_dia) / ED_dia, %]. Diameter of the aneurysms was measured on baseline images and the last preoperative follow-up study of each patient.

RESULTS

A total of 806 measurements were completed, 24 pulsatility and 2 growth measurements per patient. The mean pulsatility values at each point were as follows: Z0: 0.7±0.8 mm, Z3: 1.0±0.6 mm, Z5: 1.0±0.6 mm, Z6: 0.8±0.7 mm, Z8: 0.7±1.0 mm, Z9: 0.9±0.9 mm. Follow-up time was 5.5±2.2 years during which a growth of 13.42±9.09 mm (2.54±1.55 mm yearly) was observed. No correlation was found between pulsatility values and growth rate of the aneurysms.

CONCLUSION

The pulsatility of the aorta is in a submillimetric range for the vast majority of patients with aortic disease, thus probably not relevant regarding endograft sizing. Pulsatility of the ascending aorta is smaller than that of the descending segment, making an additional oversize of a Z0 implantation questionable.

CLINICAL IMPACT

Endovascular aortic repair reqiures precise preoperative planning. Pulsatile changes of the aortic diameter may pose issues regarding endograft sizing. In our retrospective single-centre study, aortic pulsatility of patients with AAA was measured on ECG gated CTA images. Pulsatility values reached a maximum at the descending aorta, however absolute pulsatility values did not exceed 1 mm at any point along the aorta. Therefore, significance of aortic pulsatility regarding the sizing of EVAR prostheses is questionable. Correlation between pulsatility and AAA growth was not found.

Dying to Get There: Patients Who Reside at Increased Distance from Tertiary Center Experience Increased Mortality Following Abdominal Aortic Aneurysm Rupture

BACKGROUND

Centralization of vascular surgery care for Ruptured Abdominal Aortic Aneurysms (RAAAs) to high-volume tertiary centers may hinder access to timely surgical intervention for patients in remote areas. The objective of this study was to determine the association between distance from vascular care and mortality from RAAAs in the province of Nova Scotia, Canada.

METHODS

A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients were divided into groups by estimated travel time from their place of residence to the tertiary center (<1 hr and ≥1 hr) using geographic information software. Baseline and operative characteristics were identified for all patients through available databases and completed through chart review. Mortality at home, during transfer to the vascular center, and overall 30-day mortality were compared between groups using t-test and chi-squared test, as appropriate. Multivariable logistic regression analysis was used to calculate the independent effect of travel time on survival outcomes.

RESULTS

A total of 567 patients with RAAA were identified from 2005-2015, of which 250 (44%) resided <1 hr travel time to the tertiary center and 317 (56%) resided ≥1 hr. On multivariable analysis, travel time ≥1 hr from vascular care was an independent predictor of mortality at home (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.07-2.63, P = 0.02), mortality prior to operation (OR 2.64, 95% CI 1.81-3.83, P < 0.001), and overall 30-day mortality (OR 1.61, 95% CI 1.10-2.37, P = 0.02). In patients who received an operation (n = 294), there was no association between increased travel time and mortality (OR 1.02, 95% CI 0.60-1.73, P = 0.94).

CONCLUSIONS

Travel time ≥1 hr to the tertiary center is associated with significantly higher mortality from ruptured abdominal aortic aneurysm (AAA). However, there was no difference in overall chance of survival between groups for patients that underwent AAA repair. Therefore, strategies to facilitate early detection, and timely transfer to a vascular surgery center may improve outcomes for patients with RAAA.

Outcomes in octogenarians after thoracoabdominal and juxtarenal aortic aneurysm repair using fenestrated-branched devices justifies treatment

OBJECTIVE

To compare outcomes between octogenarians and nonoctogenarians undergoing thoracoabdominal aortic aneurysm repair and juxtarenal aortic aneurysm repair using branched and/or fenestrated endovascular devices (F/BEVAR) and compare octogenarian survival to population survival statistics from Ontario, Canada.

METHODS

Patients who underwent F/BEVAR at a single institution between 2007 and 2020 were retrospectively reviewed with a median follow-up of 3.3 years (interquartile range, 1.6-5.3). The median survival of an average 84-year-old Ontarian from Canada, adjusted for a male:female ratio of 4:1, was retrieved from publicly available Statistics Canada data.

RESULTS

In total, 68 octogenarians (25.8%) and 196 nonoctogenarians (74.2%) were included (mean age, 83.5 ± 3.0 vs 71.9 ± 5.8 years; P ≤ .001). The maximum aneurysm size was significantly larger in octogenarians (68.9 ± 11.4 mm vs 65.4 ± 10.0 mm; P = .017). No differences in the number of thoracoabdominal aortic aneurysm repairs (29.4% vs 38.3%; P = .19) or operative technical success (92.6% vs 85.7%; P = .136) were observed between the two cohorts. Postoperatively, no significant differences in overall in-hospital mortality (7.3% vs 5.1%; P = .49), elective in-hospital mortality (6.1% vs 4.4%; P = .49), stroke (1.5% vs 3.6%; P = .384), or spinal cord ischemia (2.9% vs 9.2%; P = .094) were seen between octogenarians and nonoctogenarians. There was no difference in survival at 4 years between the two cohorts (62.9% vs 71.1%; P = .22), however, survival at 6 years was significantly lower for octogenarians (44.5% vs 64.1%; hazard ratio, 1.96; P = .02). The cumulative rate of reintervention (44.1% vs 41.3%; P = .84) and freedom from branch instability (67.6% vs 73.5%; P = .33) at 6 years were not different between the two groups. When comparing octogenarians who survived to discharge from index hospitalization after F/BEVAR with 84-year-old Ontarians unmatched for comorbidities, a survival difference of 4.8% and 11.1% was noted at 4 and 6 years, respectively.

CONCLUSIONS

F/BEVAR in octogenarians is associated with no differences in technical success or postoperative adverse outcomes when compared with their younger counterparts. Octogenarians had increased mortality after 4 years and their survival at 4 years was comparable with that of an 84-year-old Ontarian. F/BEVAR was safe and effective in octogenarians deemed fit for intervention. Further research into preoperative patient selection and improving perioperative outcomes is needed.

[Results of a single center vascular screening program in Germany]

BACKGROUND

Cardiovascular diseases are the main cause of death in Europe with a relevant socioeconomic burden. A screening program for vascular diseases in asymptomatic persons with a defined risk constellation can lead to an early diagnosis.

OBJECTIVE

The study examined a screening program for carotid stenosis, peripheral arterial occlusive disease (PAOD) and abdominal aortic aneurysms (AAA) in persons without any known vascular disease with respect to demographic data, risk factors, pre-existing conditions, medication intake, detection of pathological findings and/or findings requiring treatment.

MATERIAL AND METHODS

Test subjects were invited using various information material and filled in a questionnaire on cardiovascular risk factors. The screening took place with measurement of the ABI and duplex sonography as a monocentric prospective single arm study within 1 year. Endpoints were the prevalence of risk factors and pathological and/or results requiring treatment.

RESULTS

A total of 391 persons participated, 36% presented with at least 1 cardiovascular risk factor, 35.5% with 2 and 14.4% with 3 or more. The sonography showed results requiring control with a carotid stenosis of < 50-> 75% or occlusion in 9%. An AAA with a diameter of 3.0-4.5 cm was diagnosed in 0.9% and a pathological ABI < 0.9 or > 1.3 in 12.3%. The indications for a pharmacotherapy were found in 17% and no operation was recommended.

CONCLUSION

The practicability of a screening program for carotid stenosis, PAOD and AAA of a defined risk population was shown. Vascular pathologies that required treatment were hardly found in the catchment area of the hospital. Consequently, the implementation of this screening program in Germany based on the collected data cannot currently be recommended in this form.

Reconstruction of the accessory renal artery with autogenous vessels in aortic hybrid surgery: A case report

OBJECTIVE

Accessory renal artery (ARA) is a common variant of renal vessels. Currently, there are some controversies about reconstruction strategy and few cases reported in the literature. Individualized treatment should be carried out according to preoperative renal function evaluation and technical level.

METHODS

In this paper, a 50-year-old male patient was reported, who developed a dissecting aneurysm after thoracic endovascular aortic repair (TEVAR) and needed further intervention. Imaging showed that the left kidney was supplied by bilateral renal artery (false lumens), and there were left renal malperfusion complicated with abnormal renal function.

RESULTS

Autologous blood vessels were used to successfully reconstruct ARA with during hybrid surgery. Renal perfusion and renal function recovered rapidly after operation. There was no abnormality in renal indexes after 3 months follow-up.

CONCLUSION

It is beneficial and necessary to reconstruct ARA for patients with renal malperfusion or abnormal renal function before operation.

Photon-Counting Computed Tomography (PCCT): Technical Background and Cardio-Vascular Applications

Photon-counting computed tomography (PCCT) is a new advanced imaging technique that is going to transform the standard clinical use of computed tomography (CT) imaging. Photon-counting detectors resolve the number of photons and the incident X-ray energy spectrum into multiple energy bins. Compared with conventional CT technology, PCCT offers the advantages of improved spatial and contrast resolution, reduction of image noise and artifacts, reduced radiation exposure, and multi-energy/multi-parametric imaging based on the atomic properties of tissues, with the consequent possibility to use different contrast agents and improve quantitative imaging. This narrative review first briefly describes the technical principles and the benefits of photon-counting CT and then provides a synthetic outline of the current literature on its use for vascular imaging.

Change in Abdominal Aortic Aneurysm Sac Diameter After Endovascular Repair: A Single-Center Experience From Taiwan

PURPOSE

The purpose of this study was to investigate the change in the diameter of infrarenal abdominal aortic aneurysm (AAA) sacs after endovascular aortic repair (EVAR) in Taiwanese patients and to depict its association with clinical outcomes.

MATERIALS AND METHODS

This retrospective cohort study was conducted on patients who underwent EVAR for infrarenal AAA between January 2011 and December 2016. All preoperative and follow-up computed tomography (CT) images were reviewed. Postoperative CT angiography was arranged after 1 month and annually thereafter. The maximal diameter on the axial plane and the maximal diameter perpendicular to the centerline on the coronal and sagittal planes were measured. The study examined post-EVAR sac diameter change over time and compared the differences in adverse events (AEs) among groups.

RESULTS

The survey included a total of 191 patients with a median follow-up duration of 2.5 (interquartile range: 1.1-2.9) years. Overall survival rates at 1, 2, and 5 years were 92%, 81%, and 76%, respectively. According to their last CT scans, the patients were categorized into 3 groups as follows: shrinkage, stationary, and enlargement, which comprised 58 (30.4%), 118 (61.8%), and 15 (7.9%) patients, respectively. Pre-EVAR characteristics and sac diameters were similar among the groups. Sac shrinkage was exclusively observed in the first 2 years, whereas sac enlargement developed at all follow-up periods. Patients with sac enlargement had higher incidence rates of endoleaks, complications, and reintervention than the other groups.

CONCLUSION

Based on our observations, post-EVAR sac shrinkage only occurs in the first 2 years; however, post-EVAR sacs may enlarge at any point and even after 5 years. In our study, patients with sac enlargement had higher rates of adverse events and reintervention.

Routine Inferior Mesenteric Artery Embolisation is Unnecessary Before Endovascular Aneurysm Repair

OBJECTIVE

A type II endoleak is the most common complication during surveillance after endovascular aneurysm repair (EVAR), and a patent inferior mesenteric artery (IMA) is a known risk factor for an endoleak. The effect of routine IMA embolisation prior to EVAR on overall outcome is unknown. The aim of the study was to compare two strategies: routine attempted IMA embolisation prior to EVAR (strategy in centre A) and leaving the IMA untouched (strategy in centre B).

METHODS

Patients were treated with EVAR in two centres during the period 2005 - 2015, and the data were reviewed retrospectively. The primary endpoints were re-intervention rate due to type II endoleaks and the late IMA embolisation rate. Secondary endpoints included EVAR related re-intervention, sac enlargement, aneurysm rupture, and open conversion rates.

RESULTS

Strategy A was used to treat 395 patients. The IMA was patent in 268 (67.8%) patients, and embolisation was performed in 164 (41.5%). The corresponding figures for strategy B were 337 patients with 279 (82.8%) patent IMAs, two (0.6%) of which were embolised. The mean duration of follow up was 70 months for strategy A and 68.2 months for strategy B. The re-intervention rates due to a type II endoleak were 12.9% and 10.4%, respectively (p = .29), with no significant difference in the rate of re-interventions to occlude a patent IMA (2.0% and 4.7%, respectively; p = .039). The EVAR related re-intervention rate was similar, regardless of strategy (24.1% and 24.6%, respectively; p = .93). Significant sac enlargement was seen in 20.3% of cases treated with strategy A and in 19.6% treated with strategy B (p = .82). The rupture and conversion rates were 2.5% and 2.1% (p = .69) and 1.0% and 1.5% (p = .40), respectively.

CONCLUSION

The strategy of routinely embolising the IMA does not seem to yield any significant clinical benefit and should therefore be abandoned.

Prevalence and Risk Factors of Abdominal Aortic Aneurysms Detected with Ultrasound in Korea and Belgium

The objective was to investigate the prevalence of abdominal aortic aneurysms (AAAs) and the diameters of the aorta and common iliac arteries (CIAs) in a Korean cohort and secondly to analyze the differences in aortic diameter by comparison with a European cohort. The Korean cohort included participants ≥ 50 years who consented to AAA screening and data were analysed retrospectively. Aortic and common iliac diameters were measured using the outer-to-outer diameter method and prevalence rates were calculated. Common risk factors such as smoking, body mass index, pulmonary disease, hypertension, diabetes, hyperlipidaemia, ischaemic heart disease, and cerebrovascular disease were reported in association with AAA occurrence and AAA development. The aortic diameters were then compared with those in a Belgian cohort of 2487 participants identified in the Liège AAA Screening Program. An aortic size index (ASI) was also calculated to account for the potential size differences in the Belgian and Korean populations. A total of 3124 Korean participants were examined using ultrasound. The prevalence of AAAs in this cohort was 0.7%. The combined prevalence of subaneurysmal dilatation and AAA was 1.5%. The prevalence in male smokers older than 65 years was 2.7% (19/715). The mean infrarenal aortic diameter was 17.3 ± 3.1 mm in men and 15.7 ± 2.7 mm in women; the corresponding values in Belgian participants were 19.4 ± 3.0 mm in men and 17.9 ± 2.4 mm in women. The median aortic size index was 0.99 (interquartile range 0.88-1.12). The mean infrarenal aortic diameter was significantly smaller in the Korean cohort than in the Belgian cohort. Considering the observed prevalence of AAAs in different age groups, the age groups which would contribute to most cases was male persons above 66 years in both cohorts.

Protection of diabetes in aortic abdominal aneurysm: Are antidiabetics the real effectors?

Aortic aneurysms, including abdominal aortic aneurysms (AAAs), is the second most prevalent aortic disease and represents an important cause of death worldwide. AAA is a permanent dilation of the aorta on its infrarenal portion, pathologically associated with oxidative stress, proteolysis, vascular smooth muscle cell loss, immune-inflammation, and extracellular matrix remodeling and degradation. Most epidemiological studies have shown a potential protective role of diabetes mellitus (DM) on the prevalence and incidence of AAA. The effect of DM on AAA might be explained mainly by two factors: hyperglycemia [or other DM-related factors such as insulin resistance (IR)] and/or by the effect of prescribed DM drugs, which may have a direct or indirect effect on the formation and progression of AAAs. However, recent studies further support that the protective role of DM in AAA may be attributable to antidiabetic therapies (i.e.: metformin or SGLT-2 inhibitors). This review summarizes current literature on the relationship between DM and the incidence, progression, and rupture of AAAs, and discusses the potential cellular and molecular pathways that may be involved in its vascular effects. Besides, we provide a summary of current antidiabetic therapies which use could be beneficial for AAA.

One-year sac regression is associated with freedom from fatal adverse events after endovascular aneurysm repair

OBJECTIVE

Although the predictors of long-term prognosis after endovascular aneurysm repair (EVAR) have been investigated, several reports have suggested that early sac shrinkage (ESS) is associated with superior long-term prognosis. However, it was not clear whether ESS was associated with aneurysm-related mortality. The aim of this study was to define fatal adverse events and to examine their association with ESS.

METHODS

All consecutive patients who underwent EVAR for an abdominal aortic aneurysm at Nagoya University Hospital between June 2007 and August 2018 were identified. We defined ESS as an aneurysm diameter decrease of 10 mm or more at 1 year after EVAR, and we defined fatal adverse events as aneurysm-related death, aneurysm sac rupture, open conversion, secondary type Ia endoleak, or secondary type IIIa/b endoleak. Then, we evaluated the association between ESS and fatal adverse events and identified predictors of ESS.

RESULTS

During the study period, 553 patients were identified and included. Fatal adverse events occurred in 42 patients (7.6%), and the details of the fatal adverse events were as follows: 13 aneurysm-related deaths, 17 aneurysm sac ruptures, 14 open conversions, 13 type Ia endoleaks, and 6 type III endoleaks. ESS occurred in 146 patients (26.4%). Kaplan-Meier curves showed that the ESS group had a significantly lower incidence of fatal adverse events (P < .001). Multivariate analysis showed that there were significant differences in terms of 5 or more preoperatively patent lumbar arteries (odds ratio [OR], 0.67; P = .049; 95% confidence interval [CI], 0.45-1.00), chronic kidney disease (OR, 0.49; P < .01; 95% CI, 0.29-0.84), and Zenith endograft use (OR, 1.76; P < .01; 95% CI, 1.16-2.67). Furthermore, the percentage of cases that achieved an aneurysm diameter of less than 40 mm was significantly higher in the ESS group (76.0% vs 15.5%; P < .01). The use of Zenith endografts showed a significantly higher rate of aneurysm disappearance than the use of Endurant endografts (P < .01) and Excluder endografts (P < .01). In addition, it was found that ESS was more likely to occur with the use of Zenith endografts, even when propensity score matching was performed for the neck morphology.

CONCLUSIONS

ESS was associated with a lower rate of life-threatening adverse events after EVAR. The use of Zenith endografts was a predictor of ESS and was associated with increased rates of long-term sac shrinkage and aneurysm disappearance compared with the Endurant and Excluder endografts. Using the predictors of ESS identified in this study, we may be able to expand the indications for EVAR to patients with a longer life expectancy.

Ultrasound Transducer Pressure: An Unexplored Source of Abdominal Aortic Aneurysm Measurement Error

This study was aimed at quantifying the abdominal aortic aneurysm (AAA) compression phenomenon and assessing the use of a new tool to estimate transducer pressure in vivo. In this cross-sectional study, 47 participants with AAA and a median anterior-to-posterior (AP) AAA diameter of 46 mm (range: 30-76 mm) were included. The majority of the patients were overweight with body mass indexes >25 (33/47, 70%). A standardized ultrasound (US)-compatible gel pad, with a pre-defined thickness (15 mm) and mass (150 g), was interposed between the US transducer and participant to estimate the applied transducer pressure. A firm transducer pressure significantly lowered the median AP diameter from 46.1 mm (range: 29.7-76.3) to 39.4 mm (range: 21.7-67.5) (p = 0.001). The mean diameter bias between light and firm transducer pressure was 6.1 mm (95% confidence interval: 4.9-7.3). The applied transducer pressure varied significantly and could be measured by translating the deformation of a low-tech gel pad interposed between the US transducer and the participant.

Temporal trends in abdominal aortic aneurysmal disease: a nationwide cohort study on cardiovascular morbidity and medical cardioprotective therapy

Aims

Abdominal aortic aneurysmal disease is associated with increased risk of cardiovascular morbidity and death, which potentially can be reduced with cardioprotective medical therapy. The aim of this study was to observe temporal trends in prevalence and incidence of cardiovascular comorbidity as well as use of medical cardioprotective treatment in patients diagnosed with abdominal aortic aneurysmal disease.

Methods and results

This was a population-based cohort study based on data from national health registries, including all patients diagnosed with abdominal aortic aneurysms between 1998 and 2018. Data were stratified into four time periods (1999–2003, 2004–2008, 2009–2013, and 2014–2018) to illustrate trends over time. Outcome measures were (i) cardiovascular comorbidity and medical cardioprotective therapy at time of diagnosis, (ii) new admissions for atherosclerotic cardiovascular disease, and (iii) all-cause mortality after 2-year follow-up. The study cohort included 33 296 individuals. Mean age was 74 years. Prevalence of atherosclerotic cardiovascular comorbidity at diagnosis decreased from 41.5 to 32.6%. Use of statins increased from 17.9 to 66.9%, antiplatelets from 45.6 to 63.3%, and combined therapy with both antiplatelets and statins from 11.3 to 44.8%, and from 12.1 to 50.7% when anticoagulant therapy was included. Developments in medication use plateaued after 2013. Prevalence and incidence of atherosclerotic cardiovascular disease decreased through all four time periods. The same applied to all-cause mortality, which decreased from 24.3 to 12.4 deaths (per 100 person-years).

Conclusion

In patients diagnosed with abdominal aortic aneurysm, cardiovascular comorbidity at diagnosis, risk of future cardiovascular events, and all-cause mortality is decreasing. Nevertheless, cardiovascular burden and mortality rates remain substantial, and medical cardioprotective therapy can be further improved.

Endothelial pannexin-1 channels modulate macrophage and smooth muscle cell activation in abdominal aortic aneurysm formation

Pannexin-1 (Panx1) channels have been shown to regulate leukocyte trafficking and tissue inflammation but the mechanism of Panx1 in chronic vascular diseases like abdominal aortic aneurysms (AAA) is unknown. Here we demonstrate that Panx1 on endothelial cells, but not smooth muscle cells, orchestrate a cascade of signaling events to mediate vascular inflammation and remodeling. Mechanistically, Panx1 on endothelial cells acts as a conduit for ATP release that stimulates macrophage activation via P2X7 receptors and mitochondrial DNA release to increase IL-1β and HMGB1 secretion. Secondly, Panx1 signaling regulates smooth muscle cell-dependent intracellular Ca²⁺ release and vascular remodeling via P2Y2 receptors. Panx1 blockade using probenecid markedly inhibits leukocyte transmigration, aortic inflammation and remodeling to mitigate AAA formation. Panx1 expression is upregulated in human AAAs and retrospective clinical data demonstrated reduced mortality in aortic aneurysm patients treated with Panx1 inhibitors. Collectively, these data identify Panx1 signaling as a contributory mechanism of AAA formation.

Pannexin-1 ion channels on endothelial cells regulate vascular inflammation and remodeling to mediate aortic aneurysm formation. Pharmacological blockade of Pannexin-1 channels may offer translational therapeutic mitigation of aneurysmal pathology.

Percutaneous Drainage for Aortic Graft Infection Post-aneurysm Repair: A Viable Option?

Purpose

Non-operative management of aortic graft infection is usually only considered in a palliative context. We describe the safety, efficacy, and clinical outcomes of percutaneous drainage of aortic graft infections (AGI) following either open or endovascular repair of aneurysmal disease.

Methods

Twelve consecutive patients (11 males, 1 female, mean age 72.7 ± 10.3 years, age range 52-88 years) between January 2010-July 2020 who underwent percutaneous drain insertion in either an infected aortic sac or periaortic abscess cavity following endovascular or open surgical graft repair were identified. Patient and procedural characteristics as well as clinical outcomes were determined.

Results

Of the 12 patients who underwent percutaneous drain insertion, five (41.7%) had undergone open abdominal aneurysm repair, one (8.3%) open thoracoabdominal aneurysmal repair, and six (50%) endovascular abdominal aneurysm repairs. Drain size ranged from 10-20 French. All were inserted under ultrasound (US), computed tomography (CT), and/or fluoroscopic guidance. Median duration of drain placement was 55.2 days (range 3-174). Five patients (41.7%) had the drain in place as a stabilizing bridge until or after definitive surgical explantation and aortic reconstruction. Seven patients (58.3%) were managed with drain placement and antibiotic therapy without surgical intervention. Six (50%) were alive at the most recent time of follow-up (median, 732 days, range 166-1650 days). Three patients (25%) died during follow-up with causes including erosion of aortic reconstruction into sigmoid colon, unrelated chronic obstructive pulmonary disease exacerbation, and severe clostridium difficile colitis and pseudomonal pneumonia (median 1244 days, range 992-1597 days). Three (25%) patients were lost to follow-up. No drain-related complications were noted.

Conclusion

Percutaneous drainage of AGI following endovascular or open aneurysm repair is a safe and viable management option either as a temporizing measure as a bridge to surgical graft explantation or as a non-surgical therapy for long term management.

The Role of Epigenetic Modifications in Abdominal Aortic Aneurysm Pathogenesis

Abdominal aortic aneurysm (AAA) is a life-threatening disease associated with high morbidity and mortality in the setting of acute rupture. Recently, advances in surgical and endovascular repair of AAA have been achieved; however, pharmaceutical therapies to prevent AAA expansion and rupture remain lacking. This highlights an ongoing need to improve the understanding the pathological mechanisms that initiate formation, maintain growth, and promote rupture of AAA. Over the past decade, epigenetic modifications, such as DNA methylation, posttranslational histone modifications, and non-coding RNA, have emerged as important regulators of cellular function. Accumulating studies reveal the importance of epigenetic enzymes in the dynamic regulation of key signaling pathways that alter cellular phenotypes and have emerged as major intracellular players in a wide range of biological processes. In this review, we discuss the roles and implications of epigenetic modifications in AAA animal models and their relevance to human AAA pathology.

Application of a Novel Common-Iliac-Artery Skirt Technology (CST) in Treating Challenge Aorto-Iliac or Isolated Iliac Artery Aneurysms

Purpose: To report a novel common-iliac-artery skirt technology (CST) in treating challenge iliac artery aneurysms. Methods: When required healthy landing zone of common iliac artery (CIA) is not available, CST is a strategy to exclude the internal iliac artery (IIA) and prevent IIA reflux without need of embolization. Patients who received endovascular aneurysm repair (EVAR) in our center from 2014 to 2020 were retrospectively screened, and patients treated with CST or with IIA embolization (IIAE) were enrolled. Results: After retrospective screen of 524 EVAR patients, 39 CST patients, 26 IIAE patients, and 7 CST + IIAE patients were enrolled in this study. CST group suggested to have more aged, hyperlipemia, and smoking patients than IIAE group. Two groups had comparable maximal diameter of abdominal aorta (AA), CIA, EIA, but larger diameter of IIA (CST 19.82 ± 2.281 vs. IIAE 27.82 ± 3.401, p = 0.048), and CIA bifurcation (CST 25.01 ± 1.316 vs. IIAE 29.76 ± 2.775, p = 0.087) was found in IIAE group. Anatomy of 79.5% of CST patients and 92.3% of IIAE patients (p = 0.293) was not suitable for potential use of iliac branch device. CST group had significant shorter surgery time (CST 97.42 ± 3.891 vs. IIAE 141.0 ± 8.010, p < 0.001), shorter hospital stay (CST 15.35 ± 0.873 vs. IIAE 19.32 ± 1.067, p = 0.009), lower in-hospital [CST 0% (0/39) vs. IIAE 11.5% (3/26), p = 0.059] and 1-year follow-up stent related MAEs [CST 6.7% (2/30) vs. IIAE 28.6% (6/21), p = 0.052], but comparable mortality and stent related MAEs for all-cohort follow-up analysis comparing to IIAE group. In our study, a lower in-hospital buttock claudication (BC) rate for CST (CST 20.5% vs. IIAE 46.2%, p = 0.053) and a comparable erectile dysfunction (ED) rate (CST 10.3% vs. IIAE 23.1%, p = 0.352) were found between CST and IIAE groups. After 1 year, both groups had about one third relief of BC symptoms [CST 33.3% (4/12) vs. IIAE 30.7% (4/13), p = 1.000]. Subgroup analysis of 14 patents concomitant with IIA aneurysm in CST group and the 7 CST + IIAE patients were carried out, and no difference was found in mortality, stent MAEs, sac dilation, or reintervention rate. Last, illustration of seven typical CST cases was presented. Conclusion: In selected cases, the CST is a safe, feasible-and-effective choose in treating challenge iliac artery aneurysms and preventing IIA endoleak.

MiR-191 as a Key Molecule in Aneurysmal Aortic Remodeling

Abdominal aortic aneurysms (AAA) are a complex disease with an unclear pathomechanism. A positive family history is emphasized as a significant risk factor, and a nonspecific model of inheritance suggests participation of epigenetic regulation in the pathogenesis of this disease. Past studies have implicated microRNAs in the development of AAA; therefore in this project, we measured miR-191 levels in AAA patients and compared them with a control group. We found that miR-191 levels were significantly elevated in aneurysmal patients, although this did not correlate with the available clinical data. We then developed an in vitro model where, using cells with an endothelial phenotype, we determined the effect of miR-191 on the transcriptome using RNA sequencing. Subsequent pathway analysis established that some of the perturbations mediated by miR-191 can be explained by several processes which have long been observed and described in literature as accompanying the development of abdominal aortic aneurysms.

Late Open Repair of a Massive Common Iliac Artery Aneurysm after Endovascular Failure

Giant Common Iliac Artery Aneurysms (CIAA) are an uncommon pathology that may present as a late complication after endovascular aortic repair secondary to aneurysmal degeneration with endoleak. We present an unusual case of a patient presenting 9 years after index endovascular CIAA exclusion with a painless abdominal mass found to be a 20+ cm CIAA secondary to type II endoleak from a recanalized coil embolized hypogastric artery. The patient underwent open aneurysmorrhaphy with ligation of the hypogastric artery.

Thresholds for abdominal aortic aneurysm repair in Canada and United States

BACKGROUND

Previous studies have demonstrated significant geographic variations in the management of abdominal aortic aneurysms (AAA) despite standard guidelines. Differences in patient selection, operative technique, and outcomes for AAA repair in Canada versus United States were assessed.

METHODS

The Vascular Quality Initiative was used to identify all patients who underwent elective endovascular or open AAA repair between 2010 and 2019 in Canada and the United States. Demographic, clinical, and procedural characteristics were recorded and differences between countries were assessed using independent t test and χ² test. The primary outcome was the percentage of AAA repaired below recommended diameter thresholds (men, <5.5 cm; women, <5.0 cm). The secondary outcomes were in-hospital and 1-year mortality rates. Associations between region and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis.

RESULTS

There were 51,455 US patients and 1451 Canadian patients who underwent AAA repair in Vascular Quality Initiative sites during the study period. There was a higher proportion of endovascular repairs in the United States (83.7% vs 68.4%; odds ratio [OR], 2.38; 95% confidence interval [CI], 2.13-2.63; P < .001). US patients had more comorbidities, including hypertension, congestive heart failure, chronic kidney disease, and prior revascularization. The percentage of AAA repaired below recommended thresholds was significantly higher in the United States (38.8% vs 15.2%; OR, 3.57; 95% CI, 3.03-4.17; P < .001). This difference persisted after controlling for demographic, clinical, and procedural characteristics (adjusted OR, 3.57; 95% CI, 2.63-4.17; P < .001). Factors that predicted AAA repair below recommended thresholds were US region (adjusted OR, 3.57; 95% CI, 3.03-4.17), male sex (adjusted OR, 2.89; 95% CI, 2.72-3.07), and endovascular repair (adjusted OR, 2.08; 95% CI, 1.95-2.21). The in-hospital mortality rate was low (1.0% vs 0.8%) and the 1-year rate mortality was similar between countries (hazard ratio, 0.96; 95% CI, 0.70-1.31; P = .79).

CONCLUSIONS

There are significant variations in AAA management between Canada and the United States. A greater proportion of US patients underwent AAA repair below the recommended diameter thresholds. This finding is partly driven by a higher percentage of endovascular repairs. Despite these differences, the perioperative and 1-year mortality rates are similar. Future studies should investigate reasons for these variations and quality improvement projects are needed to standardize care.

Defining a master curve of abdominal aortic aneurysm growth and its potential utility of clinical management

OBJECTIVE

The maximum diameter measurement of an abdominal aortic aneurysm (AAA), which depends on orthogonal and axial cross-sections or maximally inscribed spheres within the AAA, plays a significant role in the clinical decision making process. This study aims to build a total of 21 morphological parameters from longitudinal CT scans and analyze their correlations. Furthermore, this work explores the existence of a "master curve" of AAA growth, and tests which parameters serve to enhance its predictability for clinical use.

METHODS

106 CT scan images from 25 Korean AAA patients were retrospectively obtained. We subsequently computed morphological parameters, growth rates, and pair-wise correlations, and attempted to enhance the predictability of the growth for high-risk aneurysms using non-linear curve fitting and least-square minimization.

RESULTS

An exponential AAA growth model was fitted to the maximum spherical diameter, as the best representative of the growth among all parameters (r-square: 0.94) and correctly predicted to 15 of 16 validation scans based on a 95% confidence interval. AAA volume expansion rates were highly correlated (r=0.75) with thrombus accumulation rates.

CONCLUSIONS

The exponential growth model using spherical diameter provides useful information about progression of aneurysm size and enables AAA growth rate extrapolation during a given surveillance period.

Simple diameter measurements with ultrasound can be safely used to follow the majority of patients after infrarenal endovascular aneurysm repair

BACKGROUND

The optimal imaging follow-up after infrarenal EVAR is still undefined. The objective was to study the outcome of a personalized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements for low-risk patients.

METHODS

All consecutive patients followed-up locally after elective and acute infrarenal EVAR between 2010 and 2015 were retrospectively reviewed. Patients underwent CTA at 1 month post-EVAR whereby the attending surgeon defined the subsequent follow-up. Patients considered at low risk were followed with ultrasound only assessing AAA diameter at 1, 2, 3 and every 5 years postoperatively (group A). Low-risk required a favourable preoperative anatomy especially regarding the aneurysm neck, satisfactory intraoperative result and uneventful 1 month CTA (type 2 endoleaks acceptable). Patients not fulfilling the criteria for group A were followed with yearly 3-phase-CTAs (group B).

RESULTS

222 patients with a AAA median diameter of 58 (54-68) mm were included. 191 were allocated into group A and 31 in group B. Median follow-up time was 36 (24-59) months. Five year primary and primary assisted success was 82 ± 5 % and 93 ± 3 % for group A and 70 ± 13% and 93 ± 5% for group B, respectively (P= 0.042 and P= 0.504, respectively). 16 late aneurysm-related re-interventions were performed in 12 patients (7 in group A and 9 in group B). In group A, 5 re-interventions were rupture-preventing and 2 were symptomatic. All late re-interventions in group B were performed following findings on follow-up imaging. Five-year late re-intervention-free survival was 95 ± 2 % and 84 ± 7 % for groups A and B, respectively (P=0.046). Five-year survival was 80 ± 3 % and 63 ± 10 % for group A and B, respectively (P= 0.024).

CONCLUSIONS

A customized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements in low-risk patients seems to be effective in maintaining a very high mid-term clinical success rate.

Endovascular aortic aneurysm repair with reversed chimney graft technique in a patient with crossed fused renal ectopia: a technical note

Crossed fused renal ectopia is a very rare congenital ectopia and poses great challenges when performing abdominal aortic surgery because of the accompanying abnormal vessels and urinary tracts. A 79-year-old woman with an abdominal aortic aneurysm and L-shaped crossed fused renal ectopia was referred to our facility. One of the large ectopic renal arteries arose from the right common iliac artery. The aneurysm was treated with an endovascular aortic repair. The reversed chimney graft technique was applied to preserve the ectopic renal artery while elongating the distal landing zone on the right side. The patient experienced no complications such as renal dysfunction or recurrence of the abdominal aortic aneurysm during the 6-month follow-up period.

Sex-related disparities in intervention rates and type of intervention in patients with aortic and peripheral arterial diseases in the National Inpatient Sample Database

OBJECTIVE

The first annual Women's Vascular Summit highlighted sex- and gender-related knowledge gaps in vascular disease diagnosis and treatment. This finding suggests an opportunity for further research to improve care and outcomes in people who identify as women, specifically. The purpose of this study was to a large national dataset to identify all operations performed for abdominal aortic aneurysm (AAA), carotid artery stenosis (CAS), and peripheral arterial disease (PAD) in the United States, and to provide data on sex-related disparities in treatment.

METHODS

All hospitalizations of adult patients (≥18 years old) diagnosed with AAA, CAS, or PAD who underwent vascular surgery from 2000 to 2016 were identified in the Healthcare Cost and Utilization Project National Inpatient Sample. Sex-stratified U.S. Census data and sex-specific population disease prevalence estimates from the National Institute of Health and Agency for Healthcare Research and Quality were used to calculate the number of U.S. adults with AAA, CAS, and PAD. Sex-stratified rates of surgery and incidence rate ratios were estimated using Poisson regression. Among those undergoing surgery, multivariable logistic regression was used to assess differences in endovascular vs open approach.

RESULTS

Over 16 years, there were 1,021,684 hospitalizations for vascular surgery: 13% AAA (21% female, 79% male), 40% CAS (42% female, 58% male), and 47% PAD (42% female, 58% male). Females were older than males at time of surgery (median age, 71.3 years vs 69.7 years) and less likely to have private insurance (18% vs 23%); minimal differences were seen across race/ethnicity, comorbidities, and hospital characteristics. After accounting for disease prevalence, females were still 25% less likely to undergo surgery for AAA and 30% less likely to undergo surgery for PAD compared with males with the same disease. These results were consistent over time. After adjustment, females, compared with males, were less likely to receive an endovascular procedure compared with open for AAA or CAS, and more likely to receive one for PAD.

CONCLUSIONS

From 2000 to 2016 in the United States, females were less likely to undergo intervention for AAA and PAD than males. This finding is particularly significant for PAD, because the prevalence is the same for both sexes, indicating that females are likely undertreated for PAD. Additionally, females were less likely to undergo endovascular surgery for AAA and more likely to undergo endovascular surgery for PAD than males. These findings suggest that improvement in AAA and PAD identification and management in females may improve outcomes.

Protocol for a randomised controlled trial for Treatment in Thoracic Aortic Aneurysm: Surgery versus Surveillance (TITAN: SvS)

INTRODUCTION

Ascending thoracic aortic aneurysm (ATAA) is an asymptomatic condition that can lead to catastrophic events of rupture or dissection. Current guidelines are based on limited retrospective data and recommend surgical intervention for ATAA with a diameter of greater or equal to 5.5 cm. Treatment in Thoracic Aortic Aneurysm: Surgery versus Surveillance is the first prospective, multicentre, randomised controlled trial that compares outcomes of patients undergoing early elective ascending aortic surgery to patients undergoing medical surveillance.

METHODS AND ANALYSIS

Patients between the ages of 18 and 80 with an asymptomatic ATAA between 5.0 cm and 5.4 cm in diameter are eligible for randomisation to early surgery or surveillance. Patients in the surgery group will be followed at 1 month after discharge, then annually for a minimum of 2 years and up to 5 years. Patients in the surveillance group will be followed annually from their index clinic visit for a minimum of 2 years and up to 5 years. The primary outcome is all-cause mortality at follow-up. A sample size of 618 subjects (309 in each group) will achieve an 80% power at a 0.047 significance level.

ETHICS AND DISSEMINATION

This study has received Ottawa Health Science Network Research Ethics Board approval (Protocol 20180007-01H), which was most recently updated on 25 November 2020. The Research Ethics Board have granted approval to the study at 14 participating institutions, including the Ottawa Health Science Network Research Ethics Board. On completion of data analysis, the result of the trial will be presented at national and international conferences, and published in relevant journals, regardless of the finding of the trial.

TRIAL REGISTRATION NUMBER

NCT03536312.

Fenestrated and Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysm With More Than 4 Target Visceral Vessels due to Renovisceral Arterial Anatomical Variations: Feasibility and Early Results

PURPOSE

This study describes technical success, feasibility, and early results of fenestrated and branched endovascular aortic repair (F/B-EVAR) for treatment of thoracoabdominal aortic aneurysms (TAAAs) or pararenal aneurysms with more than 4 target visceral vessels (TVs) due to renovisceral arterial anatomical variations.

MATERIALS AND METHODS

Patients with TAAAs or pararenal aortic aneurysms who had more than 4 TVs due to renovisceral arterial anatomical variations of renal, celiac, and/or superior mesenteric arteries and received F/B-EVAR between January 2017 and September 2019 at a single aortic center were included in this study. We analyzed technical success, feasibility, and early outcomes.

RESULTS

Twelve patients (mean age 70±10 years, 9 males) were included. The anatomical variations included 6 right accessory renal arteries, 8 left accessory renal arteries, and 1 celiac artery variant. Stent-grafts were fenestrated, branched or combined in 6, 5, or 1 patients, respectively. The mean operating time was 346±120 minutes, the mean fluoroscopy time was 80±29 minutes, and the mean radiation dose area product was 430±219 Gy·cm². The mean contrast volume was 129±45 mL. The total number of TVs was 64; 5 TVs in 9 patients, 6 in 2 patients, and 7 in 1 patient. Technical success was achieved in all cases. The mean intensive care unit stay was 6±5 days, and the mean total hospital stay was 14±10 days. One patient died early (30-day). Early morbidities included respiratory complication in 1 patient, renal insufficiency in 1 patient, and wound infection in 2 patients. No spinal cord ischemia, stroke, or bowel ischemia occurred. Early computed tomography angiography showed 100% patency of the bridging covered stents and TVs. The mean follow-up was 13±4.3 months. No mortality or adverse major event occurred during the follow-up. Two patients with developed type Ic endoleak related to 1 right renal artery and 1 celiac artery covered stent. Patency of the TVs during follow-up was 100%.

CONCLUSION

The use of F/B-EVAR for the treatment of TAAA with more than 4 TVs due to renovisceral arterial anatomical variations in our own experience is feasible and not related to increased morbidity and mortality.

The fate of endoleaks after endovascular aneurysm repair and the impact of oral anticoagulation on their persistence

BACKGROUND

The impact of anticoagulation on late endoleaks after endovascular aneurysm repair (EVAR) is unclear despite multiple investigators studying the relationship. The purpose of this study was to determine if long-term anticoagulation impacted the development of late endoleaks and if specific anticoagulants were more likely to exacerbate the development of endoleaks.

METHODS

Using the Society for Vascular Surgery Vascular Quality Initiative database, patients undergoing EVAR between 2003 and 2019 for abdominal aortic aneurysms were evaluated. Patients were divided into two groups: those without a late endoleak and those with a late endoleak. Bivariate analysis was performed to assess preoperative, intraoperative, postoperative, and long-term follow-up variables. A multivariable analysis was done to determine associations of independent variables with late endoleaks. Patients were further subcategorized based on anticoagulation status before and after EVAR, specific type of anticoagulation, and the presence of an index endoleaks (diagnosed at the time of EVAR) to determine the subsequent frequency of late endoleaks.

RESULTS

A total of 29,783 patients were analyzed with 2169 (7.3%) having a late endoleak identified. Several risk factors were related to late endoleaks, including anticoagulation before and after EVAR (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.57-6.96; P < .001), anticoagulation after EVAR (OR, 1.88; 95% CI, 1.43-2.49; P < .001), and index endoleak (OR, 1.45; 95% CI, 1.26-1.66; P < .001). The frequency of late endoleaks in patients anticoagulated before and after EVAR and after EVAR as compared with those never anticoagulated was 16.89% and 14.40% vs 6.95%, respectively (both P > .001). No difference in late endoleaks were noted for patients treated with warfarin and novel oral anticoagulants. The most common type of index and late endoleak identified was type II, but patients with type I, type II, and type IV index endoleaks were more commonly found to have type I, type II, and type IV late endoleaks, respectively. The frequency of late endoleaks in patients with both an index endoleak and anticoagulation after EVAR was 20.42% as compared with patients with only anticoagulation after EVAR (14.63%; P = .0015) and with patients with index endoleaks not anticoagulated (10.06%; P < .00001).

CONCLUSIONS

Late endoleaks were more common in patients treated with anticoagulation after EVAR. No difference in late endoleak frequency was detected between anticoagulation with warfarin and novel oral anticoagulants. Patients on anticoagulation and those with an index endoleak were at a higher risk of having a late endoleak.

Industry Compensation to Physician Vascular Specialist Authors of Highly-referenced Aortic Aneurysm Studies

BACKGROUND

Industry payments to physicians may influence their attitudes toward medical devices and products. Disclosure of industry compensation by authors of scientific manuscripts usually occurs at the authors' discretion and is seldom audited as part of the peer review process. The purpose of this analysis was to characterize industry compensation among highly cited research articles related to aortic aneurysm.

METHODS

A Web of Science search for English language articles published from 2013-2017 using the search term "aortic aneurysm" identified publications for this study. The top 99 most-cited publications were abstracted by author. Physician authors with reported industry compensation from 2013-2016 were identified using the ProPublica Dollars for Docs search tool (linked to Centers for Medicare and Medicaid Services Open Payments data), based on provider name, medical specialty, and geographic location. Statistical analysis included descriptive statistics and categorical tests.

RESULTS

The 99 articles had 1,264 unique authors, of whom 105 physicians (8.3%) received industry compensation during the study period. Fourteen of the 105 authors self-reported having received industry compensation. The remaining 91 authors (86.7%) did not disclose their industry-reported compensation. Industry payments during the study period totaled $6,082,574 paid through 13,489 transactions from 169 different manufacturers. In-kind items and services were the most common form of payment (65.3%). The median transaction amount was $58.32. [$138.34]. Food and beverage accounted for the largest number of transactions (N=9653), followed by travel and lodging (N=2365), consulting (N=513), and promotional speaking (N=436). Consulting accounted for the most total dollars over the study period ($1,970,606), followed by travel and lodging ($1,122,276), promotional speaking ($972,894), food and beverage ($568,251), royalty or license ($504,631), honoraria ($452,167), and education ($428,489). Royalty and license payments had the highest median transaction amount ($15,418. [$29,049]), and was the only category with a median transaction amount greater than $5,000. In contrast, several categories had median transaction amounts under $50, including food and beverage ($32. [$77]), gifts ($34. [$86]), and entertainment ($30. [$69]). No significant difference in payment amounts by medical specialty was identified (P=0.071).

CONCLUSIONS

Only 8.3% of physician authors of highly cited aortic aneurysm studies received industry compensation, but 86.7% of those physician authors receiving payments did not disclose industry compensation within the manuscripts. Potential bias associated with industry compensation may be underestimated and conservatively biased based on author self-reporting.

Quantitative analysis of dynamic computed tomography angiography for the detection of endoleaks after abdominal aorta aneurysm endovascular repair: A feasibility study

Objectives

To assess the feasibility of quantitative analysis of dynamic computed tomography angiography (dCTA) for the detection of endoleaks in patients who underwent endovascular repair of abdominal aortic aneurysms (EVAR).

Material and methods

Twenty patients scheduled for contrast-enhanced CT angiography (CTA) of the abdominal aorta post-EVAR were prospectively enrolled. All patients received a standard triphasic CTA protocol, followed by an additional dCTA. The dCTA acquisition enabled reconstruction of color-coded maps depicting blood perfusion and a dCTA dataset of the aneurysm sac. Observers assessed the dCTA and dynamic CT perfusion (dCTP) images for the detection of endoleaks, establishing diagnostic confidence based on a modified 5-point Likert scale. An index was calculated for the ratio between the endoleak and aneurysm sac using blood flow for dCTP and Hounsfield units (HU) for dCTA. The Wilcoxon test compared the endoleak index and the diagnostic confidence of the observers.

Results

In total, 19 patients (18 males, median age 74 years [70.5–75.7]) were included for analysis. Nine endoleaks were detected in 7 patients using triphasic CTA as the reference standard. There was complete agreement for endoleak detection between the two techniques on a per-patient basis. Both dCTA and dCTP identified an additional endoleak in one patient. The diagnostic confidence using dCTP for detection of endoleaks was not significantly superior to dCTA (5.0 [5–5] vs. 4.5 [4–5], respectively; p = 0.11); however, dCTP demonstrated superior diagnostic confidence for endoleak exclusion compared to dCTA (1.0 [1–1] vs 1.5 [1.5–1.5], respectively; p <0.01). Moreover, the dCTP endoleak index was significantly higher than the dCTA index (18.5 [10.8–20.5] vs. 3.5 [5–2.7], respectively; p = 0.02).

Conclusions

Quantitative analysis of dCTP imaging can aid in the detection of endoleaks and demonstrates a higher endoleak detection rate than triphasic CTA, as well as a strong correlation with visual assessment of dCTA images.

Experiência inicial com ultrassom Doppler com contraste por microbolhas em adição ao ultrassom Doppler convencional para seguimento de correção endovascular de aneurisma de aorta abdominal

Background

Microbubble contrast enhanced ultrasound (CEUS) is an accurate diagnostic method for follow-up after endovascular abdominal aortic aneurysm repair (EVAR) that has been well-established in international studies. However, there are no Brazilian studies that focus on this follow-up method.

Objectives

The objective of this study was to report initial experience with CEUS at a tertiary hospital, comparing the findings of CEUS with those of conventional Doppler ultrasound (DUS), with the aim of determining whether addition of contrast to the standard ultrasonographic control protocol resulted in different findings.

Methods

From 2015 to 2017, 21 patients in follow-up after EVAR underwent DUS followed by CEUS. The findings of these examinations were analyzed in terms of identification of complications and their capacity to identify the origin of endoleaks.

Results

There was evidence of complications in 10 of the 21 cases examined: seven patients exhibited endoleaks (33.3%); two patients exhibited stenosis of a branch of the endograft (9.52%); and one patient exhibited a dissection involving the external iliac artery (4.76%). In the 21 patients assessed, combined use of both methods identified 10 cases of post-EVAR complications. In six of the seven cases of endoleaks (85.71%), use of the methods in combination was capable of identifying the origin of endoleakage. DUS alone failed to identify endoleaks in two cases (28.5%) and identified doubtful findings in another two cases (28.5%), in which diagnostic definition was achieved after employing CEUS.

Conclusions

CEUS is a technique that is easy to perform and provides additional support for follow-up of infrarenal EVAR.