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Lyu Z, Mu N, Rezaeitaleshmahalleh M, Zhang X, McBane R, Jiang J. Automatic segmentation of intraluminal thrombosis of abdominal aortic aneurysms from CT angiography using a mixed-scale-driven multiview perception network (M 2Net) model. Comput Biol Med 2024; 179:108838. [PMID: 39033681 DOI: 10.1016/j.compbiomed.2024.108838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 06/17/2024] [Accepted: 06/29/2024] [Indexed: 07/23/2024]
Abstract
Intraluminal thrombosis (ILT) plays a critical role in the progression of abdominal aortic aneurysms (AAA). Understanding the role of ILT can improve the evaluation and management of AAAs. However, compared with highly developed automatic vessel lumen segmentation methods, ILT segmentation is challenging. Angiographic contrast agents can enhance the vessel lumen but cannot improve boundary delineation of the ILT regions; the lack of intrinsic contrast in the ILT structure significantly limits the accurate segmentation of ILT. Additionally, ILT is not evenly distributed within AAAs; its sparsity and scattered distributions in the imaging data pose challenges to the learning process of neural networks. Thus, we propose a multiview fusion approach, allowing us to obtain high-quality ILT delineation from computed tomography angiography (CTA) data. Our multiview fusion network is named Mixed-scale-driven Multiview Perception Network (M2Net), and it consists of two major steps. Following image preprocessing, the 2D mixed-scale ZoomNet segments ILT from each orthogonal view (i.e., Axial, Sagittal, and Coronal views) to enhance the prior information. Then, the proposed context-aware volume integration network (CVIN) effectively fuses the multiview results. Using contrast-enhanced computed tomography angiography (CTA) data from human subjects with AAAs, we evaluated the proposed M2Net. A quantitative analysis shows that the proposed deep-learning M2Net model achieved superior performance (e.g., DICE scores of 0.88 with a sensitivity of 0.92, respectively) compared with other state-of-the-art deep-learning models. In closing, the proposed M2Net model can provide high-quality delineation of ILT in an automated fashion and has the potential to be translated into the clinical workflow.
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Affiliation(s)
- Zonghan Lyu
- Biomedical Engineering, Michigan Technological University, Houghton, MI, 49931, USA; Center for Biocomputing and Digital Health, Health Research Institute and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, 49931, USA
| | - Nan Mu
- Biomedical Engineering, Michigan Technological University, Houghton, MI, 49931, USA; Center for Biocomputing and Digital Health, Health Research Institute and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, 49931, USA
| | - Mostafa Rezaeitaleshmahalleh
- Biomedical Engineering, Michigan Technological University, Houghton, MI, 49931, USA; Center for Biocomputing and Digital Health, Health Research Institute and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, 49931, USA
| | | | | | - Jingfeng Jiang
- Biomedical Engineering, Michigan Technological University, Houghton, MI, 49931, USA; Center for Biocomputing and Digital Health, Health Research Institute and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, 49931, USA; Mayo Clinic, Rochester, MN, 55902, USA.
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2
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Funamizu Y, Goto H, Oda A, Miki T, Saijo Y. Opportunistic Ultrasound Screening for Abdominal Aortic Aneurysm. Ann Vasc Dis 2024; 17:157-163. [PMID: 38919325 PMCID: PMC11196171 DOI: 10.3400/avd.oa.23-00110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/06/2024] [Indexed: 06/27/2024] Open
Abstract
Objective: In patients with abdominal aortic aneurysm (AAA), early detection and optimal elective treatment before rupture are desirable. In the absence of an established public screening system, opportunistic screening during ultrasound examination for another purpose might be efficacious. The aim of this study was to evaluate the efficacy of opportunistic screening for AAA. Methods: This prospective multicenter observational study enrolled patients who were scheduled to undergo ultrasound for reasons other than AAA. After the ultrasound for the original purpose, evaluation of the abdominal aorta was added. If the abdominal aorta was clear enough for measurement, its diameter and shape were recorded. Furthermore, information on comorbidities was collected for each patient. Results: A total of 10325 patients (echocardiography: 6150; abdominal ultrasound: 4162) from 16 institutions were enrolled. The abdominal aorta was well visualized in 92.9% of patients who underwent echocardiography. Among 9791 patients, AAA was diagnosed in 122 (1.3%) (107 fusiform and 15 saccular), with a diameter range of 30-63 mm. The diagnostic rate increased with age. On multivariate analysis, older age, male sex, coronary artery disease, peripheral arterial disease, and smoking habituation were the risk factors for AAA. Conclusion: Opportunistic screening for AAA was efficacious.
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Affiliation(s)
- Yasuharu Funamizu
- Clinical Physiology Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hitoshi Goto
- Department of Vascular Surgery, South Miyagi Medical Center, Ogawara, Miyagi, Japan
| | - Ayaka Oda
- Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Takashi Miki
- Clinical Physiology Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yoshifumi Saijo
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Miyagi, Japan
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Zecca F, Faa G, Sanfilippo R, Saba L. How to improve epidemiological trustworthiness concerning abdominal aortic aneurysms. Vascular 2024:17085381241257747. [PMID: 38842081 DOI: 10.1177/17085381241257747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Research on degenerative abdominal aortic aneurysms (AAA) is hampered by complex pathophysiology, sub-optimal pre-clinical models, and lack of effective medical therapies. In addition, trustworthiness of existing epidemiological data is impaired by elements of ambiguity, inaccuracy, and inconsistency. Our aim is to foster debate concerning the trustworthiness of AAA epidemiological data and to discuss potential solutions. METHODS We searched the literature from the last five decades for relevant epidemiological data concerning AAA development, rupture, and repair. We then discussed the main issues burdening existing AAA epidemiological figures and proposed suggestions potentially beneficial to AAA diagnosis, prognostication, and management. RESULTS Recent data suggest a heterogeneous scenario concerning AAA epidemiology with rates markedly varying by country and study cohorts. Overall, AAA prevalence seems to be decreasing worldwide while mortality is apparently increasing regardless of recent improvements in aortic-repair techniques. Prevalence and mortality are decreasing in high-income countries, whereas low-income countries show an increase in both. However, several pieces of information are missing or outdated, thus systematic renewal is necessary. Current AAA definition and surgical criteria do not consider inter-individual variability of baseline aortic size, further decreasing their reliability. CONCLUSIONS Switching from flat aortic-size thresholds to relative aortic indices would improve epidemiological trustworthiness regarding AAAs. Aortometry standardization focusing on simplicity, univocity, and accuracy is crucial. A patient-tailored approach integrating clinical data, multi-adjusted indices, and imaging parameters is desirable. Several novel imaging modalities boast promising profiles for investigating the aortic wall. New contrast agents, computational analyses, and artificial intelligence-powered software could provide further improvements.
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Affiliation(s)
- Fabio Zecca
- Department of Radiology, University Hospital "D. Casula", Cagliari, Italy
| | - Gavino Faa
- Department of Pathology, University Hospital "D. Casula", Cagliari, Italy
| | - Roberto Sanfilippo
- Department of Vascular Surgery, University Hospital "D. Casula", Cagliari, Italy
| | - Luca Saba
- Department of Radiology, University Hospital "D. Casula", Cagliari, Italy
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4
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Nargesi S, Abutorabi A, Mohamadi Y, Salimi J, Tajdini M, Alipour V. Cost-effectiveness analysis of endovascular versus open repair in patients with abdominal aortic aneurysm in Iran: a cross-sectional study. Int J Surg 2024; 110:3338-3345. [PMID: 38502855 PMCID: PMC11175740 DOI: 10.1097/js9.0000000000001321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Abdominal aortic aneurysm (AAA) is one of the most important cardiovascular diseases, especially in the elderly. People with this disease are at risk of rupture of the abdominal aorta and death. The present study was conducted with the aim of analyzing the cost-effectiveness of endovascular repair compared to open surgery in AAA patients in Iran. METHODS A Markov chain model was developed based on the use of endovascular repair and open surgery. The base-case patient was defined as a 65-year-old man presenting with AAA diameter greater than 5 cm. The determination of costs was from the perspective of the public sector provider. QALY was used to calculate the effectiveness. Incremental cost-effectiveness ratio (ICER) and TreeAge software were used for cost-effectiveness analysis. The follow-up period was 10 years and the willingness to pay (WTP) was determined as three times the Gross domestic product (GDP) per capita. RESULT At the end of year 10, the endovascular aneurysm repair (EVAR) strategy gained 1 318 313 559 Iranian Rial (IRR) (67 885.29$) in cost and 3.57 QALYs in effectiveness. In contrast, the use of the open surgery repair (OSR) strategy gained 1 186 761 858 IRR (61 111.16$) in cost and 3·32 QALYs in effectiveness. The incremental cost-effectiveness ratio, comparing EVAR versus OSR, was 53, 346, 3757 IRR (178.36$) per QALYs, which is lower than the proposed WTP, indicating that EVAR is more expensive and more effective. Based on the Monte Carlo simulation test, EVAR is the preferred strategy in 58.6% of the population. CONCLUSION Endovascular repair has a relative superiority compared to open surgery, and the probability of the effectiveness of endovascular repair compared to open surgery does not change with increasing willingness to pay.
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Affiliation(s)
- Shahin Nargesi
- Department of Health Management and Economics, Faculty of Health, Ilam University of Medical Sciences, Ilam
| | - Ali Abutorabi
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran
| | - Yousef Mohamadi
- Department of Anatomy, School of Medicine, Ilam University of Medical Sciences, Ilam
| | - Javad Salimi
- Vascular and Endovascular Surgery Department, Sina Hospital, Tehran University of Medical Sciences, Tehran
| | - Masih Tajdini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Alipour
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran
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Du P, Hou Y, Su C, Gao J, Yang Y, Zhang J, Cui X, Tang J. The future for the therapeutics of abdominal aortic aneurysm: engineered nanoparticles drug delivery for abdominal aortic aneurysm. Front Bioeng Biotechnol 2024; 11:1324406. [PMID: 38249799 PMCID: PMC10796665 DOI: 10.3389/fbioe.2023.1324406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/12/2023] [Indexed: 01/23/2024] Open
Abstract
Abdominal aortic aneurysm (AAA) is a severe cardiovascular disease with a high mortality rate. Several screening and diagnostic methods have been developed for AAA early diagnosis. Open surgery and endovascular aortic repair (EVAR) are clinically available for patients who meet the indications for surgery. However, for non-surgical patients, limited drugs exist to inhibit or reverse the progression of aneurysms due to the complex pathogenesis and biological structure of AAA, failing to accumulate precisely on the lesion to achieve sufficient concentrations. The recently developed nanotechnology offers a new strategy to address this problem by developing drug-carrying nanoparticles with enhanced water solubility and targeting capacity, prolonged duration, and reduced side effects. Despite the rising popularity, limited literature is available to highlight the progression of the field. Herein, in this review, we first discuss the pathogenesis of AAA, the methods of diagnosis and treatment that have been applied clinically, followed by the review of research progressions of constructing different drug-loaded nanoparticles for AAA treatment using engineered nanoparticles. In addition, the feasibility of extracellular vesicles (EVs) and EVs-based nanotechnology for AAA treatment in recent years are highlighted, together with the future perspective. We hope this review will provide a clear picture for the scientists and clinicians to find a new solution for AAA clinical management.
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Affiliation(s)
- Pengchong Du
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
| | - Yachen Hou
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
| | - Chang Su
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
| | - Jiamin Gao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
| | - Yu Yang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
| | - Jinying Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
| | - Xiaolin Cui
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Junnan Tang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Province Key Laboratory of Cardiac Injury and Repair, Zhengzhou, China
- Henan Province Clinical Research Center for Cardiovascular Diseases, Zhengzhou, China
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Flaherty DJ, Haque A. Incidental Cardiovascular Abnormalities in the Abdominal Aortic Aneurysm (AAA) Surveillance Population During the AAA Get Fit Trial: A Case Series and Review of the Literature. Cureus 2023; 15:e48271. [PMID: 38054161 PMCID: PMC10695669 DOI: 10.7759/cureus.48271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/07/2023] Open
Abstract
Background The prevalence of cardiovascular disease and incidence of major adverse cardiovascular events (MACEs) is very high among the abdominal aortic aneurysm (AAA) surveillance population. Formal assessments of and interventions to reduce cardiovascular risk are not a routine part of the surveillance programme at present. However, its potential importance is highlighted by incidental findings during the AAA Get Fit Trial, a randomised controlled trial which included baseline cardiopulmonary exercise testing (CPET). We speculate that CPET can act as an opportunistic screening programme to identify cardiovascular disease in AAA surveillance patients. Methods The AAA Get Fit Trial was a prospective, randomised controlled trial at a tertiary vascular centre, Manchester University NHS Foundation Trust, conducted between November 2017 and August 2019. Patients underwent CPET at baseline, 8, 16, 24 and 36 weeks as well as clinical history and examination and blood tests. We report on incidental cardiovascular abnormalities diagnosed during the trial. Results Of the 59 participants in the trial, four (6.8%) were identified to have abnormal findings suggestive of unstable cardiovascular disease. On subsequent further investigation, two patients were diagnosed and treated for severe coronary artery disease after abnormal ECG findings were noted during CPET. One patient was diagnosed with unstable angina after obtaining a detailed history on baseline assessment which was treated medically before going on to have a successful elective AAA repair. Conclusions There is a high incidence of MACEs among this high-risk population both pre and perioperatively. Identifying and treating cardiovascular disease among the AAA surveillance population must be a focus of the future AAA screening programme.
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Affiliation(s)
| | - Adam Haque
- Vascular Surgery, University of Manchester, Manchester, GBR
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7
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Lu L, Jin Y, Tong Y, Xiao L, Hou Y, Liu Z, Dou H. Myeloid-derived suppressor cells promote the formation of abdominal aortic aneurysms through the IL-3-ICOSL-ICOS axis. BBA ADVANCES 2023; 4:100103. [PMID: 37705722 PMCID: PMC10495679 DOI: 10.1016/j.bbadva.2023.100103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Th17 cells are powerful inflammation promoters in the pathogenesis of abdominal aortic aneurysms (AAAs). Myeloid-derived suppressor cells (MDSCs) can promote the differentiation of Th17 cells in chronic inflammatory autoimmune injury. Here, we aim to examine whether MDSCs regulate the differentiation of Th17 cells to participate in the development of AAA. We demonstrated an abnormal accumulation of MDSCs in AAA patients, which was positively associated with Th17 cells. We established angiotensin II-induced apolipoprotein E knockout mice and found the impaired immunosuppressive function of M-MDSCs. After systemic injection of anti-Gr-1 antibody in AAA mice to deplete circulating MDSCs, AAA formation and the differentiation of Th17 cells were abolished, and the overexpression of inducible T-cell costimulator (ICOS) on Th17 cells was reversed accordingly. Regulating the expression of ICOS ligand (ICOSL) on MDSCs affects the differentiation of Th17 cells. The adoptive transfer of ICOSLlowMDSCs in AAA mice inhibited the differentiation of Th17 cells and the development of AAA. Meanwhile, rIL-3 promoted the survival and immunosuppressive dysfunction of MDSCs, upregulated ICOSL expression on MDSCs by inhibiting activation of the PI3K/AKT signaling pathway, and regulated MDSCs to promote the differentiation of Th17 cells via the ICOSL-ICOS axis. An increase in serum IL-3, ICOSL+MDSCs, and ICOS+Th17 cells was detected in AAA patients, and IL-3 levels were positively correlated with the proportion of ICOSL+MDSC cells. In conclusion, we uncovered a pivotal role of MDSCs in promoting the differentiation of Th17 cells through the IL-3-ICOSL-ICOS axis during AAA, providing an important theoretical basis for understanding the pathogenesis of AAA.
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Affiliation(s)
- Li Lu
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing, China
- Jiangsu Key Laboratory of Molecular Medicine, Nanjing, China
| | - Yi Jin
- Department of Vascular Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Yuanhao Tong
- Department of Vascular Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Lun Xiao
- Department of Vascular Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Yayi Hou
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing, China
- Jiangsu Key Laboratory of Molecular Medicine, Nanjing, China
| | - Zhao Liu
- Department of Vascular Surgery, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, China
| | - Huan Dou
- The State Key Laboratory of Pharmaceutical Biotechnology, Division of Immunology, Medical School, Nanjing University, Nanjing, China
- Jiangsu Key Laboratory of Molecular Medicine, Nanjing, China
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Li GJ, Yang QH, Yang GK, Yang G, Hou Y, Hou LJ, Li ZX, Du LJ. MiR-125b and SATB1-AS1 might be shear stress-mediated therapeutic targets. Gene 2023; 857:147181. [PMID: 36623676 DOI: 10.1016/j.gene.2023.147181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023]
Abstract
The aim of the study was to explore the potential molecular mechanism associated with shear stress on abdominal aortic aneurysm (AAA) progression. This study performed RNA sequencing on AAA patients (SQ), AAA patients after endovascular aneurysm repair (EVAR, SH), and normal controls (NC). Furthermore, we identified the differentially expressed microRNAs (miRNAs), long noncoding RNAs (lncRNAs), and circular RNA (cirRNAs) and constructed competing endogenous RNA (ceRNA) networks. Finally, 164 differentially expressed miRNAs, 179 co-differentially expressed lncRNAs, and 440 co-differentially expressed circRNAs among the three groups were obtained. The differentially expressed miRNAs mainly enriched in 325 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Target genes associated with co-differentially expressed genes among the group of SH, SQ, and NC mainly enriched in 66 KEGG pathways. LncRNA-miRNA-mRNA interactions, including 15 lncRNAs, 63 miRNAs and 57 mRNAs, was constructed. CircRNA-miRNA-mRNA ceRNA network included 79 circRNAs, 21 miRNAs, and 49 mRNAs. Among them, KLRC2 and CSTF1, targeted by miR-125b, participated in cell-mediated immunity regulation. MiR-320-related circRNAs and SATB1-AS1 serving as the sponge of miRNAs, such as has-circ-0129245, has-circ-0138746, and has-circ-0139786, were hub genes in ceRNA network. In conclusion, AAA patients might be benefit from EVAR based on various pathways and some molecules, such as miR-125b and SATB1-AS1, related with shear stress.
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Affiliation(s)
- Guo-Jian Li
- Department of Vascular Surgery, Affiliated Hospital of Yunnan University, Kunming 650021, Yunnan, China
| | - Qiong-Hui Yang
- Department of Pharmaceutical, The Third People's Hospital of Yunnan Province, Kunming 650011, Yunnan, China
| | - Guo-Kai Yang
- Department of Vascular Surgery, Affiliated Hospital of Yunnan University, Kunming 650021, Yunnan, China
| | - Guang Yang
- Department of Radiology, the First People's Hospital of Anning, China
| | - Yi Hou
- Department of Vascular Surgery, Affiliated Hospital of Yunnan University, Kunming 650021, Yunnan, China
| | - Li-Juan Hou
- Department of Vascular Surgery, Affiliated Hospital of Yunnan University, Kunming 650021, Yunnan, China
| | - Zhao-Xiang Li
- Department of Vascular Surgery, Affiliated Hospital of Yunnan University, Kunming 650021, Yunnan, China
| | - Ling-Juan Du
- Department of Vascular Surgery, Affiliated Hospital of Yunnan University, Kunming 650021, Yunnan, China.
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Wang Q, Wu J, Ma Y, Zhu Y, Song X, Xie S, Liang F, Gimzewska M, Li M, Yao L. Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair. Cochrane Database Syst Rev 2023; 1:CD010185. [PMID: 36629152 PMCID: PMC9832535 DOI: 10.1002/14651858.cd010185.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. Therefore, it is critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This Cochrane Review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. However, the technique may be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the previous Cochrane Review published in 2017. OBJECTIVES To evaluate the benefits and harms of totally percutaneous access compared to cut-down femoral artery access in people undergoing elective bifurcated abdominal endovascular aneurysm repair (EVAR). SEARCH METHODS We used standard, extensive Cochrane search methods The latest search was 8 April 2022. SELECTION CRITERIA We included randomised controlled trials in people diagnosed with an AAA comparing totally percutaneous versus surgical cut-down access endovascular repair. We considered all device types. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for ruptured AAAs and those reporting aorto-uni-iliac repairs. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. short-term mortality, 2. failure of aneurysm exclusion and 3. wound infection. Secondary outcomes were 4. major complications (30-day or in-hospital); 5. medium- to long-term (6 and 12 months) complications and mortality; 6. bleeding complications and haematoma; and 7. operating time, duration of intensive treatment unit (ITU) stay and hospital stay. We used GRADE to assess the certainty of evidence for the seven most clinically relevant primary and secondary outcomes. MAIN RESULTS Three studies with 318 participants met the inclusion criteria, 189 undergoing the percutaneous technique and 129 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report the method of randomisation, allocation concealment or preselected outcomes. The other two larger studies had few sources of bias and good methodology; although one study had a high risk of bias in selective reporting. We observed no clear difference in short-term mortality between groups, with only one death occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.06 to 36.18; 2 studies, 181 participants; low-certainty evidence). One study reported failure of aneurysm exclusion. There was one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 1 study, 151 participants; moderate-certainty evidence). For wound infection, there was no clear difference between groups (RR 0.18, 95% CI 0.01 to 3.59; 3 studies, 318 participants; moderate-certainty evidence). There was no clear difference between percutaneous and cut-down femoral artery access groups in major complications (RR 1.21, 95% CI 0.61 to 2.41; 3 studies, 318 participants; moderate-certainty evidence), bleeding complications (RR 1.02, 95% CI 0.29 to 3.64; 2 studies, 181 participants; moderate-certainty evidence) or haematoma (RR 0.88, 95% CI 0.13 to 6.05; 2 studies, 288 participants). One study reported medium- to long-term complications at six months, with no clear differences between the percutaneous and cut-down femoral artery access groups (RR 0.82, 95% CI 0.25 to 2.65; 1 study, 135 participants; moderate-certainty evidence). We detected differences in operating time, with the percutaneous approach being faster than cut-down femoral artery access (mean difference (MD) -21.13 minutes, 95% CI -41.74 to -0.53 minutes; 3 studies, 318 participants; low-certainty evidence). One study reported the duration of ITU stay and hospital stay, with no clear difference between groups. AUTHORS' CONCLUSIONS Skin puncture may make little to no difference to short-term mortality. There is probably little or no difference in failure of aneurysm exclusion (failure to seal the aneurysms), wound infection, major complications within 30 days or while in hospital, medium- to long-term (six months) complications and bleeding complications between the two groups. Compared with exposing the femoral artery, skin puncture may reduce the operating time slightly. We downgraded the certainty of the evidence to moderate and low as a result of imprecision due to the small number of participants, low event rates and wide CIs, and inconsistency due to clinical heterogeneity. As the number of included studies was limited, further research into this technique would be beneficial.
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Affiliation(s)
- Qi Wang
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Yanfang Ma
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Ying Zhu
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Xiaoyang Song
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shitong Xie
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Fuxiang Liang
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Madelaine Gimzewska
- Academic Department of Vascular Surgery, Imperial College London, London, UK
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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Zhang Y, Kunnath N, Dimick JB, Scott JW, Diaz A, Ibrahim AM. Social Vulnerability And Outcomes For Access-Sensitive Surgical Conditions Among Medicare Beneficiaries. Health Aff (Millwood) 2022; 41:671-679. [PMID: 35500193 DOI: 10.1377/hlthaff.2021.01615] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Concerns have been raised over wide variation in rates of unplanned (emergency or urgent) surgery for access-sensitive surgical conditions-diagnoses requiring surgery that preferably is planned (elective) but, when access is limited, may be delayed until worsening symptoms require riskier and costlier unplanned surgery. Yet little is known about geographic and community-level factors that may increase the likelihood of unplanned surgery with adverse outcomes. We examined the relationship between community-level social vulnerability and rates of unplanned surgery for three access-sensitive conditions in 2014-18 among fee-for-service Medicare beneficiaries ages 65-99. Compared with patients from communities with the lowest social vulnerability, those from communities with the highest vulnerability were more likely, overall, to undergo unplanned surgery (36.2 percent versus 33.5 percent). They were also more likely to experience worse outcomes largely attributable to differential rates of unplanned surgery, including higher rates of mortality (5.4 percent versus 5.0 percent) and additional surgery within thirty days (19.6 percent versus 18.1 percent). Our findings suggest that policy addressing community-level social vulnerability may mitigate the observed differences in surgical procedures and outcomes for access-sensitive conditions.
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Affiliation(s)
- Yuqi Zhang
- Yuqi Zhang , Duke University, Durham, North Carolina
| | | | | | | | | | - Andrew M Ibrahim
- Andrew M. Ibrahim, University of Michigan, and HOK, Chicago, Illinois
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11
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Powell JT, Koelemay MJ. Systematic Reviews of the Literature Are Not Always Either Useful Or the Best Way To Add To Science. EJVES Vasc Forum 2021; 54:2-6. [PMID: 34917997 PMCID: PMC8668828 DOI: 10.1016/j.ejvsvf.2021.10.021] [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: 08/23/2021] [Revised: 09/12/2021] [Accepted: 10/18/2021] [Indexed: 12/31/2022] Open
Abstract
Systematic reviews are becoming more popular as a way of doing research; however, not all systematic reviews are clinically useful and sometimes another type of review (scoping, topical, or critical) would be of greater value to the clinical and scientific community. The different types of review and their use are described, illustrated by examples relevant to vascular surgery.
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Affiliation(s)
| | - Mark J.W. Koelemay
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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12
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Affiliation(s)
- Andres Schanzer
- From the Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.); and the Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston (G.S.O.)
| | - Gustavo S Oderich
- From the Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.); and the Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston (G.S.O.)
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13
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Shi J, Guo J, Li Z, Xu B, Miyata M. Importance of NLRP3 Inflammasome in Abdominal Aortic Aneurysms. J Atheroscler Thromb 2021; 28:454-466. [PMID: 33678767 PMCID: PMC8193780 DOI: 10.5551/jat.rv17048] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/14/2022] Open
Abstract
Abdominal aortic aneurysm (AAA) is a chronic inflammatory degenerative aortic disease, which particularly affects older people. Nucleotide-binding oligomerization domain-like receptor family protein 3 (NLRP3) inflammasome is a multi-protein complex and mediates inflammatory responses by activating caspase 1 for processing premature interleukin (IL)-1β and IL-18. In this review, we first summarize the principle of NLRP3 inflammasome activation and the functionally distinct classes of small molecule NLRP3 inflammasome inhibitors. Next, we provide a comprehensive literature review on the expression of NLRP3 inflammasome effector mediators (IL-1β and IL-18) and components (caspase 1, apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC) and NLRP3) in clinical and experimental AAAs. Finally, we discuss the influence of genetic deficiency or pharmacological inhibition of individual effector mediators and components of NLRP3 inflammasome on experimental AAAs. Accumulating clinical and experimental evidence suggests that NLRP3 inflammasome may be a promise therapeutic target for developing pharmacological strategies for clinical AAA management.
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Affiliation(s)
- Jinyun Shi
- Center for Hypertension Care, Shanxi Medical University First Hospital, Taiyuan, Shanxi Province, P. R. China
| | - Jia Guo
- Center for Hypertension Care, Shanxi Medical University First Hospital, Taiyuan, Shanxi Province, P. R. China
| | - Zhidong Li
- Department of Pharmacology, Shanxi Medical University, Taiyuan, Shanxi Province, P. R. China
| | - Baohui Xu
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Masaaki Miyata
- School of Health Science, Faculty of Medicine, Kagoshima University, Kagoshima University, Kagoshima, Japan
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