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Skov RAC, Eiberg JP, Rouet L, Eldrup N, Zielinski AH, Broda MA, Goetze JP, Ghulam QM. Anticoagulants and reduced thrombus load in abdominal aortic aneurysms assessed with three-dimensional contrast-enhanced ultrasound examination. J Vasc Surg 2023; 77:143-149. [PMID: 35931398 DOI: 10.1016/j.jvs.2022.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/30/2022] [Accepted: 07/15/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The relationship between intraluminal thrombus (ILT) and abdominal aortic aneurysm (AAA) growth and rupture risk remains ambiguous. Studies have shown a limited effect of antiplatelet therapy on ILT size, whereas the impact of anticoagulant therapy on ILT is unresolved. This study aims to evaluate an association between antithrombotic therapy and ILT size assessed with three-dimensional contrast-enhanced ultrasound (3D-CEUS) examination in a cohort of patients with AAA. METHODS In a cross-sectional study, 309 patients with small AAAs were examined with 3D-CEUS. Patients were divided into three groups based on prescribed antithrombotic therapy: anticoagulant (n = 36), antiplatelet (n = 222), and no antithrombotic therapy (n = 51). Patient ILT size was calculated in volume and thickness and compared between the three groups. RESULTS Patients on anticoagulants had a significantly lower estimated marginal mean ILT volume of 16 mL (standard error [SE], ±3.2) compared with 28 mL (SE, ±2.7) in the no antithrombotic group and 30 mL (SE, ±1.3) in the antiplatelet group when adjusting for AAA volume (P < .001) and comorbidities (P < .001). In addition, patients on anticoagulant therapy had significantly lower estimated marginal mean ILT thickness of 10 mm (SE, ±1.1) compared with 13 mm (SE, ±0.9) in the no antithrombotic group of and 13mm (SE, ±0.4) in the antiplatelet group when adjusting for AAA diameter (P = .03) and comorbidities (P = .035). CONCLUSIONS A 3D-CEUS examination is applicable for ILT assessment and demonstrates that patients with AAA on anticoagulant therapy have lower ILT thickness and volume than patients with AAA on antiplatelet therapy and those without antithrombotic therapy. Causality between anticoagulants and ILT size, and extrapolation to AAA growth and rupture risk, is unknown and merits further investigations, to further nuance US-based AAA surveillance strategy.
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Affiliation(s)
- Rebecca Andrea Conradsen Skov
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark.
| | - Jonas P Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
| | | | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Alexander H Zielinski
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Magdalena A Broda
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark; Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Qasam M Ghulam
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
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Vermeulen JJM, Meijer M, de Vries FBG, Reijnen MMPJ, Holewijn S, Thijssen DHJ. Reply. J Vasc Surg 2023; 77:311-314. [PMID: 36549795 DOI: 10.1016/j.jvs.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/16/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Jenske J M Vermeulen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands; Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Maartje Meijer
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frederique B G de Vries
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | | | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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3
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Incomplete analysis of the association of abdominal aortic aneurysm wall characteristics with outcome. J Vasc Surg 2023; 77:310-311. [PMID: 36549794 DOI: 10.1016/j.jvs.2022.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 12/24/2022]
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4
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Singh TP, Moxon JV, Gasser TC, Dalman RL, Bourke M, Bourke B, Tomee SM, Dawson J, Golledge J. Effect of telmisartan on the peak wall stress and peak wall rupture index of small abdominal aortic aneurysms: An exploratory analysis of the TEDY trial. Eur J Vasc Endovasc Surg 2022; 64:396-404. [DOI: 10.1016/j.ejvs.2022.07.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022]
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The Detrimental Role of Intraluminal Thrombus Outweighs Protective Advantage in Abdominal Aortic Aneurysm Pathogenesis: The Implications for the Anti-Platelet Therapy. Biomolecules 2022; 12:biom12070942. [PMID: 35883500 PMCID: PMC9313225 DOI: 10.3390/biom12070942] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/20/2022] [Accepted: 07/01/2022] [Indexed: 02/01/2023] Open
Abstract
Abdominal aortic aneurysm (AAA) is a common cardiovascular disease resulting in morbidity and mortality in older adults due to rupture. Currently, AAA treatment relies entirely on invasive surgical treatments, including open repair and endovascular, which carry risks for small aneurysms (diameter < 55 mm). There is an increasing need for the development of pharmacological intervention for early AAA. Over the last decade, it has been increasingly recognized that intraluminal thrombus (ILT) is involved in the growth, remodeling, and rupture of AAA. ILT has been described as having both biomechanically protective and biochemically destructive properties. Platelets are the second most abundant cells in blood circulation and play an integral role in the formation, expansion, and proteolytic activity of ILT. However, the role of platelets in the ILT-potentiated AAA progression/rupture remains unclear. Researchers are seeking pharmaceutical treatment strategies (e.g., anti-thrombotic/anti-platelet therapies) to prevent ILT formation or expansion in early AAA. In this review, we mainly focus on the following: (a) the formation/deposition of ILT in the progression of AAA; (b) the dual role of ILT in the progression of AAA (protective or detrimental); (c) the function of platelet activity in ILT formation; (d) the application of anti-platelet drugs in AAA. Herein, we present challenges and future work, which may motivate researchers to better explain the potential role of ILT in the pathogenesis of AAA and develop anti-platelet drugs for early AAA.
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Živić J, Virag L, Horvat N, Smoljkić M, Karšaj I. The risk of rupture and abdominal aortic aneurysm morphology: A computational study. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3566. [PMID: 34919341 DOI: 10.1002/cnm.3566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/18/2021] [Accepted: 12/15/2021] [Indexed: 06/14/2023]
Abstract
Prediction of rupture and optimal timing for abdominal aortic aneurysm (AAA) surgical intervention remain wanting even after decades of clinical, histological, and numerical research. Although studies estimating rupture from AAA geometrical features from CT imaging showed some promising results, they are still not being used in practice. Patient-specific numerical stress analysis introduced too many assumptions about wall structure for the related rupture potential index (RPI) to be considered reliable. Growth and remodeling (G&R) numerical models eliminate some of these assumptions and thus might have the most potential to calculate mural stresses and RPI and increase our understanding of rupture. To recognize numerical models as trustworthy, it is necessary to validate the computed results with results derived from imaging. Elastin degradation function is one of the main factors that determine idealized aneurysm sac shape. Using a hundred different combinations of variables defining AAA geometry or influences AAA stability (elastin degradation function parameters, collagen mechanics, and initial healthy aortic diameters), we investigated the relationship between AAA morphology and RPI and compared numerical results with clinical findings. Good agreement of numerical results with clinical expectations from the literature gives us confidence in the validity of the numerical model. We show that aneurysm morphology significantly influences the stability of aneurysms. Additionally, we propose new parameters, geometrical rupture potential index (GRPI) and normalized aneurysm length (NAL), that might predict rupture of aneurysms without thrombus better than currently used criteria (i.e., maximum diameter and growth rate). These parameters can be computed quickly, without the tedious processing of CT images.
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Affiliation(s)
- Josip Živić
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Lana Virag
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Nino Horvat
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | | | - Igor Karšaj
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
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Niklas N, Gutowski P, Kazimierczak A, Rynio P. Abdominal Aortic Aneurysm Morphology as an Essential Criterion for Stratifying the Risk of Aneurysm Rupture. J Clin Med 2022; 11:jcm11040933. [PMID: 35207223 PMCID: PMC8875520 DOI: 10.3390/jcm11040933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022] Open
Abstract
The current stratification model of aneurysm rupture seems to be insufficient in some clinical cases. In our study, we determined the differences in wall structure between ruptured and unruptured aneurysms. We obtained computed tomography angiograms and categorized them into the following three groups, consisting of 49 patients each: the group with ruptured abdominal aortic aneurysms (rAAA), symptomatic (sAAA), and asymptomatic (aAAA). The three-dimensional AAA anatomy was digitally reconstructed for each patient through semi-automatically obtained segmentation, and each aneurysm was distinguished by the following three parameters: AFL (aneurysm flow lumen), ILT (intraluminal thrombus), and calcifications. The AFL volume was greater in rAAA compared with aAAA (p = 0.004), the ILT volume was greater in aAAA than in rAAA (p = 0.013), and the AFL/ILT surface ratio was bigger in rAAA than in aAAA (p < 0.001), sAAA than in aAAA (p = 0.033), and rAAA than in sAAA (p = 0.016). AFL/ILT surface*100 was defined as an independent predictive factor of rAAA to aAAA (OR 1.187; 95% CI 1.099–1.281), to sAAA (OR 1.045; 95% CI 1.004–1.087), and in sAAA vs. aAAA (OR 1.067; 95% CI 1.017–1.119). Consequently, the wall of rAAA differs significantly from unruptured aneurysms. The AFL/ILT surface ratio might indicate an increased risk of aneurysm rupture and the occurrence of symptoms in AAA.
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8
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Kessler V, Klopf J, Eilenberg W, Neumayer C, Brostjan C. AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis. Biomedicines 2022; 10:94. [PMID: 35052774 PMCID: PMC8773452 DOI: 10.3390/biomedicines10010094] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.
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Affiliation(s)
| | | | | | | | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria; (V.K.); (J.K.); (W.E.); (C.N.)
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9
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Singh TP, Moxon JV, Iyer V, Gasser TC, Jenkins J, Golledge J. Comparison of peak wall stress and peak wall rupture index in ruptured and asymptomatic intact abdominal aortic aneurysms. Br J Surg 2021; 108:652-658. [PMID: 34157087 DOI: 10.1002/bjs.11995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/01/2020] [Accepted: 07/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Previous studies have suggested that finite element analysis (FEA) can estimate the rupture risk of an abdominal aortic aneurysm (AAA); however, the value of biomechanical estimates over measurement of AAA diameter alone remains unclear. This study aimed to compare peak wall stress (PWS) and peak wall rupture index (PWRI) in participants with ruptured and asymptomatic intact AAAs. METHODS The reproducibility of semiautomated methods for estimating aortic PWS and PWRI from CT images was assessed. PWS and PWRI were estimated in people with ruptured AAAs and those with asymptomatic intact AAAs matched by orthogonal diameter on a 1 : 2 basis. Spearman's correlation coefficient was used to assess the association between PWS or PWRI and AAA diameter. Independent associations between PWS or PWRI and AAA rupture were identified by means of logistic regression analyses. RESULTS Twenty individuals were included in the analysis of reproducibility. The main analysis included 50 patients with an intact AAA and 25 with a ruptured AAA. Median orthogonal diameter was similar in ruptured and intact AAAs (82·3 (i.q.r. 73·5-92·0) versus 81·0 (73·2-92·4) mm respectively; P = 0·906). Median PWS values were 286·8 (220·2-329·6) and 245·8 (215·2-302·3) kPa respectively (P = 0·192). There was no significant difference in PWRI between the two groups (P = 0·982). PWS and PWRI correlated positively with orthogonal diameter (both P < 0·001). Participants with high PWS, but not PWRI, were more likely to have a ruptured AAA after adjusting for potential confounders (odds ratio 5·84, 95 per cent c.i. 1·22 to 27·95; P = 0·027). This association was not maintained in all sensitivity analyses. CONCLUSION High aortic PWS had an inconsistent association with greater odds of aneurysm rupture in patients with a large AAA.
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Affiliation(s)
- T P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia
| | - J V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - V Iyer
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia
- Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - T C Gasser
- KTH Solid Mechanics, Department of Engineering Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - J Jenkins
- Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Townsville, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia
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10
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Horvat N, Virag L, Karšaj I. Mechanical role of intraluminal thrombus in aneurysm growth: A computational study. Biomech Model Mechanobiol 2021; 20:1819-1832. [PMID: 34148166 DOI: 10.1007/s10237-021-01478-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/07/2021] [Indexed: 12/25/2022]
Abstract
Models that seek to improve our current understanding of biochemical processes and predict disease progression have been increasingly in use over the last decades. Recently, we proposed a finite element implementation of arterial wall growth and remodeling with application to abdominal aortic aneurysms (AAAs). The study focused on changes within the aortic wall and did not include the complex role of intraluminal thrombus (ILT) during the AAA evolution. Thus, in this work, we extend the model with a gradual deposition of ILT and its mechanical influence on AAA growth. Despite neglecting the increased biochemical activity due to the presence of a proteolytically active luminal layer of ILT, and thus underestimating rupture risk potential, we show that ILT helps to slow down the growth of the aneurysm in the axial direction by redirecting blood pressure loading from the axial-radial plane to predominately radial direction. This very likely lowers rupture potential. We also show that the ratio of ILT volume to volume sac is an important factor in AAA stabilization and that fully thrombosed aneurysms could stabilize quicker and at smaller maximum diameters compared to partially thrombosed ones. Furthermore, we show that ILT formation and the associated mural stress decrease negatively impact the wall constituent production and thickness. Although further studies that include increased biochemical degradation of the wall after the formation of ILT and ILT deposition based on hemodynamics are needed, the present findings highlight the dual role an ILT plays during AAA progression.
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Affiliation(s)
- Nino Horvat
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ivana Lučića 5, 10000, Zagreb, Croatia
| | - Lana Virag
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ivana Lučića 5, 10000, Zagreb, Croatia
| | - Igor Karšaj
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ivana Lučića 5, 10000, Zagreb, Croatia.
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11
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Boyd AJ. Intraluminal thrombus: Innocent bystander or factor in abdominal aortic aneurysm pathogenesis? JVS Vasc Sci 2021; 2:159-169. [PMID: 34617066 PMCID: PMC8489244 DOI: 10.1016/j.jvssci.2021.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) represent a complex multifactorial hemodynamic, thrombotic, and inflammatory process that can ultimately result in aortic rupture and death. Despite improved screening and surgical management of AAAs, the mortality rates have remained high after rupture, and little progress has occurred in the development of nonoperative treatments. Intraluminal thrombus (ILT) is present in most AAAs and might be involved in AAA pathogenesis. The present review examined the latest clinical and experimental evidence for possible involvement of the ILT in AAA growth and rupture. METHODS A literature review was performed after a search of the PubMed database from 2012 to June 2020 using the terms "abdominal aortic aneurysm" and "intraluminal thrombus." RESULTS The structure, composition, and hemodynamics of ILT formation and propagation were reviewed in relation to the hemostatic and proteolytic factors favoring ILT deposition. The potential effects of the ILT on AAA wall degeneration and rupture, including a review of the current controversies regarding the position, thickness, and composition of ILT, are presented. Although initially potentially protective against increased wall stress, increasing evidence has shown that an increased volume and greater age of the ILT have direct detrimental effects on aortic wall integrity, which might predispose to an increased rupture risk. CONCLUSIONS ILT does not appear to be an innocent bystander in AAA pathophysiology. However, its exact role remains elusive and controversial. Despite computational evidence of a possible protective role of the ILT in reducing wall stress, increasing evidence has shown that the ILT promotes AAA wall degeneration in humans and in animal models. Further research, with large animal models and with more chronic ILT is crucial for a better understanding of the role of the ILT in AAAs and for the potential development of targeted therapies to slow or halt AAA progression.
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Affiliation(s)
- April J. Boyd
- Department of Vascular Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Wang H, Ou J, Gong W, Wang H, Freebody J. Morphologic Features of Symptomatic and Ruptured Abdominal Aortic Aneurysm in Asian Patients. Ann Vasc Surg 2020; 72:445-453. [PMID: 33157247 DOI: 10.1016/j.avsg.2020.09.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/13/2020] [Accepted: 09/22/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND To evaluate morphologic features of symptomatic and ruptured abdominal aortic aneurysms in Asian patients. METHODS Two hundred sixty four continuous candidates with an abdominal aortic aneurysm (AAA) were retrospectively identified from a tertiary hospital database between January 2017 and May 2019. The patients meeting inclusion criteria were divided into symptomatic or ruptured AAA (srAAA) and asymptomatic AAA (asAAA) groups. Their computed tomography angiographies were reconstructed using centerline technique and the geometric features of AAAs between the 2 groups were compared. RESULTS One hundred two patients fulfilled selection criteria (mean age 71 years, 80 men), comprising 35 srAAAs and 67 asAAAs. There was no essential association between gender, smoking or hypertension, and AAA-associated symptoms or rupture. The maximum diameter (5.8 ± 1.4 cm vs. 5.0 ± 0.9 cm; P = 0.001), length (8.8 ± 0.6 cm vs. 7.0 ± 0.3 cm; P = 0.002), and intraluminal thrombus (ILT) thickness (1.7 ± 0.2 cm vs. 1.3 ± 0.1 cm; P = 0.039) of AAAs were independent risk factors for AAA-associated symptoms or rupture (binary logistic regression, P < 0.05), but AAA length and ILT were strongly correlated with the AAA diameter (Pearson correlation coefficient value of 0.591 and 0.444) whereas other factors such as aneurysmal tortuosity, aneurysmal neck anatomy, or common iliac artery geometry were nonsignificant. CONCLUSIONS AAA diameter, length, and intraluminal thrombus thickness were identified as risk factors for AAA-associated symptoms in Asian patients. While the diameter is regarded as the most important predictor for symptoms and rupture, AAA length and ILT thickness should also be taken into consideration when contemplating intervention, particularly for borderline and smaller aneurysms.
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Affiliation(s)
- Huaxin Wang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiale Ou
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China.
| | - Wei Gong
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Haibo Wang
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - John Freebody
- Department of Radiology, The Queen Elizabeth Hospital, Adelaide, Australia
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Takagi H, Hari Y, Nakashima K, Kuno T, Ando T. The association of volume of intramural thrombus with rupture of abdominal aortic aneurysm. J Vasc Surg 2020; 71:1069-1070.e3. [PMID: 32089202 DOI: 10.1016/j.jvs.2019.10.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/19/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan; Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yosuke Hari
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan; Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kouki Nakashima
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan; Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Toshiki Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY
| | - Tomo Ando
- Division of Interventional Cardiology, Department of Cardiology New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
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14
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Molacek J. Editorial commentary: Abdominal aortic aneurysm - Size still matters. Trends Cardiovasc Med 2019; 30:505-506. [PMID: 31883861 DOI: 10.1016/j.tcm.2019.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 11/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Jiri Molacek
- Vascular Surgery Dpt., University Hospital in Pilsen, School of Medicine in Pilsen, Charles University, Czech Republic.
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15
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Singh TP, Wong SA, Moxon JV, Gasser TC, Golledge J. Systematic review and meta-analysis of the association between intraluminal thrombus volume and abdominal aortic aneurysm rupture. J Vasc Surg 2019; 70:2065-2073.e10. [DOI: 10.1016/j.jvs.2019.03.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/19/2019] [Indexed: 01/08/2023]
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Spanos K, Nana P, Kouvelos G, Mpatzalexis K, Matsagkas M, Giannoukas AD. Anatomical Differences Between Intact and Ruptured Large Abdominal Aortic Aneurysms. J Endovasc Ther 2019; 27:117-123. [PMID: 31709885 DOI: 10.1177/1526602819886568] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Purpose: To compare different anatomical characteristics between intact and ruptured large abdominal aortic aneurysms (rAAA >80 mm) with the goal of refining the process of estimating rupture risk. Materials and Methods: A retrospective study involving 62 male patients with large (>80 mm) aneurysms matched for age and smoking produced a 31-patient elective group with a mean maximum aneurysm diameter of 92±9.7 mm and a 31-patient rAAA group (mean maximum aneurysm diameter 95.7±12 mm). Preoperative computed tomography angiography scans were analyzed with a dedicated workstation, and anatomical characteristics of the aortic neck, iliac arteries, and aneurysm were compared in multivariable regression analyses; the outcomes are given as the odds ratio (OR) with 95% confidence interval (CI). The prognostic utility of several characteristics as predictors of rupture occurrence was examined with receiver operating characteristic (ROC) curves. Results: Anatomical characteristics differing significantly between elective and ruptured aneurysms were the infrarenal aortic neck diameters at 5 mm, 10 mm and 15 mm; the neck length and calcification; the common iliac artery (CIA) lengths; the iliac artery indexes; the left CIA and external iliac artery diameters; and the total and true lumen aneurysm volumes. Intraluminal thrombus (ILT) volume did not differ (p=0.76), although its distribution in elective vs ruptured cases did [absent: 0% vs 19%, respectively (p=0.025); circumferential: 61% vs 35%, respectively (p=0.04)]. Total aneurysm volume was higher in rAAA (442±140 mL) vs intact AAA (331±143 mL, p=0.014), while the ILT/total aneurysm volume rate was lower in rAAA (55%) vs intact AAA (70%, p=0.02). Multivariate analysis determined that a shorter left CIA (OR 1.07, 95% CI 1.01 to 1.1, p=0.016) and a smaller total aneurysm volume (OR 1.007, CI. 1.001 to 1.014, p=0.016) were associated with intact AAA. After a ROC curve analysis, left CIA length <50 mm demonstrated a lower incidence of rupture (sensitivity 60% and specificity 78%), while total aneurysm volume <380 mL had 60% sensitivity and specificity. Conclusion: Large rAAAs seem to have different anatomical characteristics than similarly sized intact AAAs. Large intact AAAs have lower total aneurysm volumes and shorter left CIAs, with higher ILT/aneurysm volume rates.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Petroula Nana
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Mpatzalexis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Qiu Y, Wang Y, Fan Y, Peng L, Liu R, Zhao J, Yuan D, Zheng T. Role of intraluminal thrombus in abdominal aortic aneurysm ruptures: A hemodynamic point of view. Med Phys 2019; 46:4263-4275. [PMID: 31206182 DOI: 10.1002/mp.13658] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/27/2019] [Accepted: 06/05/2019] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Intraluminal thrombus (ILTs) are found in most abdominal aortic aneurysms (AAAs) of clinically relevant size; however, the role of ILTs in AAA ruptures remains unclear. This study investigated the role of the presence and thickness of ILTs in AAA ruptures by analyzing the hemodynamic environment in ruptured AAAs (RAAAs). METHODS Three-dimensional reconstructions from computed tomography scans were performed, and 13 RAAA cases were categorized into a no-ILT group, a thin-layered ILT group (thickness < 3 mm), and a thick-layered ILT group. The hemodynamic features of the RAAAs were assessed using computational fluid dynamics simulation. RESULTS The thin- and thick-layered ILT groups showed significant differences in aneurysm diameters (P < 0.05). The three types of AAAs ruptured at different flow regions, with different hemodynamic features: (a) the no-ILT AAAs ruptured at regions of flow recirculation where velocity and wall shear stresses (WSSs) were close to zero; (b) the thin-layered ILT AAAs ruptured at sites at which the dominant flow impinged the wall; and (c) the thick-layered ILT AAAs ruptured at the border of the dominant flow channel and recirculation zone where the flow velocity and pressure changed dramatically. CONCLUSIONS Hemodynamic characteristics influence the rupture mechanisms of particular AAAs differently on the basis of the presence and thickness of ILTs. Recirculation flows and low WSSs may have negative effects by inducing local rupture or positive effects by promoting the formation of thin-layered ILTs. However, eccentrically located thick-layered ILTs may increase the rupture risk of small AAAs because of their location in the sac lumen, which results in chaotic flow patterns and rapid increases in flow resistance.
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Affiliation(s)
- Yue Qiu
- Department of Applied Mechanics, Sichuan University, Chengdu, 610065, China
| | - Yi Wang
- Department of Computer Science, Sichuan University of Science and Engineering, Zigong, Sichuan, 643000, China
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, P. R. China
| | - Liqing Peng
- The Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Rong Liu
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hong Kong, China
| | - Jichun Zhao
- Department Vascular Surgery of West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ding Yuan
- Department Vascular Surgery of West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Tinghui Zheng
- Department of Applied Mechanics, Sichuan University, Chengdu, 610065, China
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Siika A, Lindquist Liljeqvist M, Hultgren R, Gasser TC, Roy J. Aortic Lumen Area Is Increased in Ruptured Abdominal Aortic Aneurysms and Correlates to Biomechanical Rupture Risk. J Endovasc Ther 2018; 25:750-756. [PMID: 30354931 DOI: 10.1177/1526602818808292] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To investigate how 2-dimensional geometric parameters differ between ruptured and asymptomatic abdominal aortic aneurysms (AAAs) and provide a biomechanical explanation for the findings. METHODS The computed tomography angiography (CTA) scans of 30 patients (mean age 77±10 years; 23 men) with ruptured AAAs and 60 patients (mean age 76±8 years; 46 men) with asymptomatic AAAs were used to measure maximum sac diameter along the center lumen line, the cross-sectional lumen area, the total vessel area, the intraluminal thrombus (ILT) area, and corresponding volumes. The CTA data were segmented to create 3-dimensional patient-specific models for finite element analysis to compute peak wall stress (PWS) and the peak wall rupture index (PWRI). To reduce confounding from the maximum diameter, 2 diameter-matched groups were selected from the initial patient cohorts: 28 ruptured AAAs and another with 15 intact AAAs (diameters 74±12 vs 73±11, p=0.67). A multivariate model including the maximum diameter, the lumen area, and the ILT area of the 60 intact aneurysms was employed to predict biomechanical rupture risk parameters. RESULTS In the diameter-matched subgroup comparison, ruptured AAAs had a significantly larger cross-sectional lumen area (1954±1254 vs 1120±623 mm2, p=0.023) and lower ILT area ratio (55±24 vs 68±24, p=0.037). The ILT area (2836±1462 vs 2385±1364 mm2, p=0.282) and the total vessel area (3956±1170 vs 4338±1388 mm2, p=0.384) did not differ statistically between ruptured and intact aneurysms. The PWRI was increased in ruptured AAAs (0.80 vs 0.48, p<0.001), but the PWS was similar (249 vs 284 kPa, p=0.194). In multivariate regression analysis, lumen area was significantly positively associated with both PWS (p<0.001) and PWRI (p<0.01). The ILT area was also significantly positively associated with PWS (p<0.001) but only weakly with PWRI (p<0.01). The lumen area conferred a higher risk increase in both PWS and PWRI when compared with the ILT area. CONCLUSION The lumen area is increased in ruptured AAAs compared to diameter-matched asymptomatic AAAs. Furthermore, this finding may in part be explained by a relationship with biomechanical rupture risk parameters, in which lumen area, irrespective of maximum diameter, increases PWS and PWRI. These observations thus suggest a possible method to improve prediction of rupture risk in AAAs by measuring the lumen area without the use of computational modeling.
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Affiliation(s)
- Antti Siika
- 1 Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | | | - Rebecka Hultgren
- 1 Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,2 Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - T Christian Gasser
- 3 Department of Solid Mechanics, School of Engineering Sciences, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Joy Roy
- 1 Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,2 Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Kontopodis N, Koncar I, Tzirakis K, Tavlas E, Davidovic L, Ioannou CV. Intraluminal Thrombus Deposition Is Reduced in Ruptured Compared to Diameter-matched Intact Abdominal Aortic Aneurysms. Ann Vasc Surg 2018; 55:189-195. [PMID: 30287289 DOI: 10.1016/j.avsg.2018.07.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/23/2018] [Accepted: 07/07/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study is to compare the pattern of intraluminal thrombus (ILT) deposition in diameter-matched ruptured and nonruptured abdominal aortic aneurysms (AAAs). METHODS We performed a single-center, retrospective study. Ruptured AAAs were collected during 24 months. Diameter-matched intact lesions were randomly selected in a 2:1 ratio and served as controls. ILT cross-sectional area, relative area, maximum thickness, and asymmetric distribution were recorded at the site of maximum aneurysm size and compared between groups. Moreover, additional comparisons were performed inside the group of ruptured AAAs, between the site of maximum size and the site of rupture. RESULTS Fifteen ruptured cases were compared with 30 nonruptured cases. ILT relative area (37.5% vs. 73.5%, P = 0.004) and maximum thickness (14.5 vs. 28 mm, P= 0.0017) were significantly reduced among ruptured compared to intact AAAs. The latter group presented mostly an anterior eccentric ILT deposition, while the former presented a more symmetrical pattern. The site of rupture was located at the site of maximum size in only 2 cases. In general, ILT was reduced at the site of rupture compared to the site of maximum aneurysm size in ruptured cases but differences did not reach statistical significance. CONCLUSIONS In similar sized AAAs, ILT is reduced in ruptured compared to nonruptured cases.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, Medical School, University of Crete, Heraklion, Greece.
| | - Igor Koncar
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Vascular and Endovascular Surgery, Clinic Center of Serbia, Belgrade, Serbia
| | - Konstantinos Tzirakis
- Institute of Applied Mathematics, Foundation of Research and Technology Hellas, Heraklion, Greece
| | - Emmanouil Tavlas
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, Medical School, University of Crete, Heraklion, Greece
| | - Lazar Davidovic
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Vascular and Endovascular Surgery, Clinic Center of Serbia, Belgrade, Serbia
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, Medical School, University of Crete, Heraklion, Greece
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Filis K, Tsioufis C, Sianou A, Triantafillou K, Sigala F, Galyfos G. Critical evaluation on proper antithrombotic treatment in different groups of patients undergoing vascular surgery. Hellenic J Cardiol 2018; 59:313-316. [PMID: 29723662 DOI: 10.1016/j.hjc.2018.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 04/21/2018] [Accepted: 04/24/2018] [Indexed: 12/14/2022] Open
Abstract
Antithrombotic treatment including anticoagulants and antiplatelets has evolved during the last decades, and several recommendations have been included in the latest guidelines regarding the proper management of patients undergoing vascular surgery. However, there are significant differences compared to older recommendations, and indications vary among patients with peripheral artery disease, carotid disease, and abdominal aortic aneurysm. In this mini review, we critically evaluate all these data to produce useful conclusions for everyday clinical practice.
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Affiliation(s)
- Konstantinos Filis
- First Department of Propedeutic Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Argyri Sianou
- Department of Microbiology, Areteion Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Fragiska Sigala
- First Department of Propedeutic Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - George Galyfos
- First Department of Propedeutic Surgery, Hippocration Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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Common First-Pass CT Angiography Findings Associated With Rapid Growth Rate in Abdominal Aorta Aneurysms Between 3 and 5 cm in Largest Diameter. AJR Am J Roentgenol 2018; 210:431-437. [DOI: 10.2214/ajr.17.18094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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23
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Virag L, Wilson JS, Humphrey JD, Karšaj I. Potential biomechanical roles of risk factors in the evolution of thrombus-laden abdominal aortic aneurysms. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:10.1002/cnm.2893. [PMID: 28447404 PMCID: PMC5658277 DOI: 10.1002/cnm.2893] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/23/2017] [Accepted: 04/23/2017] [Indexed: 05/22/2023]
Abstract
Abdominal aortic aneurysms (AAAs) typically harbour an intraluminal thrombus (ILT), yet most prior computational models neglect biochemomechanical effects of thrombus on lesion evolution. We recently proposed a growth and remodelling model of thrombus-laden AAAs that introduced a number of new constitutive relations and associated model parameters. Because values of several of these parameters have yet to be elucidated by clinical data and could vary significantly from patient to patient, the aim of this study was to investigate the possible extent to which these parameters influence AAA evolution. Given that some of these parameters model potential effects of factors that influence the risk of rupture, this study also provides insight into possible roles of common risk factors on the natural history of AAAs. Despite geometrical limitations of a cylindrical domain, findings support current thought that smoking, hypertension, and female sex likely increase the risk of rupture. Although thrombus thickness is not a reliable risk factor for rupture, the model suggests that the presence of ILT may have a destabilizing effect on AAA evolution, consistent with histological findings from human samples. Finally, simulations support two hypotheses that should be tested on patient-specific geometries in the future. First, ILT is a potential source of the staccato enlargement observed in many AAAs. Second, ILT can influence rupture risk, positively or negatively, via competing biomechanical (eg, stress shielding) and biochemical (ie, proteolytic) effects. Although further computational and experimental studies are needed, the present findings highlight the importance of considering ILT when predicting aneurysmal enlargement and rupture risk.
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Affiliation(s)
- Lana Virag
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - John S. Wilson
- Department of Radiology, Emory University, Atlanta, GA, USA
| | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
| | - Igor Karšaj
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
- Address for Correspondence: Igor Karšaj, Ph.D., Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ivana Lučića 5, Zagreb, 10000, Croatia, Phone: +38516168125,
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Lindquist Liljeqvist M, Hultgren R, Siika A, Gasser TC, Roy J. Gender, smoking, body size, and aneurysm geometry influence the biomechanical rupture risk of abdominal aortic aneurysms as estimated by finite element analysis. J Vasc Surg 2017; 65:1014-1021.e4. [PMID: 28342508 DOI: 10.1016/j.jvs.2016.10.074] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 10/14/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Finite element analysis (FEA) has been suggested to be superior to maximal diameter measurements in predicting rupture of abdominal aortic aneurysms (AAAs). Our objective was to investigate to what extent previously described rupture risk factors were associated with FEA-estimated rupture risk. METHODS One hundred forty-six patients with an asymptomatic AAA of a 40- to 60-mm diameter were retrospectively identified and consecutively included. The patients' computed tomography angiograms were analyzed by FEA without (neutral) and with (specific) input of patient-specific mean arterial pressure (MAP), gender, family history, and age. The maximal wall stress/wall strength ratio was described as a rupture risk equivalent diameter (RRED), which translated this ratio into an average aneurysm diameter of corresponding rupture risk. RESULTS In multivariate linear regression, RREDneutral increased with female gender (3.7 mm; 95% confidence interval [CI], 0.13-7.3) and correlated with patient height (0.27 mm/cm; 95% CI, 0.11-0.43) and body surface area (BSA, 16 mm/m2; 95% CI, 8.3-24) and inversely with body mass index (BMI, -0.40 mm/kg m-2; 95% CI, -0.75 to -0.054) in a wall stress-dependent manner. Wall stress-adjusted RREDneutral was raised if the patient was currently smoking (1.1 mm; 95% CI, 0.21-1.9). Age, MAP, family history, and patient weight were unrelated to RREDneutral. In specific FEA, RREDspecific increased with female gender, MAP, family history positive for AAA, height, and BSA, whereas it was inversely related to BMI. All results were independent of aneurysm diameter. Peak wall stress and RRED correlated with aneurysm diameter and lumen volume. CONCLUSIONS Female gender, current smoking, increased patient height and BSA, and low BMI were found to increase the mechanical rupture risk of AAAs. Previously described rupture risk factors may in part be explained by patient characteristic-dependent variations in aneurysm biomechanics.
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Affiliation(s)
| | - Rebecka Hultgren
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Antti Siika
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - T Christian Gasser
- Department of Solid Mechanics, School of Engineering Sciences, Royal Institute of Technology, Stockholm, Sweden
| | - Joy Roy
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Wemmelund H, Jørgensen TMM, Høgh A, Behr-Rasmussen C, Johnsen SP, Lindholt JS. Low-dose aspirin and rupture of abdominal aortic aneurysm. J Vasc Surg 2016; 65:616-625.e4. [PMID: 27460909 DOI: 10.1016/j.jvs.2016.04.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/26/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The use of low-dose aspirin (acetylsalicylic acid [ASA]) has been suggested to attenuate growth of abdominal aortic aneurysms (AAAs), yet solid clinical evidence of this hypothesis is still missing. This study aimed to investigate whether preadmission ASA use influenced the risk of presenting with rupture of AAA (rAAA) on hospital admission and subsequent 30-day case fatality. METHODS There were 4010 patients with an incident diagnosis of rAAA and 4010 age- and sex-matched AAA patients identified in the Danish National Registry of Patients. Data on comorbidity, concomitant drug use, primary health care utilization, socioeconomic status, and vital status were obtained from nationwide health care and administrative registries. RESULTS Preadmission ASA use was identified for 1815 (45.3%) rAAA patients and 2111 (52.6%) AAA patients, corresponding to a crude odds ratio for rAAA in ASA users of 0.72 (95% confidence interval [CI], 0.66-0.79) compared with nonusers. However, after adjustment for possible confounders, no association between ASA use and the risk of rAAA was found (adjusted odds ratio, 0.97; 95% CI, 0.86-1.08). The aggregated 30-day rAAA case-fatality rate for users of ASA was 66.0% compared with 56.9% for nonusers, corresponding to an adjusted mortality rate ratio of 1.16 (95% CI, 1.06-1.27). CONCLUSIONS Preadmission ASA use is not associated with an altered risk of AAA rupture but seems to be associated with a worse prognosis after rupture of AAA.
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Affiliation(s)
- Holger Wemmelund
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Trine M M Jørgensen
- Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Annette Høgh
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | | | - Søren P Johnsen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jes S Lindholt
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark; Elitary Research Centre of Individualised Medicine in Arterial Disease (CIMA), Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
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Schmitz-Rixen T, Keese M, Hakimi M, Peters A, Böckler D, Nelson K, Grundmann RT. Ruptured abdominal aortic aneurysm—epidemiology, predisposing factors, and biology. Langenbecks Arch Surg 2016; 401:275-88. [DOI: 10.1007/s00423-016-1401-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/04/2016] [Indexed: 12/19/2022]
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Kontopodis N, Pantidis D, Dedes A, Daskalakis N, Ioannou CV. The - Not So - Solid 5.5 cm Threshold for Abdominal Aortic Aneurysm Repair: Facts, Misinterpretations, and Future Directions. Front Surg 2016; 3:1. [PMID: 26835458 PMCID: PMC4725249 DOI: 10.3389/fsurg.2016.00001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/07/2016] [Indexed: 01/17/2023] Open
Abstract
Abdominal aortic aneurysms (AAAs) represent a focal dilation of the aorta exceeding 1.5 times its normal diameter. It is reported that 4-8% of men and 0.5-1% of women above 50 years of age bear an AAA. Rupture represents the most disastrous complication of aneurysmal disease that is accompanied by an overall mortality of 80%. Autopsy data have shown that nearly 13% of AAAs with a maximum diameter ≤5 cm were ruptured and 60% of the AAAs >5 cm in diameter never ruptured. It is therefore obvious that the "maximum diameter criterion," as a single parameter that fits all patients, is obsolete. Investigators have begun a search for more reliable rupture risk markers for AAA expansion, such as the level and change of peak wall stress or AAA geometry. Furthermore, it is becoming more and more evident that intraluminal thrombus (ILT), which is present in 75% of all AAAs, affects AAA features and promotes their expansion. Though these hemodynamic properties of AAAs are significant and seem to better describe rupture risk, they are in need of specialized equipment and software and demand time for processing making them difficult in use and unattractive to clinicians in everyday practice. In the search for the addition of other risk factors or user-friendly tools, which may predict AAA expansion and rupture, the use of the asymmetrical ILT deposition index seems appealing since it has been reported to identify AAAs that may have an increased or decreased growth rate.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, University Hospital of Heraklion, University of Crete Medical School , Crete , Greece
| | - Dimitrios Pantidis
- Vascular Surgery Unit, University Hospital of Heraklion, University of Crete Medical School , Crete , Greece
| | - Athansios Dedes
- Vascular Surgery Department, Red Cross Hospital , Athens , Greece
| | - Nikolaos Daskalakis
- Vascular Surgery Unit, University Hospital of Heraklion, University of Crete Medical School , Crete , Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, University Hospital of Heraklion, University of Crete Medical School , Crete , Greece
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Georg Y, Delay C, Schwein A, Lejay A, Thaveau F, Gaertner S, Stephan D, Heim F, Chakfe N. [Contribution of mathematical models and biomechanical properties in predicting the risk of abdominal aortic aneurysm rupture]. ACTA ACUST UNITED AC 2015; 41:63-8. [PMID: 26318549 DOI: 10.1016/j.jmv.2015.07.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 07/17/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Rupture is the worst outcome of abdominal aortic aneurysm (AAA). The decision to operate should include counterbalancing the risk of aneurysm rupture against the risk of aneurysm repair, within the context of a patient's overall life expectancy. Current surgical guidelines are based on population studies, and important variables are missed in predicting individual risk of rupture. METHODS In this literature review, we focused on the contribution of biomechanical and mathematical models in predicting risk of AAA rupture. RESULTS Anatomical features as diameter asymmetry and lack of tortuosity are shown to be anatomical risk factors of rupture. Wall stiffness (due to modifications of elastin and collagen composition) and increased inflammatory response are also factors that affect the structural integrity of the AAA wall. Biomechanical studies showed that wall strength is lower in ruptured than non-ruptured AAA. Intra-luminal thrombus also has a big role to play in the occurrence of rupture. Current mathematical models allow more variables to be included in predicting individual risk of rupture. CONCLUSION Moving away from using maximal transverse diameter of the AAA as a unique predictive factor and instead including biological, structural and biomechanical variables in predicting individual risk of rupture will be essential in the future and will help gain precision and accuracy in surgical indications.
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Affiliation(s)
- Y Georg
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Service de chirurgie vasculaire et transplantation rénale, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP n(o) 426, 67091 Strasbourg cedex, France
| | - C Delay
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Service de chirurgie vasculaire et transplantation rénale, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP n(o) 426, 67091 Strasbourg cedex, France
| | - A Schwein
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Service de chirurgie vasculaire et transplantation rénale, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP n(o) 426, 67091 Strasbourg cedex, France
| | - A Lejay
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Service de chirurgie vasculaire et transplantation rénale, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP n(o) 426, 67091 Strasbourg cedex, France
| | - F Thaveau
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Service de chirurgie vasculaire et transplantation rénale, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP n(o) 426, 67091 Strasbourg cedex, France
| | - S Gaertner
- Service des maladies vasculaires, hypertension artérielle et pharmacologie clinique, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - D Stephan
- Service des maladies vasculaires, hypertension artérielle et pharmacologie clinique, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - F Heim
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Laboratoire de physique et mécanique textile, ENSISA, 11, rue Alfred-Werner, 68093 Mulhouse cedex, France
| | - N Chakfe
- Groupe européen de recherche sur les prothèses appliquées à la chirurgie vasculaire (Geprovas), faculté de médecine, institut d'anatomie pathologique, 4, rue Kirschleger, 67085 Strasbourg cedex, France; Service de chirurgie vasculaire et transplantation rénale, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP n(o) 426, 67091 Strasbourg cedex, France.
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Sultan S, Hynes N, Kavanagh EP, Diethrich EB. How does the multilayer flow modulator work? The science behind the technical innovation. J Endovasc Ther 2015; 21:814-21. [PMID: 25453884 DOI: 10.1583/14-4858.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Sherif Sultan
- 1 Western Vascular Institute and the Department of Vascular and Endovascular Surgery, University College Hospital Galway, Ireland
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31
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Metaxa E, Kontopodis N, Tzirakis K, Ioannou CV, Papaharilaou Y. Effect of Intraluminal Thrombus Asymmetrical Deposition on Abdominal Aortic Aneurysm Growth Rate. J Endovasc Ther 2015; 22:406-12. [DOI: 10.1177/1526602815584018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To determine the relationship between asymmetrical intraluminal thrombus (ILT) deposition in abdominal aortic aneurysm (AAA) and growth rate and to explore its biomechanical perspective. Methods: Thirty-four patients with AAA underwent at least 2 computed tomography scans during surveillance. The volumes of the AAA (VAAA) and thrombus (VILT) and the maximum thrombus thickness (ILTthick) were computed. Thrombus distribution was evaluated by introducing the asymmetrical thrombus deposition index (ATDI), with positive and negative values (–1<ATDI<1) associated with anterior and posterior ILT deposition, respectively. Finite element analysis was applied to estimate wall stress. Aneurysms were divided into high and low growth rate groups based on the cohort’s median growth rate, and the abovementioned parameters were compared between groups. Results: Most AAAs had asymmetrical anterior thrombus deposition. The high and low growth rate groups did not present significant differences in maximum diameter, VAAA, VILT, or maximum ILTthick. However, the high growth rate group had significantly higher ATDI (p=0.02). The ATDI<0 group (posterior ILT distribution) presented a significantly lower median growth rate compared to that of ATDI≥0 group (anterior or symmetrical ILT deposition; p=0.029). The specificity of an ATDI<0 criterion for identifying AAAs with a growth rate below the cohort median was 89%. The ATDI<0 group had a significantly lower posterior maximum wall stress compared with that of the ATDI≥0 group (p=0.03). Overall peak wall stress did not differ between groups. Conclusion: Posterior thrombus deposition in AAAs is associated with significantly lower growth rate and lower posterior maximum wall stress compared with that of AAAs with anterior thrombus deposition and could potentially indicate a lower rupture risk.
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Affiliation(s)
- Eleni Metaxa
- Institute of Applied and Computational Mathematics, Foundation for Research and Technology–Hellas, Heraklion, Crete, Greece
| | - Nikolaos Kontopodis
- Institute of Applied and Computational Mathematics, Foundation for Research and Technology–Hellas, Heraklion, Crete, Greece
- Vascular Surgery Department, University of Crete Medical School, Heraklion, Crete, Greece
| | - Konstantinos Tzirakis
- Institute of Applied and Computational Mathematics, Foundation for Research and Technology–Hellas, Heraklion, Crete, Greece
| | - Christos V. Ioannou
- Vascular Surgery Department, University of Crete Medical School, Heraklion, Crete, Greece
| | - Yannis Papaharilaou
- Institute of Applied and Computational Mathematics, Foundation for Research and Technology–Hellas, Heraklion, Crete, Greece
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Erhart P, Grond-Ginsbach C, Hakimi M, Lasitschka F, Dihlmann S, Böckler D, Hyhlik-Dürr A. Finite Element Analysis of Abdominal Aortic Aneurysms: Predicted Rupture Risk Correlates With Aortic Wall Histology in Individual Patients. J Endovasc Ther 2014; 21:556-64. [DOI: 10.1583/14-4695.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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