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van Tongeren OLRM, Rastogi V, Vecht DE, Ultee KHJ, Hoeks SE, Verhagen HJM, de Bruin JL. Metformin Use and Long-term Outcomes Including Aneurysm Sac Dynamics Following EVAR for Infrarenal Abdominal Aortic Aneurysm: "A Retrospective Study". J Endovasc Ther 2024:15266028241268500. [PMID: 39140336 DOI: 10.1177/15266028241268500] [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: 08/15/2024]
Abstract
PURPOSE Metformin, widely used for the treatment of diabetes mellitus (DM), has shown potential for inhibiting abdominal aortic aneurysm (AAA) growth by reducing extracellular matrix remodeling and inflammation. However, its influence on clinical outcomes and aneurysm sac dynamics after endovascular aneurysm repair (EVAR) remains uncertain. This retrospective study aims to explore the effects of metformin on long-term outcomes following EVAR. MATERIALS AND METHODS Patients who underwent elective standard EVAR for infrarenal AAA at a single academic Dutch hospital from 2000 to 2022 were included. We collected baseline patient demographics, comorbid conditions, anatomical and operative characteristics, and 30-day postoperative events. Metformin use was defined as using it preceding EVAR. The primary outcome, the postoperative aneurysm sac volume over time, was investigated using linear mixed-effects modeling. The secondary outcomes, 8-year all-cause mortality and freedom from graft-related events, were evaluated using Kaplan-Meier methods. RESULTS We analyzed 685 patients, including 634 (93%) non-metformin users and 51 (7%) metformin users. The median follow-up period was similar (4.0 years [IQR=1.5, 6.5] vs 5.0 years [IQR=2.0, 8.0]; p=0.091). Patients on metformin had a preoperative aneurysm sac volume of 153 cc (IQR=114, 195) compared with 178 cc (IQR=133, 240) for non-metformin patients (p=0.054). At 30 days post-EVAR, metformin patients had a comparable mean aneurysm sac volume compared with non-metformin patients (metformin: -19.4 cc [95% confidence interval [CI]: -47.4, 8.5]; p=0.173). The effect of metformin on aneurysm growth over time was not significant (-3.9 cc/year; [95% CI: -22.7, 14.9]; p=0.685). Following risk-adjusted analysis, metformin use was associated with similar rates of all-cause mortality (metformin vs no metformin: 50% vs 44%; hazard ratio [HR]=1.11, 95% CI: 0.66, 1.88; p=0.688) and freedom from graft-related events (metformin vs no metformin: 63% vs 66%; HR=1.82, 95% CI: 0.98, 3.38; p=0.059). CONCLUSION Although metformin use may reduce preoperative AAA growth, it does not seem to influence overall/long-term post-EVAR AAA sac dynamics, all-cause mortality, or freedom from graft-related events. These findings suggest that the potential protective effect of metformin on AAA may not be sustained after EVAR. Further prospective studies are needed to investigate the mechanisms underlying the potential role of metformin in AAA management following EVAR. CLINICAL IMPACT There is currently no approved pharmacological treatment available to slow the abdominal aortic aneurysm (AAA) growth rate and reduce the related risk of rupture. In our retrospective analysis including 685 patients undergoing EVAR for infrarenal AAA, we found that metformin use was not associated with improved post-EVAR outcomes, such as a reduction of aneurysm sac volume over time, eight-year all-cause mortality, or freedom of graft-related events. These findings suggest that the potential protective effect of metformin on AAA may not be sustained after EVAR and underscore the need for ongoing research into this area.
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Affiliation(s)
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David E Vecht
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Klaas H J Ultee
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Zhao W, Li B, Hao J, Sun R, He P, Lv H, He M, Shen J, Han Y. Therapeutic potential of natural products and underlying targets for the treatment of aortic aneurysm. Pharmacol Ther 2024; 259:108652. [PMID: 38657777 DOI: 10.1016/j.pharmthera.2024.108652] [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: 12/25/2023] [Revised: 03/22/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024]
Abstract
Aortic aneurysm is a vascular disease characterized by irreversible vasodilatation that can lead to dissection and rupture of the aortic aneurysm, a life-threatening condition. Thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA) are two main types. The typical treatments for aortic aneurysms are open surgery and endovascular aortic repair, which are only indicated for more severe patients. Most patients with aneurysms have an insidious onset and slow progression, and there are no effective drugs to treat this stage. The inability of current animal models to perfectly simulate all the pathophysiological states of human aneurysms may be the key to this issue. Therefore, elucidating the molecular mechanisms of this disease, finding new therapeutic targets, and developing effective drugs to inhibit the development of aneurysms are the main issues of current research. Natural products have been applied for thousands of years to treat cardiovascular disease (CVD) in China and other Asian countries. In recent years, natural products have combined multi-omics, computational biology, and integrated pharmacology to accurately analyze drug components and targets. Therefore, the multi-component and multi-target complexity of natural products have made them a potentially ideal treatment for multifactorial diseases such as aortic aneurysms. Natural products have regained popularity worldwide. This review provides an overview of the known natural products for the treatment of TAA and AAA and searches for potential cardiovascular-targeted natural products that may treat TAA and AAA based on various cellular molecular mechanisms associated with aneurysm development.
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Affiliation(s)
- Wenwen Zhao
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China.
| | - Bufan Li
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Jinjun Hao
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Ruochen Sun
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Peng He
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Hongyu Lv
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Mou He
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Jie Shen
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China
| | - Yantao Han
- School of Basic Medicine, Qingdao Medical College, Qingdao University, Qingdao 266071, China.
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Golledge J, Thanigaimani S, Powell JT, Tsao PS. Pathogenesis and management of abdominal aortic aneurysm. Eur Heart J 2023:ehad386. [PMID: 37387260 PMCID: PMC10393073 DOI: 10.1093/eurheartj/ehad386] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/16/2023] [Accepted: 05/29/2023] [Indexed: 07/01/2023] Open
Abstract
Abdominal aortic aneurysm (AAA) causes ∼170 000 deaths annually worldwide. Most guidelines recommend asymptomatic small AAAs (30 to <50 mm in women; 30 to <55 mm in men) are monitored by imaging and large asymptomatic, symptomatic, and ruptured AAAs are considered for surgical repair. Advances in AAA repair techniques have occurred, but a remaining priority is therapies to limit AAA growth and rupture. This review outlines research on AAA pathogenesis and therapies to limit AAA growth. Genome-wide association studies have identified novel drug targets, e.g. interleukin-6 blockade. Mendelian randomization analyses suggest that treatments to reduce low-density lipoprotein cholesterol such as proprotein convertase subtilisin/kexin type 9 inhibitors and smoking reduction or cessation are also treatment targets. Thirteen placebo-controlled randomized trials have tested whether a range of antibiotics, blood pressure-lowering drugs, a mast cell stabilizer, an anti-platelet drug, or fenofibrate slow AAA growth. None of these trials have shown convincing evidence of drug efficacy and have been limited by small sample sizes, limited drug adherence, poor participant retention, and over-optimistic AAA growth reduction targets. Data from some large observational cohorts suggest that blood pressure reduction, particularly by angiotensin-converting enzyme inhibitors, could limit aneurysm rupture, but this has not been evaluated in randomized trials. Some observational studies suggest metformin may limit AAA growth, and this is currently being tested in randomized trials. In conclusion, no drug therapy has been shown to convincingly limit AAA growth in randomized controlled trials. Further large prospective studies on other targets are needed.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Douglas, Townsville, QLD, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, 1 James Cook Drive, Douglas, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD, Australia
| | - Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Douglas, Townsville, QLD, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, 1 James Cook Drive, Douglas, Townsville, QLD, Australia
| | - Janet T Powell
- Department of Surgery & Cancer, Imperial College London, Fulham Palace Road, London, UK
| | - Phil S Tsao
- Department of Cardiovascular Medicine, Stanford University, 450 Serra Mall, Stanford, CA, USA
- VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA, USA
- Stanford Cardiovascular Institute, Stanford University, 450 Serra Mall, Stanford, CA, USA
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Dihoum A, Rena G, Pearson ER, Lang CC, Mordi IR. Metformin: evidence from preclinical and clinical studies for potential novel applications in cardiovascular disease. Expert Opin Investig Drugs 2023; 32:291-299. [PMID: 36972373 DOI: 10.1080/13543784.2023.2196010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION For a long time, metformin has been the first-line treatment for glycaemic control in type 2 diabetes, however, the results of recent cardiovascular outcome trials of sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists have caused many to question metformin's position in the guidelines. Although there are several plausible mechanisms by which metformin might have beneficial cardiovascular effects, for example its anti-inflammatory effects and metabolic properties, and numerous observational data suggesting improved cardiovascular outcomes with metformin use, the main randomised clinical trial data for metformin was published over 20 years ago. Nevertheless, the overwhelming majority of participants in contemporary type 2 diabetes trials were prescribed metformin. AREAS COVERED In this review we will summarise the potential mechanisms of cardiovascular benefit with metformin, before discussing clinical data in individuals with or without diabetes. EXPERT OPINION Metformin may have some cardiovascular benefit in patients with and without diabetes, however the majority of clinical trials were small and are before the use SGLT2 inhibitors and GLP1-RAs. Larger contemporary randomised trials with metformin evaluating its cardiovascular benefit are warranted.
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Affiliation(s)
- Adel Dihoum
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, United Kingdom
| | - Graham Rena
- Division of Cellular Medicine, University of Dundee, Dundee, United Kingdom
| | - Ewan R Pearson
- Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, United Kingdom
| | - Ify R Mordi
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, United Kingdom
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Picatoste B, Cerro-Pardo I, Blanco-Colio LM, Martín-Ventura JL. Protection of diabetes in aortic abdominal aneurysm: Are antidiabetics the real effectors? Front Cardiovasc Med 2023; 10:1112430. [PMID: 37034348 PMCID: PMC10076877 DOI: 10.3389/fcvm.2023.1112430] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Aortic aneurysms, including abdominal aortic aneurysms (AAAs), is the second most prevalent aortic disease and represents an important cause of death worldwide. AAA is a permanent dilation of the aorta on its infrarenal portion, pathologically associated with oxidative stress, proteolysis, vascular smooth muscle cell loss, immune-inflammation, and extracellular matrix remodeling and degradation. Most epidemiological studies have shown a potential protective role of diabetes mellitus (DM) on the prevalence and incidence of AAA. The effect of DM on AAA might be explained mainly by two factors: hyperglycemia [or other DM-related factors such as insulin resistance (IR)] and/or by the effect of prescribed DM drugs, which may have a direct or indirect effect on the formation and progression of AAAs. However, recent studies further support that the protective role of DM in AAA may be attributable to antidiabetic therapies (i.e.: metformin or SGLT-2 inhibitors). This review summarizes current literature on the relationship between DM and the incidence, progression, and rupture of AAAs, and discusses the potential cellular and molecular pathways that may be involved in its vascular effects. Besides, we provide a summary of current antidiabetic therapies which use could be beneficial for AAA.
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Affiliation(s)
- Belén Picatoste
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- Biomedicine Department, Alfonso X El Sabio University, Madrid, Spain
- Correspondence: Belén Picatoste ,
| | - Isabel Cerro-Pardo
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Luis M. Blanco-Colio
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Jose L. Martín-Ventura
- Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- CIBERCV, Madrid, Spain
- Medicine Department, Autonoma University of Madrid, Madrid, Spain
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Response to "Re Athero-occlusive disease appears to be associated with slower abdominal aortic aneurysm growth: an exploratory analysis of the TEDY trial". Eur J Vasc Endovasc Surg 2022; 64:139-140. [PMID: 35660002 DOI: 10.1016/j.ejvs.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 01/11/2023]
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Pena RC, Bowman MAH, Ahmad M, Pham J, Kline-Rogers E, Case MJ, Lee J, Eagle K. An Assessment of the Current Medical Management of Thoracic Aortic Disease: A Patient-Centered Scoping Literature Review. Semin Vasc Surg 2022; 35:16-34. [DOI: 10.1053/j.semvascsurg.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 11/11/2022]
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